Cardiorespiratory effects of flexible fiberoptic

bronchoscopy in critically ill patients.

C E Lindholm, B Ollman, J V Snyder, E G Millen and A Grenvik

Chest 1978;74;362-368
DOI 10.1378/chest.74.4.362

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© 1978 American College of Chest Physicians
 CLINICAL INVESTIGATIONS

Cardiorespiratory Effects of Flexible

Fiberoptic Bronchoscopy in Critically Ill
Patients*
Carl-Eric Lindholm, M.D.;#{176}#{176}Bengt Oilman, M.D.;t
James V. Snyder, M.D.;j Eugene G. Millen, B.S.;
Ake Grenvik, M.D., F.C.C.P.

The flexible fiberoptic bronchoscope is used increasingly pattern caused by flexible fiberoptic bronchoscopy
often as a multipurpose instrument in critical care medi- (FFB) may in some cases cause dangerous cardiopul-
cine. In poor risk patients who need continuous me- monary distress. For example, changes of infrabronchial
chanical ventilation, rigid open tube bronchoscopy is a pressure, tidal volume, PaO,, PaCO2 and cardiac output
problem. With the flexible fiberoptic bronchoscope, may be caused by the procedure. Further, it is of great
however, diagnostic and therapeutic procedures can be importance to resfrict suction through the insfrument to
carried out without interruption of ongoing mechanical short periods to avoid dangerous alterations in the venti-
ventilation. This procedure offers the possibility of lation perfusion relationship. Since serious complications
bronchoscopy with reduced risk in debilitated patients. may occur, it is mandatory that the bronchoscopist be
However, in these critically ill patients, the cardiopul- aware of the potential pathophysiologic effects of FFB
monary system is functioning at the borderline of its during mechanical ventilation of critically ill patients.
ability. Therefore, even the small changes in ventilation

C omplications
copy ( FFB )
from
in alert,
flexible fiberoptic
spontaneously
bronchos-
breathing
publication.
inserted for
of these patients
Six
monitoring
had intravascular
of pulmonary arterial
catheters
pressure
( PAP ) , pulmonary artery occlusive pressure, systemic ar-
patients are rare.1 Most reported incidents, such as terial pressure and central venous pressure. Tracheal pressure
drug hypersensitivity, toxic effects of local anesthet- was measured intermittently in these patients with a trans-
ics and examinations by inexperienced physicians ducer connected to the air-filled suction port of the broncho-
have usually been minor ones. In critically ill scope. Cardiac output was investigated by dye dilution tech-
mque. Measurements were performed before, during and
patients, on the other hand, even a standard proce-
after FFB and derived variables were calculated from these
dure may inadvertently affect the cardiorespiratory data, according to standard physiologic formulae.
system, particularly during mechanical ventilation, An Olympus bronchofiberscope (type BF-5B2, external
when FFB is performed through an endotracheal diameter [ED] = 5.7 mm) was used in all patients. When
mechanically ventilated patients were studied, the broncho-
tube.5’6 The goal of this article is to report some
scope was passed through a commercially available swivel
cardiorespiratory variables which may be influenced
adaptor with a rubber diaphragm ( Instrumentation Indus-
by FFB on such patients. tries, Inc, Pittsburgh) which prevented loss of any part of the
delivered repiratory gases.
MATERIAL AND METHODS Two dogs under tracheal intubation and with mechanical
ventilation, were also studied during FFB to further analyze
Diagnosis, therapy and complications in a series of 55 the effects of this procedure. A tracheal catheter was inserted
adult patients have already been discussed in a previous transcutaneously to a level below the endotracheal tube to
permit continuous recording of intratrachal pressure. Venti-
#{176}From the Departments of Anesthesiology and Otolaryn..
gology, Universities of Pittsburgh (Pennsylvania) and lator frequency, exhaled tidal volume and pressure in the
Uppsala ( Sweden). ventilator tubing were simultaneously and continuously re-
#{176}#{176}Associate
Professor of Otolaryngology, University of Upp- corded, in addition.
sala School of Medicine.
tChief, Department of Otolaryngology, Central Hospital,
Visby, Sweden. RESULTS
Assistant Professor of Anesthesiology/Critical Care Medi-
cine, University of Pittsburgh School of Medicine. Intratracheal Pressure Variatior
§Associate Professor of Medicine, Medical College of Vir-
ginia, Richmond. Spontaneously breathing patients. Ten spon-
#{182}Professorof Anesthesiology/Critical Care Medicine, Uni-
versity of Pittsburgh School of Medicine. taneously breathing, unintubated patients were
Manuscript received March 1; accepted March 30. studied during transnasal insertion of the broncho-
Reprint requests: Dr. Grenvik, Presbyterian-University Hos-
pita), 230 Lothrop Street, Pittsburgh 15213 fiberscope. The intratracheal pressure on the aver-

