Bronchoscopy Equipment

Quick Answer

Bronchoscopy equipment in the ICU encompasses flexible video bronchoscopes (most common, OD 4.0-6.0mm), rigid bronchoscopes (for massive hemoptysis/central airway obstruction), and single-use disposable scopes (eliminating cross-contamination risk - PMID: 32066163). Key components include the insertion tube (fiberoptic bundles or chip-on-tip CMOS), control handle (angulation lever, suction port, working channel), light source (LED/Xenon 300W), and video processor (HD output). The working channel (2.0-3.2mm) enables suction, BAL, and instrument passage. ICU indications include: diagnostic (BAL for VAP with 10^4 CFU/mL threshold, diffuse alveolar hemorrhage, immunocompromised infections), therapeutic (secretion clearance, atelectasis treatment), and procedural (difficult intubation, percutaneous tracheostomy guidance - PMID: 26848035). Critical considerations include bronchoscope-ETT size matching (scope OD should be ≤66% of ETT ID to prevent auto-PEEP), adequate sedation/paralysis, maintenance of PEEP during procedure, and proper reprocessing (high-level disinfection or single-use - PMID: 30041876). Complications include transient hypoxemia (common), hypercapnia, bleeding, pneumothorax (<1%), and arrhythmias.

---

CICM Exam Focus

What Examiners Expect

Second Part Written (SAQ):

Common SAQ stems:

• "Describe the types of bronchoscopes available for ICU use and their indications."
• "Outline the technique for bronchoalveolar lavage (BAL) in a mechanically ventilated patient, including preparation, procedure, and interpretation of results."
• "Discuss the role of bronchoscopy in percutaneous dilational tracheostomy (PDT)."
• "Describe the advantages and disadvantages of single-use versus reusable bronchoscopes."
• "Outline the complications of bronchoscopy in the critically ill and strategies to minimize them."
• "Discuss the reprocessing requirements for flexible bronchoscopes."

SAQ scoring expectations:

• Classification of bronchoscope types (flexible, rigid, video, single-use)
• Understanding of equipment specifications (OD, working channel, light source)
• Knowledge of ICU indications (diagnostic vs therapeutic)
• BAL technique and interpretation (cell counts, microbiology thresholds)
• Safety considerations (ETT-bronchoscope size matching, sedation, PEEP)
• Infection control and reprocessing principles

Second Part Hot Case:

Typical presentations:

• Patient with new pulmonary infiltrates requiring diagnostic bronchoscopy
• Difficult airway requiring awake fiberoptic intubation
• Lobar collapse requiring therapeutic bronchoscopy
• PDT with bronchoscopic guidance
• Massive hemoptysis requiring urgent airway management

Examiners assess:

• Appropriate indication for bronchoscopy
• Equipment selection and preparation
• Risk assessment and optimization
• Procedural technique description
• Complication recognition and management
• Interpretation of BAL results

Second Part Viva:

Expected discussion areas:

• Bronchoscope types and specifications
• Light source physics (Xenon vs LED, wavelength)
• Working channel applications
• BAL technique and normal/abnormal cell differentials
• Ventilation strategies during bronchoscopy
• Single-use vs reusable scope evidence
• High-level disinfection requirements
• Complications and their prevention

Examiner expectations:

• Fluent discussion of equipment specifications
• Understanding of physics (fiberoptics vs chip-on-tip)
• Evidence-based comparison of single-use vs reusable
• Knowledge of infection control guidelines
• Practical approach to BAL interpretation
• Risk mitigation strategies

Common Mistakes

• Not knowing bronchoscope outer diameters (adult 5.0-5.5mm, slim 3.5-4.2mm)
• Confusing working channel diameter with outer diameter
• Using oversized bronchoscope causing dangerous auto-PEEP
• Not maintaining PEEP during bronchoscopy in ARDS patients
• Inadequate sedation leading to coughing and desaturation
• Misinterpreting BAL cell counts (normal neutrophils <3%, not 10%)
• Not knowing BAL threshold for VAP diagnosis (10^4 CFU/mL)
• Ignoring reprocessing time requirements (>20 minutes HLD)
• Not recognizing single-use scope indications (MDRO colonization)

