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is called Morison’s pouch. In this image, the anechoic space between the liver and kidney indicates the presence of free intra-abdominal fluid."/>
Figure 4.10 The potential space between the liver and right kidney is called Morison’s pouch. In this image, the anechoic space between the liver and kidney (arrow) indicates the presence of free intra‐abdominal fluid.
Figure 4.11 Bladder view (transverse orientation) with a Foley (balloon filled with water (anechoic), arrow). In the presence of a Foley, the bladder should be empty. If the bladder is not empty, look for an obstruction in the Foley catheter which may need to be flushed or replaced.
Figure 4.12 Assess for leg vein thrombosis. See text for scanning sequence. (A) Without compression. The vein appears anechoic without echogenic material within. (B) With compression via the US probe the femoral vein (FV) collapses. This indicates the absence of a thrombus in the FV at this level.
Additional material for this chapter can be found online at:
www.wiley.com/go/mayer/mountsinai/criticalcare
This includes multiple choice questions and Videos 4.1 and 4 2 .
CHAPTER 5 Bronchoscopy
Moses Bachan and Zinobia Khan
James J. Peters VA Medical Center, New York, NY, USA
OVERALL BOTTOM LINE
In patients with respiratory insufficiency/emergent evaluation with bronchoscopy can prevent morbidity and mortality.
Bronchoscopy provides a means to evaluate the airways; it can be both diagnostic and therapeutic.It is essential that all intensivists have an understanding of bronchoscopy and be able to perform this life‐saving procedure in critical situations.Some life‐threating situations where bronchoscopy can be used are:Difficult intubations.Complete lung atelectasis secondary to mucus impaction.Lavage for aspiration of blood and stomach contents.Removal of foreign objects.Hemoptysis.
Introduction
Bronchoscopy is a procedure utilized to visualize the airways. There are three types:
Flexible bronchoscopy (or white light bronchoscopy) uses a small (5–6 mm diameter) flexible instrument that can access the distal airways. This requires conscious sedation.
Rigid bronchoscopy is usually done in the OR, using a rigid instrument larger than the flexible scope. It requires general anesthesia and can only access the proximal airways.
Virtual bronchoscopy uses images to reconstruct a 3D picture of the airways. This is a non‐invasive procedure.
In this chapter we will be discussing flexible bronchoscopy which is used by the intensivist in the ICU on critically ill patients.
The bronchoscope
The handle on the top of the bronchoscope is for up and down movement of the bronchoscope tip; the tip moves up and down in one plane. The right thumb is used to flex and re‐flex the handle. The upward movement of the handle moves the tip down and vice versa.
The protruding gray color knob on top is for suctioning of fluid. The right index finger is used on the suction port. Other movement is achieved by movements at the wrist.
The protruding gray color knob second from the top is for instillation of fluid and accessories (working channel).
Indications
Atelectasis.
Large volume aspirate for lavage.
Non‐resolving pneumonia, to collect samples.
Percutaneous tracheostomy placement.
Endotracheal tube (ETT) placement with difficult intubations.
Evaluation of tracheostomy tube or ETT.
Aid to relieve thick secretions/mucus impaction, mostly in spinal cord injury patients (this is done frequently prior to extubation of a ventilated patient).
Hemoptysis.
Small foreign body removal.
Suspected airway obstruction, e.g. tracheal stenosis, endobronchial lesions.
Pre‐procedure
Obtain informed consent (in ICU this is usually from the health care proxy).
NPO for at least 4–6 hours prior to the procedure if possible in non‐emergent or non‐intubated patients; tube feeds should be held before the procedure.
Perform time out.
Set up: done in a monitored setting with ECG recording, BP monitoring, O2 saturation monitoring, bronchoscope, accessories for the bronchoscope (e.g. brush, forceps, balloon), bronchoscopic adaptor (ventilator and bronchoscope can both be use at the same time), specimen collecting system, saline (some should be ice cold), alcohol, slides, epinephrine, lidocaine (solution and gel), oxygen, ETT, oral piece, gauzes, port syringes, suctioning system, IV fluid, sedative, analgesics, lubrication, vasopressor agents, and resuscitation medications (e.g. naloxone) available if needed.
Protective wear available.
Personnel: bronchoscopist, bronchoscopist assistant (to help with use of forceps, brush, ETT stabilization, etc.), critical care nurse, and respiratory therapist.
Lab work: generally not needed but PTT and INR in cases of hemoptysis.
In non‐intubated patients, the nares/airways should be anesthetized with aerosolized lidocaine and lidocaine gel.
In intubated patients, the ETT should be at least 7.5–8 mm in diameter for the typical bronchoscope to pass. ETT change may be necessary.
In intubated patients, the airway can be sprayed with lidocaine or the lidocaine can be nebulized before the start of the procedure. About 400–600 mg can be safely used for the entire procedure.
Sedatives should be given for moderate sedation in non‐intubated patients. Typical medications are midazolam (noted to decrease salivation during bronchoscopy) or propofol used with fentanyl (to decrease coughing). For intubated and sedated patients, an increase in the baseline sedative(s) is required.