Clinical and breathing behavior in subjects undergoing bronchoscopy supported with noninvasive mechanical ventilation

Abstract

Introduction: Bronchoscopy is an invasive procedure used increasingly in intensive care units, with diagnostic and therapeutic purposes. There is a group of subjects in whom the risk of being intubated increase morbidity and mortality. The use of noninvasive mechanical ventilation (NIV) prevents hypoxemia during bronchoscopy, thus avoiding acute respiratory failure.

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Volume 2 • Issue 1 • 1000106
J Respir Med, an open access journal
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Giugliano et al., J Respir Med 2018, 2:1
*Corresponding author: Claudia C Giugliano, Department of Intensive Care
Medicine, Clinica Alemana de Santiago, Clinica Alemana-Universidad del
Desarrollo, Chile, Tel: +56222106421; E-mail: cgiuglianoj@alemana.cl
Received February 09, 2018; Accepted February 12, 2018; Published February
19, 2018
Citation: Giugliano CC, Cerpa FA, Keymer JE, Perez RA, Romero CP, et al. (2018)
Clinical and Breathing Behavior in Subjects Undergoing Bronchoscopy Supported
with Noninvasive Mechanical Ventilation. J Respir Med 2: 106.
Copyright: © 2018 Giugliano CC, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Abstract
Introduction: Bronchoscopy is an invasive procedure used increasingly in intensive care units, with diagnostic and
therapeutic purposes. There is a group of subjects in whom the risk of being intubated increase morbidity and mortality.
The use of noninvasive mechanical ventilation (NIV) prevents hypoxemia during bronchoscopy, thus avoiding acute
respiratory failure.
Objectives: Describe the clinical behavior of subjects who were supported with NIV and the complications
associated with bronchoscopy that may result in endotracheal intubation.
Methods: Descriptive study of 25 procedures in adult subjects with indication of bronchoscopy, who presented
acute respiratory failure and the need for NIV during hospitalization or were supported with NIV for bronchoscopy for
risk reduction.
Results: No subjects had any complication that required an articial airway and invasive mechanical ventilation.
There was no statistical difference in clinical outcomes.
Conclusion: There were no complications associated with the technique; subjects remained clinically stable during
and after the procedure. There is need more studies to standardize the technique and demonstrate that it is safe and
reproducible in other centers.
Clinical and Breathing Behavior in Subjects Undergoing Bronchoscopy
Supported with Noninvasive Mechanical Ventilation
Claudia C Giugliano1*, Felipe A Cerpa1, Juan E Keymer1, Rodrigo A Perez1, Carolina P Romero1, Hugo R Budini1, Daniel Caceres1, Agustin
Camus1, Sebastian Fernandez-Bussy2 and Jeronimo Graf1
1Department of Intensive Care Medicine, Clinica Alemana de Santiago, Clinica Alemana-Universidad del Desarrollo, Chile
2Pneumology Intervention Unit, Clinica Alemana de Santiago, Clinica Alemana-Universidad del Desarrollo, Chile
Keywords: Bronchoscopy; Non-invasive mechanical ventilation;
Bronchoalveolar lavage; Critical care unit
Abbreviations: HR: Heart Rate; f: Respiratory Rate; SpO2: Oxygen
Saturation; IPAP: Inspiratory Positive Pressure; EPAP: Espiratory
Positive Pressure; PIP: Peak Inspiratory Pressure; VTe: Espiratory Tidal
Volu me
Introduction
Bronchoscopy is an invasive procedure for examination of the
tracheobronchial tree, which is very important in the diagnosis
and treatment of pulmonary diseases [1]. e use of diagnostic
or therapeutic bronchoscopy has been increasing in the Intensive
Care Units (ICU) in the last years [2], because of the possibility of
performing it next to subject's bed, describing less complication [2].