---

Key Points

Must-Know Facts

1. Bronchoscope Types: Flexible video (standard adult OD 5.0-5.5mm, slim 3.5-4.2mm, therapeutic 6.0-6.4mm), rigid (stainless steel, OD 7-14mm, for hemoptysis/obstruction), single-use disposable (OD 5.0mm, CMOS chip-on-tip, eliminates cross-contamination). Video bronchoscopes have replaced fiberoptic in modern ICU practice (PMID: 28414407).

2. Working Channel Specifications: Standard 2.0-2.2mm (suction, BAL, small instruments), therapeutic 2.8-3.2mm (larger forceps, stents, coagulation). Minimum for effective suction of thick secretions is 2.0mm. Channel patency must be confirmed before each use.

3. Light Source Technology: Xenon (300W, 5500K color temperature, external tower), LED (integrated into portable systems, lower power, cooler operation). Light transmission: fiberoptic bundles (reusable) vs chip-on-tip CMOS sensors (video/single-use) providing HD resolution 1920x1080.

4. ETT-Bronchoscope Size Matching: Bronchoscope OD should be ≤66% of ETT internal diameter to prevent auto-PEEP. ETT 7.0mm → scope ≤4.5mm, ETT 8.0mm → scope ≤5.3mm, ETT 9.0mm → scope ≤6.0mm. Clearance <2mm causes dangerous intrinsic PEEP and impaired ventilation (PMID: 21876408).

5. BAL Technique: Wedge bronchoscope in subsegmental bronchus, instill 100-300mL sterile saline in 20-60mL aliquots, aspirate with gentle suction, expect >40% return for adequate sample. First aliquot = bronchial sample, subsequent = alveolar sample. Normal differential: macrophages 85-95%, lymphocytes 5-15%, neutrophils <3%, eosinophils <1% (PMID: 22794300).

6. ICU Indications - Diagnostic: VAP diagnosis (BAL with >10^4 CFU/mL threshold - PMID: 24742068), diffuse alveolar hemorrhage (sequential bloody return), immunocompromised infections (PCP, CMV, fungal), ARDS mimics (eosinophilic pneumonia), airway inspection (post-intubation injury, tracheal stenosis).

7. ICU Indications - Therapeutic: Refractory lobar atelectasis (secretion clearance), massive hemoptysis (cold saline lavage, topical epinephrine, tamponade), foreign body removal, difficult intubation guidance (awake FOI), percutaneous tracheostomy guidance (midline confirmation, posterior wall protection - PMID: 26848035).

8. Procedural Safety: Pre-oxygenate FiO2 1.0, ensure adequate sedation ± paralysis, increase PEEP to compensate for scope-induced leak, maintain continuous SpO2 monitoring, have rescue airway equipment available. Abort if SpO2 <90% sustained or hemodynamic instability.

9. Single-Use vs Reusable Evidence: Single-use eliminates cross-contamination risk (reusable contamination rates 14-28% after HLD - PMID: 30041876), immediately available without reprocessing delay, comparable clinical performance (PMID: 32066163). Cost-effective when procedure volume <3/week or MDRO risk high.

10. Reprocessing Requirements: Pre-cleaning at point of use, leak testing, manual brush cleaning (critical step), high-level disinfection (glutaraldehyde, OPA, or peracetic acid for validated time), sterile water rinse, alcohol flush, forced air drying, vertical storage. Total cycle >45 minutes. Failure at any step → contamination risk (PMID: 33355524).