362 LINDHOLM ET AL CHEST, 74: 4, OCTOBER, 1978

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© 1978 American College of Chest Physicians
 CmH2O SPONTANEOUS VENTILATION
+40
. TRANSNASALLY WITHOUT TUBE THROUGH TRACHEAL TUBE
+20

Y Y T T
0
#{149}r
jIL
1
jL
III III
III’TT TT TT

20 I I TT
9
9 9.5 9.5
OT TT
75 9
Ficunx 1. Intratracheal pressure variation in
-40
17 spontaneously breathing patients during
TT-TRACHEOSTOMY TUBE FF8, 10 without and 7 with tracheal intuba-
OT - OROTRACHEAL TUBE tion. The bronchoscope had an external diam-
VALUES BELOW EACH BAR-TUBE DIAMETERS INmmID eter of 5.7 mm.

age varied -5.2

between
cm H20 (SD±2.5) during the only patient with a 7.0 mm internal diameter
inhalation and + 3.5 cm H20 (SD ± 2.5) during ( ID) tracheal tube. The mean tracheal PEEP was
exhalation ( Fig 1 ). However, in seven intubated + 10.4 cm H20 ( SD ± 9.3) in these 25 patients.
patients, also breathing spontaneously, intratracheal Each patient’s prescribed tidal volume was 10-15
pressure during FFB showed much greater differ- mi/kg body weight, and was unchanged during
ence between inhalation and exhalation pressure. In FFB. Peak tracheal inhalation pressure varied be-
two patients, the intratracheal pressure during in- tween 18 and 60 cm H20 (mean 33.7, SD ± 11.5)
halation was repeatedly observed to be -20 cm H20. and peak ventilator pressure varied between 28 and
In one of these two patients, the pressure at exhala- 80 cm H20 (mean 52.8, SD ± 13.9). These values
tion reached + 20 cm H20. The average of the in- were influenced by the fact that the pop-off valve of
halation pressures in all seven patients was -10.6 cm the ventilator was set at 60-80 cm H20. One patient
H20 ( SD ± 6.9) and the average of the exhalation “fighting the ventilator” created a tracheal pressure
pressures was + 9.0 cm H20 ( SD ± 5.6). of - 35 cm H20 during attempts at spontaneous
Controlled mechanical ventilation of patients. inhalation (Fig 2).
Thirty-eight of the 55 patients were managed on Controlled mechanical ventilation of dogs. Figure
volume-set ventilators. Different sized endo- 3 demonstrates instantaneous pressure changes in
tracheal tubes were utilized, as indicated by the ventilator tubing and in a dog’s trachea during
each patient’s laryngotracheal dimensions. Intra- and following the insertion of the bronchofiberscope
tracheal pressure was monitored in 25 of these pa- through a 7.0 mm ID endotracheal tube. The dog
tients (Fig 2). Positive end-expiratory pressure was ventilated at a rate of 30 cycles/minute and
(PEEP) was discontinued during FFB. However, a with a tidal volume of 30 mI/kg body weight by a
PEEP effect was immediately noticed upon inser- Harvard piston animal ventilator. At insertion of the
lion of the bronchofiberscope through the tracheal bronchofiberscope, the peak intratracheal pressure
tube in all but five patients. In eight patients, this fell slightly before gradually increasing to a peak
PEEP was above 18 cm H20, reaching 35 cm H20 in levelof2l mm Hg (29 cm 1120). At the sametime, a
VOLUME CONTROLLED VENTILATION
CmH2O