During the bronchoscopy procedure, the bronchoscope diameter plays
an important role in airway obstruction [2]. In subjects with native
airway, the bronchoscope occupies approximately 10% of the trachea
internal diameter, causing decrease in tidal volume (VT), increased
respiratory work, altered respiratory mechanics and gas exchange,
causing hypoxemia and hypercapnia [1,2]. In a bronchoscopy without
complications, the arterial oxygen pressure (PaO2) decreases between
10 to 20 mmHg. In hypoxemic subjects, there is an increased risk of
developing acute respiratory failure (ARF) and arrhythmias during
bronchoscopy. A bronchoscopy contraindication in non-intubated
subjects is severe hypoxemia, being the option the orotracheal
intubation and mechanical ventilation to ensure adequate gas exchange
during bronchoscopy [3]. is is the reason because of some clinicians
are reticent to perform bronchoscopy in hypoxemic subjects, despite
increasing the possibility of a correct diagnosis [4]. e problem
of intubates hemato-oncological, immunosuppressed or chronic
respiratory subjects, is the increase of morbidity and mortality. During
bronchoscopy, samples are usually taken for secrection culture. When
suction is applied, volume and positive pressure at the end of expiration
(PEEP) are reduced, facilitating alveolar closure and thus venous
admission, both of which are detrimental to pulmonary mechanics,
altering lung mechanics and respiratory work. Aer a bronchoscopy
the normalization time may take several hours in subjects with severe
pulmonary parenchymal alterations. In subjects with severe hypoxemia
(PaO2/Fio2<200), NIV improves gas exchange during and aer
bronchoscopy, thus reducing complications. Although bronchoscop
with NIV has evidence to support its use (1,14,15), there is still
unknown, and subjects must be intubated to perform it, or simply is
not performed.
Methods
A descriptive transversal study was included adults subjects from
Clínica Alemana de Santiago Critical Care Unit, between March 2015
and May 2016, with ARI diagnostic, who required a diagnostic or
therapeutic bronchoscopy. Of the 25 performed bronchoscopies, 17
procedures had to be managed with NIV during their hospitalization,
while the other 8, was supported during the procedure to reduce
the risks associated with being subjects with basic pathologies such
as hemato-oncological, immunosuppressed or chronic respiratory

Citation: Giugliano CC, Cerpa FA, Keymer JE, Perez RA, Romero CP, et al. (2018) Clinical and Breathing Behavior in Subjects Undergoing
Bronchoscopy Supported with Noninvasive Mechanical Ventilation. J Respir Med 2: 106.
Page 2 of 3
Volume 2 • Issue 1 • 1000106
J Respir Med, an open access journal
pathologies. When exposed to hypoxemia, they are at increased risk
of severe respiratory failure and consequently being intubated, which
increases their morbidity and mortality. A NIV V60 Respironics® and
a Fitlife Respironics® facial mask were used for all bronchoscopy. e
facial mask was modied, was removed the partition wall located
in the zone of the anti-asphyxiation valve at the elbow of the mask,
leaving a space to introduce the exible bronchoscopy, which is close
when it is not inserted (Figure 1). e NIV was programmed in bilevel
mode, the programmed pressures depend on the needs of each subject,
looking for VT between 6-8 ml/kg IBW. e inspired oxygen fraction
(Fio2) was programmed in 100% two minutes before the procedure,
continuous hemodynamic monitoring was performed through bedside
monitor of the room. ere was a trained team, a bronchopulmonary
medical doctor with expertise in bronchoscopy technique, the resident
medical doctor of the unit who indicated sedation with Propofol
and Fentanyl, to achieve SAS (Sedation-Agitation Scale) of 1-2, a
nurse who administered the drugs, and 2 respiratory therapist, one
that continuously programmed NIV during the bronchoscopy to
achieve the target VT and the second, which recorded the data. For
data collation, a record sheet was designed with; Age, sex, APACHE
II, diagnosis, bronchoscopy motive, heart rate (HR), respiratory rate
(f), oxygen saturation (SpO2), SAS, ventilatory mode and pressures
(IPAP- EPAP), ventilator leakage, expired tidal volume (VTe). All these
variables were recorded two minutes before, during (every minute) and
5 minutes aer the procedure. Complications were evaluated during
and up to 24 hours following the procedure. Among the complications
to be observed were: refractory oxygen desaturation, arrhythmias,
airway bleeding, agitation, acute coronary syndrome, cardiac arrest,
orotracheal intubation and death. is study was approved by the
Scientic Teaching Department and Ethics Committee of Clinica
Alemana de Santiago, and all participants or their representatives
signed the informed consent prior to the procedure. STATA 12 was the
statistical analysis soware used to analyze the data. Statistical analysis
was performed using descriptive statistics, median and interquartile
range, and T-Student's test was used for the comparison of paired
samples, with a signicance level of 0,05 (p>0.05).