Memory Aids

BRONCH - Equipment Components:

• Body = Insertion tube (fiberoptic bundles or CMOS chip)
• Rotation = Control handle with angulation lever (180°/130°)
• Output = Video processor (HD 1080p to bedside monitor)
• Narrow = Working channel (2.0-3.2mm diameter)
• Channels = Suction, biopsy, instrument ports
• Handle = Light guide, suction valve, working channel port

BAL - Normal Cell Differential:

• Big macrophages = 85-95% (phagocytic alveolar cells)
• Anti-inflammatory lymphocytes = 5-15%
• Limited neutrophils = <3% (elevation = infection/ARDS)

SIZE - ETT-Bronchoscope Matching:

• Scope should be
• Inside diameter of ETT
• Zero-point-six-six (≤66%)
• Equals safe clearance (≥2mm gap)

---

Definition & Epidemiology

Definition

Bronchoscopy is an endoscopic procedure that enables direct visualization of the tracheobronchial tree for diagnostic and therapeutic purposes. In the ICU setting, bronchoscopy is performed primarily using flexible video bronchoscopes for airway assessment, secretion clearance, bronchoalveolar lavage (BAL), difficult intubation, and procedural guidance.

Bronchoscopy Equipment encompasses the instruments, accessories, and infrastructure required for safe and effective bronchoscopic procedures:

Classification of Bronchoscopes

By Flexibility:

By Imaging Technology:

By Usage:

Epidemiology

International Data:

• 40-60% of ICU patients undergo at least one bronchoscopy during admission (PMID: 28414407)
• BAL diagnostic yield: 50-70% for identification of pathogen in suspected VAP (PMID: 24742068)
• Bronchoscopy-related mortality: <0.01% in ICU settings
• Major complications (bleeding, pneumothorax): 0.5-2% of procedures
• Transient hypoxemia: 20-40% of procedures (usually recovers rapidly)

Australian/NZ Data (ANZICS):

• >95% of Australian ICUs have flexible bronchoscopy capability
• Single-use bronchoscope adoption: Increasing, particularly in units with low procedure volume
• Mandatory bronchoscopy guidance for PDT in most Australian ICUs
• Indigenous health considerations: Higher rates of bronchiectasis and TB in Aboriginal and Torres Strait Islander populations may increase bronchoscopy requirements
• Remote/rural: RFDS and retrieval services carry portable bronchoscopy for difficult airway management

Procedure Frequency per 100 ICU Admissions:

• Diagnostic bronchoscopy/BAL: 10-20
• Therapeutic bronchoscopy (secretions/atelectasis): 5-10
• Difficult intubation guidance: 2-5
• PDT guidance: 5-15 (varies by unit practice)
• Massive hemoptysis (urgent): <1

High-Risk Populations:

• Aboriginal and Torres Strait Islander peoples: Higher rates of chronic lung disease, bronchiectasis; bronchoscopy valuable for diagnosis and therapeutic secretion clearance
• Maori populations: Elevated COPD and respiratory infection rates
• Immunocompromised: BAL essential for opportunistic infection diagnosis (PCP, CMV, aspergillosis)
• Post-transplant: Surveillance bronchoscopy for rejection, infection

---

Applied Basic Sciences

This section bridges First Part basic sciences with Second Part clinical practice

Physics of Bronchoscopy Imaging

Fiberoptic Principles

Traditional fiberoptic bronchoscopes use coherent fiber bundles for image transmission:

• Total internal reflection: Light travels within glass fibers by reflecting off the fiber-air interface when the angle of incidence exceeds the critical angle
• Fiber bundle composition: 10,000-30,000 individual fibers, each 8-12 micrometers diameter
• Coherent arrangement: Fibers maintain exact spatial relationship from distal tip to eyepiece
• Image resolution: Limited by fiber count (pixelation effect)
• Illumination fibers: Separate non-coherent bundle transmits light to tissue

Video Bronchoscope (Chip-on-Tip) Technology

Modern video bronchoscopes use electronic imaging:

• CMOS sensors: Complementary Metal-Oxide-Semiconductor chips at distal tip
• CCD sensors: Charge-Coupled Device (older technology, higher power consumption)
• Resolution: 400,000 - 2,000,000 pixels (HD quality)
• Advantages: Superior resolution, color accuracy, digital recording, image enhancement
• Disadvantages: Higher cost, electronic vulnerability, moisture sensitivity

Light Source Physics

Anatomy Relevant to Bronchoscopy

Tracheobronchial Tree Anatomy:

Trachea (15-20cm length, 2.0-2.5cm diameter)
├── Right Main Bronchus (shorter, wider, more vertical - 25° from midline)
│   ├── Right Upper Lobe Bronchus (most common foreign body location)
│   │   ├── Apical (B1)
│   │   ├── Posterior (B2)
│   │   └── Anterior (B3)
│   ├── Right Middle Lobe Bronchus
│   │   ├── Lateral (B4)
│   │   └── Medial (B5)
│   └── Right Lower Lobe Bronchus
│       ├── Superior (B6)
│       ├── Medial basal (B7)
│       ├── Anterior basal (B8)
│       ├── Lateral basal (B9)
│       └── Posterior basal (B10)
└── Left Main Bronchus (longer, narrower, more horizontal - 45° from midline)
    ├── Left Upper Lobe Bronchus
    │   ├── Upper Division
    │   │   ├── Apicoposterior (B1+2)
    │   │   └── Anterior (B3)
    │   └── Lingular Division
    │       ├── Superior lingular (B4)
    │       └── Inferior lingular (B5)
    └── Left Lower Lobe Bronchus
        ├── Superior (B6)
        ├── Anteromedial basal (B7+8)
        ├── Lateral basal (B9)
        └── Posterior basal (B10)

Bronchoscopic Landmarks:

• Carina: Bifurcation of trachea, normally sharp and mobile with respiration
• Tracheal rings: C-shaped cartilage anterolaterally, membranous portion posteriorly
• Vocal cords: First landmark during intubation, must visualize for ETT confirmation
• Subglottic region: Narrowest point in pediatric airway
• Right middle lobe orifice: Common site of collapse (acute angle, small diameter)

Physiology of Bronchoscopy in Mechanically Ventilated Patients

Airway Resistance Changes:

The bronchoscope occupies a portion of the ETT lumen, dramatically increasing airway resistance:

• Resistance equation: R = 8μL / πr^4 (Poiseuille's law)
• Effective ETT reduction: 8.0mm ETT with 5.0mm scope → effective lumen 3.0mm
• Resistance increase: 4-8 fold increase in inspiratory resistance
• Auto-PEEP generation: Reduced expiratory flow → air trapping → intrinsic PEEP

Example Calculation:

ETT ID 8.0mm, Bronchoscope OD 5.5 mm:

• Cross-sectional area ETT: π × 4² = 50.3 mm²
• Cross-sectional area scope: π × 2.75² = 23.8 mm²
• Remaining area: 50.3 - 23.8 = 26.5 mm² (53% reduction)
• Effective diameter: √(26.5/π) × 2 = 5.8mm equivalent

Ventilation Considerations During Bronchoscopy:

Gas Exchange Effects:

• Hypoxemia: Decreased ventilation, V/Q mismatch, suction removing oxygen
• Hypercapnia: Decreased minute ventilation, increased dead space
• Acidosis: Usually transient respiratory acidosis
• Recovery: Typically 5-15 minutes post-procedure

Pharmacology of Sedation for Bronchoscopy

Sedation Goals:

• Adequate anxiolysis and amnesia
• Suppression of cough reflex
• Maintenance of hemodynamic stability
• Rapid recovery post-procedure
• Avoidance of respiratory depression (if spontaneously breathing)

Commonly Used Agents:

Topical Anesthesia:

• Lidocaine 1-2%: Spray or nebulized for airway topicalization
• Maximum dose: 4-5 mg/kg (toxic threshold 5mg/kg)
• Application: Vocal cords, trachea, carina, bronchi
• Duration: 15-30 minutes
• Toxicity signs: Perioral numbness, tinnitus, seizures

Neuromuscular Blockade:

• Not routinely required but may facilitate procedure
• Prevents coughing and airway movement
• Rocuronium 0.6-1.2 mg/kg or cisatracurium 0.1-0.2 mg/kg
• Consider for PDT, difficult airways, prolonged procedures

---

Bronchoscope Types and Specifications

Flexible Video Bronchoscopes

Standard Adult Bronchoscope:

Slim/Diagnostic Bronchoscope:

Therapeutic/Large Channel Bronchoscope:

Rigid Bronchoscopes

Indications in ICU:

• Massive hemoptysis uncontrolled by flexible bronchoscopy
• Central airway obstruction (tumor, foreign body)
• Therapeutic interventions (stent placement, laser, cryotherapy)
• Requires general anesthesia and OR setting (rarely bedside)

Specifications:

Advantages:

• Large channel for massive suction (blood, clots)
• Secures airway while providing therapy
• Allows passage of large instruments
• Simultaneous ventilation possible

Disadvantages:

• Requires OR, general anesthesia
• Cannot reach peripheral airways
• Risk of dental trauma, tracheal injury
• Specialist equipment and training required

Single-Use (Disposable) Bronchoscopes

Evidence Base:

The shift toward single-use bronchoscopes is supported by evidence of persistent contamination in reprocessed reusable scopes:

• Contamination rates: 14-28% of "patient-ready" reusable bronchoscopes show microbial contamination (PMID: 30041876)
• Biofilm formation: Complex channel design promotes biofilm resistant to HLD
• Outbreak reports: Multiple nosocomial transmission events linked to contaminated bronchoscopes (PMID: 28231131)
• Single-use elimination: Completely removes cross-contamination risk (PMID: 32066163)

Common Single-Use Systems:

Advantages of Single-Use:

• Infection control: Zero cross-contamination risk
• Availability: Always ready, no reprocessing delay
• Quality assurance: Every scope is new (no degradation)
• Cost transparency: Predictable per-procedure cost
• Storage: Shelf-stable, minimal space requirements

Disadvantages:

• Cost per procedure: Higher than amortized reusable cost
• Environmental impact: Plastic waste generation
• Image quality: Some earlier models inferior (now comparable)
• Working channel: Generally 2.0-2.2mm (not therapeutic size)

Cost-Effectiveness Indications:

Single-use bronchoscopes are cost-effective when:

• Procedure volume <150-200 per year (<3/week)
• High MDRO prevalence requiring enhanced infection control
• Emergency availability required 24/7
• Reprocessing infrastructure costs high
• Risk of litigation for cross-contamination significant

---

Equipment Setup and Light Sources

Complete Bronchoscopy Setup

Essential Equipment Checklist:

Light Source Technology

Xenon Light Sources:

Advantages:

• Excellent color reproduction for tissue assessment
• High intensity for deep penetration
• Gold standard for therapeutic procedures

Disadvantages:

• Bulky tower-based unit
• Heat generation (fire risk with high FiO2)
• Limited portability
• Lamp replacement costs

LED Light Sources:

Advantages:

• Instant on/off capability
• Minimal heat generation (safer with high FiO2)
• Portable and battery-powered options
• Long LED lifespan
• Lower power consumption
• Integrated into single-use systems

Disadvantages:

• Color reproduction may be slightly inferior
• Lower maximum intensity than xenon
• May not be sufficient for therapeutic procedures

Video Processor Specifications

Modern HD Processor Features:

Narrow Band Imaging (NBI):

Some advanced systems include NBI technology:

• Uses specific blue (415nm) and green (540nm) wavelengths
• Enhances visualization of mucosal vascular patterns
• May improve detection of dysplasia and malignancy
• Limited ICU application (primarily diagnostic endoscopy)