+80 T
T
, T

+ 60 T I T
I I II II T
T TIl T
I TT I T I
+40
I
+20
TI’
jIIjIITIJiI ITIT

I
0
ItIfi ‘‘I’ll
I I I I II I iiJ I I

OT TT TT OT OT OT OT OT OT OT OT TTTTTTTTTTTT TTTTOTTTTTTTTT
9 9 9 9 9 9 9 9 9 9.59.59.59.5
7 T5 7.5 7.5 7.5 8 8 8 8 8.5 8.5
-20

OT
-40
8.5
TT-TRACHEOSTOMY TUBE DOTTED BARS - VENTILATOR PRESSURE - - -

OT-OROTRACHEALTUBE SOLID BARS- INTRATRACHEAL PRESSURE

VALUES BELOW EACH BAR - TUBE DIAMETERS IN mmID

FIGURE 2. Ventilator and intratracheal pressure variation in patients with volume-controlled

ventilation during FFB. The bar in the middle breaking the pattern represents a patient with
an orotnacheal tube of 8.5 mm ID, who was not properly sedated, “fighting” controlled ventila-
tion by making frequent attempts at spontaneous breathing.

CHEST, 74: 4, OCTOBER, 1978 EFFECTS OFFLEXIBLE F1BEROPTIC BRONCHOSCOPY IN CRmCALI.Y ILL 363

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© 1978 American College of Chest Physicians
 mmHg FIGURE 3. Simultaneous recording of ventilator
and intratracheal pressure in a dog during con-
20
trolled mechanical ventilation through a tracheal
?qq7,,,fl,
tube of 7.0 mm ID with a tidal volume of 30
mi/kg body weight and ventilator rate of 30
cycles/mm. Insertion of the 5.7 mm ED bron-
PRESSURE
VENTILATOR 0 choscope resulted in immediate elevation of peak
20 inspiratory ventilator pressure due to airway ob-
struction. Full deflection of recording pen pre-
TRACHEAL vented by selection of too narrow scale. The
PRESSURE tracheal pressure tracing shows a more gradual
elevation of peak inhalation pressure and a marked
0
PEEP effect of 16 mm Hg, still rising when suc-
i 4 t tion started after one minute. When a negative
pressure of 62 mm Hg was applied to the suction
INSEATION SUCTION SUCTION
port, in six ventilator cycles ( 12 seconds ) the in-
DISCONTI NUED tratracheal pressure became continuously nega-
tive, indicating removal of air from the lungs in
spite of unchanged ventilator function. Discon-
tinuation of suction gradually restored pre-suction
tracheal pressures, which finally returned to con-
mm Hg
trol values upon removal of bronchoscope ( at
the very end of the recording).

FIGURE 4. Ventilator and intratracheal pressure

VENTILATOR simultaneously recorded in a dog with controlled
PRESSURE mechanical ventilation during FFB through a 7.0
mm ID tracheal tul)e. As in Figure 3, the tidal
volume was 30 mI/kg body weight, but the
ventilator rate only 10 cycles/mm. With rapid
TRACHEAL recording paper speed, retarding effects of bron-
PRESSURE choscope on tracheal pressure was olwious during
both inhalation and exhalation.