Results
A total of 25 bronchoscopies assisted with NIV were performed,
which an average duration of 6 minutes. Of these, 19 (76%) were only
diagnosis bronchoscopy and 6 (24%) were for diagnosis and treatment
(Table 1). e gender distribution was 56% male, with a mean age of 67
(17-71) years and mean APACHE II of 13 (10-16). e ICU admission
diagnoses were grouped in acute hypoxemic insuciency (40%), chronic
respiratory failure (12%), hemato-oncological (32%) and others (16%)
like neuromuscular pathologies and suspected alveolar haemorrhage.
Of the study group, 68% of the subjects were connected to NIV before
bronchoscopy, and the most common reasons for their connection were
increased respiratory work (32%) and desaturation (28%). In relation
to ventilatory mode, before bronchoscopy 16% were in CPAP mode,
and aer that, 12% return to CPAP mode. e remaining 32% of the
procedures did not meet clinical or gasometric NIV connection criteria
and were connected to NIV to assist bronchoscopy because of the high
risk of hypoxemic failure. Of these procedures, two had diagnosis of
diuse pulmonary disease, two hemato-oncologic, two suspicions of
alveolar hemorrhage, one airway obstruction by a foreign body and
one abdominal septic shock. None of these subjects required post-
procedure NIV. e clinical variables were recorded before, during
and aer the procedure (Table 2). Before bronchoscopy mean HR was
91 (74-112) beats/min, f 22 (21-32) breaths/min, SpO2 99% (96-100),
IPAP and EPAP of 12 (10-14) cm H2O and 8 (6-8) cm H2O respectively.
e ventilator mean leaks was 6 (1-21) L/min and the mean VTe 428
(335-500) ml. During the bronchoscopy procedure the mean HR was
91 (76-106) beats/min, the median f was 23 (21-28) breaths/min, SpO2
99% (98-100), IPAP of 20 (18-25) cm H2O, and EPAP of 8 (7-10) cm
H2O, mean leakage of 8 (75-96) L/Min and VTe of 340 (270-460) ml.
And nally, aer bronchoscopy the median HR was 90 (71-106) beats/
min, f 25 (21-28) breaths/min and SpO2 of 100% (97-100), IPAP of 12
(10-16) cm H2O and EPAP of 7 (6-8) cm H2O, leak of 0 (0-7) L/min and
VTe of 389 (336-489) ml. During and 24 hours aer the bronchoscopy,
there were no desaturations, arrhythmias, airway bleeding, agitation,
acute coronary syndrome, cardiac arrest, orotracheal intubation or
death, in any of the 25 procedures. When assessing the dierence on
the registered variables before and aer the bronchoscopy procedure
Mean (intercuartile range) or nº (%)
Bronchoscopy Procedures 25
Age, years 67 (17-71)
Sex ratio (m/f) 14-11
APACHE II Score 13 (10-16)
Underlying Diagnosis
Hypoxemic respiratory insufciency 10 (40%)
Chronic respiratory insufciency 3 (12%)
Hemato-Oncologic 8 (32%)
Other 4 (16%)
Indication for bronchoscopy
Diagnostic 19 (76%)
Therapeutic 0 (0%)
Diagnostic and therapeutic 6 (24%)
Table 1: Patient characteristics, values given as mean (interquartile range) or nº (%).
Variables
2 min before
bronchoscopy
During
bronchoscopy
5 min after
bronchoscopy
HR (beats/min) 91 (74-112) 91 (76-106) 90 (71-106)
f (breaths/min) 22 (21-32) 23 (21-28) 25 (21-28)
SpO
2
(%) 99 (96-100) 99 (98-100) 100 (97-100)
IPAP (cmH
2
O) 12 (10-14) 20 (18-25) 12 (10-16)
EPAP(cmH
2
O) 8 (6-8) 8 (7-10) 7 (6-8)
PIP (cmH
2
O) 8 (7-9) 18 (15-21) 14 (11-18)
Leak (L/min) 6 (1-21) 88 (75-96) 0 (0-7)
VTe (ml) 428 (335-500) 340 (270-460) 389 (336-489)
Complications 0/25 0/25
Table 2: Clinical and ventilatory variables, values given as mean (interquartile
range).