---

Suction and Biopsy Channels

Working Channel Design

The working channel is a critical component enabling suction, lavage, and instrument passage:

Channel Specifications by Scope Type:

Suction Considerations

Suction Physics:

• Wall suction pressure: 150-300 mmHg (typical ICU wall outlets)
• Flow rate: Dependent on channel diameter and secretion viscosity
• Bernoulli effect: Rapid suction can cause mucosal trauma
• Intermittent technique: Brief suction intervals prevent mucosal injury

Optimizing Suction Efficiency:

1. Use largest channel diameter compatible with ETT
2. Ensure adequate wall suction pressure (>150 mmHg)
3. Keep suction tubing short and wide-bore
4. Use intermittent suction (avoid continuous)
5. Irrigate with saline to loosen thick secretions
6. Consider mucolytics (N-acetylcysteine) for inspissated mucus

Instruments for Working Channel

Sampling Instruments:

Therapeutic Instruments:

---

ICU Indications

Diagnostic Indications

1. Ventilator-Associated Pneumonia (VAP):

BAL is the primary diagnostic modality for VAP in many centers:

Evidence (PMID: 24742068): BAL provides higher specificity than ETA, enabling antibiotic de-escalation in 30-50% of cases.

Technique for VAP Diagnosis:

1. Wedge bronchoscope in affected lobe (based on CXR/CT)
2. Instill 120-180mL sterile saline in 60mL aliquots
3. Aspirate with gentle suction
4. Send for quantitative culture, Gram stain, cell count
5. Consider empiric antibiotics while awaiting results

2. Diffuse Alveolar Hemorrhage (DAH):

Sequential BAL is diagnostic when aliquots become progressively more bloody:

Common causes in ICU:

• Vasculitis (GPA, microscopic polyangiitis)
• Coagulopathy (anticoagulation, DIC)
• Thrombocytopenia
• Pulmonary-renal syndromes

3. Immunocompromised Patients:

BAL is gold standard for opportunistic infections:

4. ARDS Mimics:

BAL helps identify treatable conditions masquerading as ARDS:

5. Airway Assessment:

Therapeutic Indications

1. Secretion Clearance and Atelectasis:

Bronchoscopy for mucus plugging when conservative measures fail:

Technique:

1. Identify affected bronchi visually
2. Instill 20-30mL warm saline
3. Suction with intermittent technique
4. Consider N-acetylcysteine instillation for thick mucus
5. Repeat until airway cleared
6. Post-procedure CXR to confirm re-expansion

Evidence: Limited RCT evidence; observational studies suggest improvement in atelectasis resolution (PMID: 28414407)

2. Massive Hemoptysis Management:

Hemoptysis >200-600mL/24h or causing hemodynamic/respiratory compromise:

If flexible bronchoscopy fails, rigid bronchoscopy allows:

• Large-volume suction of blood/clots
• Secure airway during intervention
• Electrocautery, laser, or cryotherapy

3. Foreign Body Removal:

Less common in adults but important indication:

• Aspirated teeth, dental fragments post-trauma
• Food bolus (impaired swallow reflex)
• Tracheostomy-related fragments

Instruments: Grasping forceps, basket retrieval, cryoadhesion

Procedural Guidance

1. Difficult Intubation:

Flexible bronchoscopic intubation is gold standard for predicted difficult airway:

AFOI Technique:

1. Topicalize airway (nebulized lidocaine, spray-as-you-go)
2. Sedate with dexmedetomidine (maintains airway reflexes)
3. Advance scope through nose or mouth
4. Visualize glottis and pass scope into trachea
5. Railroad ETT over bronchoscope
6. Confirm position with carina visualization
7. Remove bronchoscope while holding ETT

2. Percutaneous Dilational Tracheostomy (PDT):

Bronchoscopic guidance during PDT is standard practice in most Australian ICUs:

