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INTRODUCTION

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Fiberoptic bronchoscopy is a useful skill for the emergency physician. This procedure allows navigation of the upper airways, placement of endotracheal tubes, and evaluation of the proximal and distal airways. As an extension of airway and ventilator management, proficiency in flexible fiberoptics is an important tool used in critical care medicine.

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The history of the bronchoscope began in 1897 with Gustav Killian, affectionately known as the “father of bronchoscopy” when he used direct visualization of trachea/bronchi to remove a foreign body (bone lodged in R main). In the 1900s, rigid bronchoscopy improved treatments for lung cancer, and in 1904 Chevalier Jackson added an electric light source and suctioning capability. By 1966, Dr. Shigeto Ikeda (Pentax) created the first flexible fiberoptic bronchoscope, and use expanded from evaluation intraoperatively to guide pulmonary sample collection and surgical biopsies. In the 1980s, Asahi Pentax replaced fiberoptic bundles with a charge coupled sensor at the tip of the scope to allow video screen projection of images. Now multiple manufacturers have fiberoptic devices of varying sizes, lengths, and calibers, with even small portable endoscopes for procedural guidance. With the advent of video laryngoscopy, similar technology now has extended to bronchoscopes, creating video bronchoscopes that are less prone to breakage.

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The purpose of this chapter is to review the knowledge required to perform bronchoscopy safely for a wide variety of common reasons in the intensive care unit (ICU) and emergency department (ED). Considerations for performing bronchoscopy in the ED usually relate to placement of airway (procedural guidance for endotracheal tube) or treatment of large airway occlusion (removal of large mucus plug). Reasons for the procedure to be performed in the ED include urgent need to establish airway (clinical decompensation, stridor, upper airway occlusion) or hypoxia.

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Optical fibers within the bronchoscope are polymers that guide light and use video to display images. A channel providing ability to deliver medications such lidocaine, suctioning of secretions or hemorrhage, and delivery of tools for snaring foreign bodies is standard for bronchoscopes. Luminal size determines strength and ability to effectively clear secretions; “pediatric” scopes, often measuring 4–5 mm in diameter, are less effective for hemoptysis, and are usually reserved only for procedural guidance of challenging upper airway anatomy.

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Overall, bronchoscopy is a safe procedure with a mortality of 0% to 1%. There is a complications rate of 0.08% to 10% (PTX). Minor complications include infection, bleeding, hypoxemia, cardiac arrhythmia (secondary to lidocaine toxicity), and medication reaction (anesthesia or sedatives).1,2 Other complications include tachycardia/bradycardia, bronchospasm/laryngospasm, cough, dyspnea, sore throat, apnea, seizure, desaturation, pneumothorax, and pulmonary edema. Hypoxemia is common during this procedure due to sedation impairing ventilation, and lavage of alveolar segments35 (Tables 14-1 and 14-2).

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TABLE 14-1:

Diagnostic & Therapeutic Indications

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