Figure 1: Left: Elbow mask with and without partition wall. Right: NIV mask with
modied elbow for the bronchoscope introduction.

Citation: Giugliano CC, Cerpa FA, Keymer JE, Perez RA, Romero CP, et al. (2018) Clinical and Breathing Behavior in Subjects Undergoing
Bronchoscopy Supported with Noninvasive Mechanical Ventilation. J Respir Med 2: 106.
Page 3 of 3
Volume 2 • Issue 1 • 1000106
J Respir Med, an open access journal
we can observe that HR mean was 92 ± 20.9 and 90.5 ± 18.6 beats/min
(p=0.52), previous and posterior f was 28 ± 17.44 and 24.2 ± 5 breaths/
min (p=0.26), for SpO2 it was 97.88 ± 2.7 and 98.2 ± 2.1% (p=0.64). In
the ventilatory variables IPAP previous and posterior was 11.2 ± 5.8 and
12.6 ± 5.4 cmH2O (p=0.33), EPAP of 7.5 ± 1.4 and 7.8 ± 1.5 cmH2O
(p=0.27), inspiratory peak pressure (PIP) of 8.4 ± 2.5 and 14.4 ± 5
cmH2O (p=0.00), Vt of 439.6 ± 160.2 and 474.9 ± 162.32 ml (p=0.22)
and leakage of 14.5 ± 23.8 and 8.6 ± 12.9 L/min (p=0.11), where only
the dierence between PIP was statistically signicant (Table 3).
Discussion
A lot of reports describe the use of NIV to prevent hypoxemia
during bronchoscopy, preventing desaturation and thus acute
respiratory failure or it exacerbation [1-15], by maintaining
spontaneous ventilation during the procedure, it ensures V/Q balance
and hemodynamic stability. Randomized trials provide evidence for the
use of NIV in ARF to prevent orotracheal intubation in subjects with
exacerbations of COPD, acute cardiogenic pulmonary edema and in
immune compromised subjects [6,10,13] reducing rates of intubation,
length of hospital stay, and mortality [11,12]. ere were performed
25 bronchoscopy procedures, where no subject required orotracheal
intubation at 24 hours aer de procedure, unlike what was found by
Baumann et al. 2011, where 10% of the subjects required orotracheal
intubation at 8 hours aer the procedure, a dierence that may be due
to the greater severity of their population [14], but which is debatable,
because Korkmaz et al. [15] had a 32% of orotracheal intubation at 24
hours aer the bronchoscopy with an APACHE II similar to that in this
study.
Conclusion
Clinical and ventilatory variables remained stable before
bronchoscopy in relation to the baseline, without the need for greater
ventilatory support, making this technique a safe procedure for
subjects with ARF diagnosis that require a diagnostic or therapeutic
bronchoscopy. With regard to leakage measured by the NIV, these
exceeded 60LPM during the bronchoscopy, mainly due to suction,
which could be compensated by the constant setting of the NIV to
reach the target VT, thereby preventing disre-clusion and hypoxemia.
Authors’ contributions
CG, FC, JG and SFB have made substantial contributions to the
conception and design of the study. SFB performed the bronchoscopies.
JEK, RP, CR, HB and DC collected the data. CG, RP and AC performed
the analysis and interpretation of data. CG and FC draed the
manuscript.
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Variables 2 min before
bronchoscopy
5 min after
bronchoscopy P value
HR (beats/min) 92 ± 20.9 90.5 ± 18.6 p=0.52
f (breaths/min) 28 ± 17.44 24.2 ± 5 p=0.26
SpO2 (%) 97.88 ± 2.7 98.2 ± 2.1 p=0.64
IPAP (cmH2O) 11.2 ± 5.8 12.6 ± 5.4 p=0.33
EPAP (cmH2O) 7.5 ± 1.4 7.8 ± 1.5 p=0.27
PIP (cmH2O) 8.4 ± 2.5 14.4 ± 5
p=0.0*
Vte (ml) 439.6 ± 160.2 474.9± 162.32 p=0.22
Leak(L/min)
14.5 ± 2. 8 8.6 ± 12.9 p=0.11
Table 3: Comparison before and after variables, values given as mean ± SD.