Role of Bronchoscopy:

• Confirms midline needle entry through tracheal rings
• Visualizes guidewire position
• Detects posterior tracheal wall injury
• Identifies paratracheal insertion
• Confirms final tracheostomy position

Evidence (PMID: 26848035, 33819239):

• Systematic reviews show bronchoscopy and ultrasound guidance have similar safety profiles
• Bronchoscopy provides direct visualization of needle entry
• Ultrasound identifies vessels but not internal tracheal anatomy
• Many centers use combined approach (ultrasound for vessels, bronchoscopy for tracheal guidance)

Technique:

1. Withdraw ETT to just below vocal cords (cuff visible bronchoscopically)
2. Advance bronchoscope past ETT tip to mid-trachea
3. Surgeon identifies tracheal rings with needle
4. Confirm midline needle entry on bronchoscopy
5. Visualize guidewire passage (avoid posterior wall)
6. Monitor dilation and tracheostomy insertion
7. Confirm tracheostomy position and carina visibility

Complications Reduced by Bronchoscopy:

• Paratracheal false passage
• Posterior tracheal wall injury
• Tracheal ring fracture (excessive force)
• Malpositioning (too high or low)

3. ETT Position Confirmation:

---

Procedural Considerations

Pre-Procedure Assessment

Patient Selection and Risk Assessment:

Contraindications:

Sedation and Analgesia

Goals:

1. Adequate depth to prevent coughing and movement
2. Maintain hemodynamic stability
3. Ensure rapid recovery post-procedure
4. Minimize respiratory depression

Recommended Approach for Intubated Patients:

For Awake Fiberoptic Intubation:

Ventilation During Bronchoscopy

Standard Approach for Intubated Patients:

1. Pre-oxygenate: FiO2 1.0 for 3-5 minutes
2. Use bronchoscopy adapter: Swivel connector with diaphragm port
3. Increase set PEEP: Compensate for leak around bronchoscope
4. Tolerate higher peak pressures: Due to increased resistance
5. Extend expiratory time: Prevent auto-PEEP
6. Monitor continuously: SpO2, EtCO2, hemodynamics
7. Pause procedure if: SpO2 <90%, significant arrhythmia, hemodynamic instability

ETT Size Considerations:

High-Risk Patients (ARDS, High PEEP Requirements):

• Consider brief disconnection with rapid reconnection (if essential)
• Use closed-suction bronchoscopy adapter
• Maintain PEEP throughout procedure
• Accept transient hypercapnia
• Shorten procedure duration to minimum necessary
• Consider postponing non-urgent bronchoscopy

Non-Intubated Patients

Bronchoscopy through Nasal or Oral Route:

Contraindications for Non-Intubated Bronchoscopy:

• Unable to maintain SpO2 >90% on supplemental O2
• High aspiration risk
• Massive hemoptysis
• Severe respiratory distress
• Uncooperative patient

---

Complications and Contraindications

Complications

Common Complications (>5% incidence):

Infrequent Complications (1-5% incidence):

Rare but Serious Complications (<1% incidence):

Contraindications

Absolute Contraindications:

Relative Contraindications:

Complication Management

Hypoxemia During Procedure:

1. Withdraw bronchoscope
2. Increase FiO2 to 1.0
3. Restore PEEP
4. Manual bag ventilation if needed
5. Wait for recovery (SpO2 >95%)
6. Consider aborting or modifying procedure

Bleeding:

Pneumothorax:

• Suspect if post-procedure desaturation
• Confirm with CXR or ultrasound
• Small (<2cm) and stable: observe with serial imaging
• Large or symptomatic: chest tube insertion

---

BAL Technique and Interpretation

Bronchoalveolar Lavage Technique

Preparation:

1. Review indication and target lobe (based on imaging)
2. Confirm equipment: sterile saline (warm to body temperature), 60mL syringes, specimen traps
3. Optimize patient: pre-oxygenate, adequate sedation
4. Plan sample handling: microbiology, cytology, cell count