PEEP of 16 mm Hg ( 22 cm H2O ) was gradually A second dog was ventilated with a pre-set tidal
created within the tracheal bronchial tree. When volume of 30 nil/kg body weight at a rate of 20
suction was applied to the bronchofiberscope, the cycles per minute via three different caliber tubes:
intratracheal pressure fell to negative values within 7.0, 8.0 and 9.0 mm ID. The pressure in the ventila-
12 seconds (Fig 3). Rapid paper speed on the re- tor tubing and the trachea was continuously re-
corder demonstrates the retardation of both inhala- corded as was the exhaled tidal volume. FFB was
tion and exhalation pressure in the trachea of the carried out through each of the different caliber
same dog, still intubated with the 7.0 mm ID tube, tubes and a series of recordings were made ( Fig
but now ventilated with 10 cycles/minute and a 5).
tidal volume of 30 ml/kg body weight (Fig 4). It is Cardiopulmonary parameters were recorded prior
also obvious that both tracheal peak inhalation pres- to FFB and again when the bronchofiberscope had
sure and PEEP have decreased considerably at this been in situ within the tube for two minutes. With
lower ventilator rate. the 9.0 mm ID tube, the pressure in the ventilator
Cm H20
5O r
I TV SET AT 30m1/kgBW UVENTILATOR PRESSURE
INTRATRACHEAL PRESSURE
+40 - f 20 CYCLES I MINUTE
SUCTION 62 TORR
7
+30

+20 FIGURE 5. Effects of FFB via different size oro-

9fl H 8 tracheal
ventilation
tubes during controlled
of a dog. Ventilator
mechanical
and intra-
+10 tracheal pressure as well as exhaled tidal vol-
ume ( TV exhaled ) were continuously record-
ed Ventilator tidal volume constant at 30 ml/

0
390 390 390 340 300
F1ii 0 390 390 390 TV
kg body weight.
(PRE) FFB, when
Values
the
were registered
bronchoscope
before
had been
50 25 present for two minutes ( 2’ ) and for 10 mm-
utes during on-going suctioning ( 10’ + S).
-10 Values 10 minutes after the end of the pro-
PRE 2’ 0+ S 0’ p EXHALED cedure ( 10’P ) were also obtained. For discus-
sion of results see text.

364 LINDHOLM ET AL CHEST, 74: 4, OCTOBER, 1978

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© 1978 American College of Chest Physicians
tubing showed little change, but for the 8.0 mm ID Table 1-Blood Gas Changes in Connection with
Flexible Fiberoptic Bronchoscopy (FF8) during
tube, there was an increase in both ventilator peak
Spontaneous Ventilation in Six Patients *
inhalation pressure and intratracheal peak inhala-
tion pressure. At the same time, a PEEP of 9 cm Mean SD Ranges
H20 was created and the exhaled tidal volume de-
FIo 0.77 0.30 0.4-1.0
creased from 390 to 300 ml. When the 7.0 mm ID
Pa02 Prior to FFB 127.8 46.7 65-190
tube was used, ventilator peak inhalation pressure (mm Hg) During FFB 94.3 31.6 63-136
increased to as much as 50 cm H20. Peak intra- After FFB 142.0 56.7 68-243
tracheal pressure was 25 cm H20 and the PEEP rose PaCO2 Prior to FFB 36.2 4.0 31-42
to 16 cm H20. The exhaled tidal volume could no (mm Hg) During FFB 35.8 4.8 31-42
longer be measured with a Wright respirometer. After FFB 35.7 3.9 31-39

After 10 minutes of FFB and with on-going sue- pH Prior to FFB 7.49 0.10 7.36-7.59
During FFB 7.44 0.08 7.33-7.52
tion (62 mm Hg negative pressure) for at least 15
After FFB 7.44 0.08 7.36-7.54
seconds ( 10’ + S ) the exhaled tidal volume was
#{149}No
changes statistically significant.
dramatically decreased, regardless of tube size. Both
12 L/min of 02 delivered via nebulizer set at 40, 70 or
ventilator and intratracheal peak inhalation pressure
100 percent and consequently
02 different flow of room air
decreased and there was negative end-expiratory entrapment. The respiratory gas mixture delivered to the
pressure when the 9.0 and 8.0 mm ID tubes were patient via standard semiopen facema.sk, through one port
used. The effect on intratracheal pressure was most of which FFB was performed without changing adjustment
pronounced when the 7.0 mm ID tube was utilized. of 02 delivery.
The intratracheal pressure was then negative during dure. FIo2 was 0.5-1.0 (mean FIo2 0.7) and the
the entire respiratory cycle and no expired tidal tracheal tube varied in size between 7.5 and 9.5 mm
volume could be measured.
ID ( mean 8.7 mm ID ). The ventilator frequency
Ten minutes following the end of FFB, both yen- was set between 12 and 18 cycles per minute ( mean
tilator and intratracheal pressures had approximate- 15 cycles per minute).
ly returned to pre-FFB levels. However, these values
The mean Pa02 increased from a pre-FFB value
tended to be lower for the 8.0 mm ID tube than for
of 106.4 mm Hg to 118.5 mm Hg during FFB and
the 9 mm ID tube and still lower for the 7.0 mm ID continued to increase to 134.6 mm Hg 15 minutes
tube as the dog became increasingly depressed by after the end of the procedure. The mean PaCO2
anesthesia as the experiment proceeded. increased from a pre-FFB value of 29.6 to 38.4 mm
Blood Gas Analyses Hg during the FFB. It then decreased again to 32.0
mm Hg 15 minutes after the withdrawal of the
Spontaneously-breathing patients. In six of the ten
instrument. The mean pH was 7.48 prior to, 7.38
spontaneously-breathing patients without intubation
during and 7.44 15 minutes after FFB. Additional
and with transnasal FFB, arterial blood gas values
information on range and SD of the above values are
were obtained before, during and 15 minutes after
given in Table 2.
FFB. The blood samples during FFB were taken
between five and ten minutes after the start of the Table 2-Blood Gas Changes in Connection with
Flexible Fiberoptic Bronchoscopy (FFB) in 15
procedure when intermittent suctioning through the
Non-paralyzed Patients during Volume Controlled
instrument channel had been performed (Table 1).
Mechanical Ventilation
The mean Pa02 decreased from a pre-FFB value of
127.8 to 94.3 mm Hg during FFB and increased Mean SD Range
again to a value of 142.0 mm Hg after the end of the Airway 8.71 0.64 7.5-9.5
procedure ( Table 1 ). Mean PaCO2 values were es- (mm ID)
sentially unchanged as were the pH values. FIo 0.71 0.17 0.5-1.0
Controlled mechanical ventilation of patients. Ar- Pa02 Prior to FFB 108.4 44.7 60-242
terial blood gas values were obtained in 15 of the (mm Hg) During FFB 118.5(NS) 50.6 58-270
patients on controlled mechanical ventilation via After FFB 134.6(NS) 68.1 58-280
orotracheal tubes or tracheostomy tubes with the PaCO2 Prior to FFB 29.6 5.5 21-39
(mm Hg) During FFB 38.4(P <.01) 10.9 25-57
bronchofiberscope inserted through the tube during
After FFB 32.0(NS) 6.5 21-43
on-going mechanical ventilation. Samples were
pH Prior to FFB 7.48 0.08 7.38-7.62
taken before, during and 15 minutes after FFB (Ta-
During FFB 7.38(P<.O1) 0.09 7.19-7.50
ble 2) . In this group of patients, some intermittent After FFB 7.44(NS) 0.09 7.31-7.63
suctioning with removal of tracheobronchial secre- analysis results in parenthesis after mean values
tions had been performed before the blood samples
refer to differences between control values prior to FFB and
were taken 5-10 minutes after the start of the proce- results obtained during and after FFB.

CHEST, 74: 4, OCTOBER, 1978 EFFECTS OF FLEXIBLE FIBEROPTIC BRONCHOSCOPY IN CRITICALLY ILL 365

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© 1978 American College of Chest Physicians
 0 PaCO2
. P002

100
50 IAC 0 TIDAL VOLUME
OUTPUT
0I
10

50
FIGURE 6. Variation of four variables during
FFB in six critically ill patients during on-go-
ing controlled mechanical ventilation. Pre-
bronchoscopy values set at 100%. Measure-
C’ I I I I ments were repeated at two minutes after in-
10 MIN sertion of the bronchoscope, at 10 minutes
DURING MIN. 5 MIN. during on-going intermittent suctioning and
2 MIN. INTERMITTENT POST
FFB POST
FFB
SUCTION at five and 15 minutes following FFB.

Cardiopulmonary Response tance in maintaining essential functions of the venti-

In the six patients with appropriate intravascular latory system.
catheters, hemodynamic measurements were per- With transnasal insertion of the bronchofiber-
formed in addition to blood gas analyses and deter- scope in spontaneously breathing patients, the ob-
minations of respiratory parameters. Studies were struction is moderate and usually tolerable, and only
performed immediately prior to FFB, two minutes small variations in the intratracheal pressure occur,
after insertion of the bronchofiberscope without sue- as demonstrated by the ten patients presented in
lion, after ten minutes of FFB with intermittent Figure 1. The instrument occupies only about 10
suction, and at five and 15 minutes after removal of percent of the tracheal cross-sectional area and
the bronchofiberscope (Fig 6). about 15 percent of the cross-sectional area at the
Although the set tidal volumes on the ventilator
cricoid ring in the adult male. In intubated patients,
remained unchanged, the patients’ measured ex- however, the tube itself claims space in the airway,
haled tidal volumes decreased drastically in all cases, especially if the tube is cuffed, and further obstruc-
particularly during FFB with on-going suction. The lion by the bronchoscope will significantly increase
tidal volume returned to control values immediately flow resistance. In a tube with a 9 mm ID, a flexible

following removal of the bronchofiberscope. bronchoscope with a diameter of 5.7 mm occupies

Cardiac output showed an increase during FFB,
no less than 40 percent of the cross-sectional area
particularly when combined with suctioning. Again, Cross sectional Eqyivalent tube
air way area without bronchoscope
the values returned to almost control level after 15 9mm ID

minutes when FFB was discontinued.

After an initial, almost unchanged value two mm-
utes after insertion of the bronchofiberscope, Pa02
decreased dramatically during FFB with intermit-
tent suctioning. PaCO2, on the other hand, increased
not only after two minutes of FFB, but also showed
a further increase at ten minutes of FFB with inter-
mittent suctioning. Pa02 returned towards the initial
value faster than did the PaCO2.

DISCUSSION

Variation in Tracheal Pressure 7 7.5 8 8.5 9 9.5 10 mm ID

Tube with bronchoscope

As a foreign body in the airway, the flexible fiber-
FIGURE 7. Diagram showing cress-section of different caliber
optic bronchoscope occupies in the
ventilatQry space
tubes (outer cfrcle) containing three different size broncho-
trachea and the bronchial lumen. In the endo- scopes (filled center) : A) 5 mm ED; B) 5.7 mm ED. White
tracheal tube, it leaves only a cylindrical rim of free area within the tubes shows available cross-sectional airway
area. Inserted: Relation between available cross-sectional air-
air space for ventilatory purposes. The size, and also
way area of the trachea and the bronchofiberscope in non-
possibly the shape of this space is of crucial impor- intubated normal patients.

366 LINDHOLM El AL CHEST, 74: 4, OCTOBER, 1978

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© 1978 American College of Chest Physicians
while in an 8 mm tube, 51 percent, and in a 7 mm Elevation of Pco2 principally reflects decreased
tube no less than 66 percent will be obstructed (Fig alveolar ventilation. This is caused by suctioning of
7). This leads to high air flow resistance causing respiratory gas from the bronchi, which may create a
high exhalation and low inhalation tracheal pres- negative tracheal pressure ( Fig 3 ), resulting in
sures. With controlled mechanical ventilation dramatically decreased tidal volume (Fig 5) . These
through a tracheal tube, the high exhalation resis- effects are due to continued use of suction when
tance very quickly results in a PEEP of dangerously secretions are not being removed, ie the suction
high levels, if the tube is narrow, ie with an ID less channel is filled with air. The net effect is elevation
than 8.0 mm. of Pco2 (Fig 6). However, as long as the instrument
With a tube of 7.0 mm ID, PEEP of 35 cm H20 channel is occluded by secretions, suctioning does
was measured in one patient ( Fig 2), a value which not affect ventilation.
probably could cause mediastinal emphysema and The increase in cardiac output (Fig 6) may be
pneumothorax even in normal healthy subjects.9’1#{176} related to catecholamine release from tracheal
Signs of mediastinal emphysema were indeed ap- stimulation, hypoxemia, elevation of PC02,14 patient
parent radiographically following this procedure. apprehension or other factors.
PEEP, as transiently created during FFB, may be
of value in patients with acute interstitial lung dis- CoNciUsIoNs
ease, eg pulmonary edema.11’12 PEEP of more than
Risks Commonly Associated with FFB during
20 cm H20 was not observed during FFB through
Mechanical Ventilation
8.0 mm ID tubes (Fig 2). Thus, 8.0 mm ID appears
to be the minimum size tube through which FFB Introduction of the bronchoscope. A decrease in
should be performed with a standard bronchoscope endotracheal inflation pressure will result in de-
(5.7 mm ED), without risking high levels of PEEP creased tidal volume, decreased Pa02 and increased
and concomitant barotrauma. PaCO2. In spite of the reduced inspiratory pressure,
Both intratracheal peak inhalation pressure and the PEEP effect
may cause more barotrauma.
PEEP are also influenced by the respiratory rate, as Incautious application of suction. Further de-
can be seen when the readings in Figures 3 and 4 are crease in endotracheal inflation pressure with de-
compared. A high rate will increase and a low rate creased tidal volume to possible evacuation of gas
will decrease the retarding and damping effect of from the lungs, reducing the FRC with severe hypox-
the bronchoscope, since this effect is flow related. emia as a consequence.

Changes Effected in Blood Gases

Recommendations
The aim of FFB on ICU patients is often the
therapeutic removal of secretions from medium- When performing FFB in critically ill patients
sized bronchi to resolve atelectases and improve during mechanical ventilation, the following points
respiration.5’7’8’103 This is achieved both by the are important: ( 1 ) use tracheal tube no smaller than
PEEP created by introduction of the bronchoscope 8.0 mm ID; (2) discontinue PEEP; (3) increase
and by removal of mucus plugs and pooled secre- FIo2 to 1.0; (4) monitor visually for adequate chest
tions. Both these mechanisms contribute to the in- excursions; (5) suction for short periods only; (6)
crease in Pa02, seen during and after FFB in our analyze arterial blood frequently; (7) rule out medi-
patients ( Table 2) . However, removal of tracheal astinal emphysema and pneumothorax by x-ray
gas by excessive use of suction eliminates the PEEP examination after FFB.
effect, and may decrease lung volume to well below
the functional residual capacity, FRC (Fig 5). This REFERENCES
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368 UNDHOLM El AL CHEST, 74: 4, OCTOBER, 1978

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Cardiorespiratory effects of flexible fiberoptic bronchoscopy in critically ill
patients.
C E Lindholm, B Ollman, J V Snyder, E G Millen and A Grenvik
Chest 1978;74; 362-368
DOI 10.1378/chest.74.4.362
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