Procedure:

Target Lobes:

Optimizing Recovery:

• Use gentle suction (avoid wall suction at max)
• Keep scope wedged to prevent leak
• Warm saline improves recovery
• Multiple small aliquots better than fewer large volumes
• Position patient with target lobe dependent if possible

Normal BAL Cellular Differential

Abnormal BAL Patterns

Neutrophilia (>10%):

Quantitative Culture Thresholds (PMID: 22444053):

Lymphocytosis (>15%):

Eosinophilia (>25%):

Hemorrhagic BAL:

Causes of DAH in ICU:

Special Stains and Tests:

---

Infection Control and Reprocessing

Contamination Risks with Reusable Bronchoscopes

Evidence of Contamination:

Multiple studies have demonstrated persistent contamination despite standard reprocessing:

• 14-28% of "patient-ready" bronchoscopes contaminated (PMID: 30041876)
• 60% have visible debris or fluid in channels
• 95% have positive microbial cultures or elevated ATP/protein
• Outbreak reports: MDR organisms transmitted via contaminated scopes (PMID: 28231131)

Risk Factors for Contamination:

Reprocessing Requirements

Multi-Society Guidelines (PMID: 21247651):

HLD Agents:

Shift Toward Sterilization

FDA and AORN Recommendations (PMID: 33818611):

Given ongoing outbreaks and contamination evidence, guidelines increasingly recommend:

1. Sterilization (when possible) over HLD for complex endoscopes
2. Single-use bronchoscopes for high-risk situations
3. Enhanced surveillance: Culturing of reprocessed scopes
4. Borescope inspection: Periodic internal channel visualization

Sterilization Methods:

Single-Use Bronchoscope Indications

Recommended Indications for Single-Use:

Cost-Benefit Analysis:

Single-use scope cost: ~$200-350 per unit

Cost of HAI: $10,000-50,000 per episode (including prolonged ICU stay, antibiotics, investigations)

Break-even: If single-use prevents even 1 infection per 50-100 uses, cost-effective

Australian/NZ Standards

Infection Control Requirements:

Indigenous Health Considerations:

• Higher rates of TB, bronchiectasis in Aboriginal and Torres Strait Islander populations
• Ensure single-use or rigorous reprocessing when cross-infection risk is high
• Consider infection control implications in remote/rural settings
• Adequate interpreter services for consent to invasive procedures

---

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Peoples

Increased Bronchoscopy Requirements:

Cultural Considerations:

Remote/Rural Considerations:

• Bronchoscopy may not be available locally
• Retrieval services (RFDS) may carry portable bronchoscopy
• Transfer to regional/metropolitan center may be required
• Telemedicine guidance for basic airway procedures
• Single-use bronchoscopes ideal for remote settings (no reprocessing)

Maori Health (New Zealand)

Te Tiriti o Waitangi Principles:

Cultural Practices:

Health Disparities:

• Higher rates of respiratory infections
• Increased bronchiectasis prevalence
• Later presentations to healthcare
• Poorer access to specialized services
• Efforts to improve equity in bronchoscopy access important

---

SAQ Practice Questions

SAQ 1: Bronchoscopy Equipment and Indications

Question:

A 58-year-old man with acute myeloid leukaemia (AML) on induction chemotherapy is intubated in your ICU with severe hypoxemic respiratory failure. He has new bilateral pulmonary infiltrates on chest CT. His FiO2 requirement is 0.7 with PEEP 12 cmH2O, SpO2 94%. Platelet count is 45 × 10⁹/L. You are considering diagnostic bronchoscopy.

a) Outline the types of bronchoscopes available for ICU use and their key specifications. (6 marks)

b) Describe your approach to performing bronchoalveolar lavage (BAL) in this patient, including preparation, technique, and safety considerations. (8 marks)

c) How would you interpret the BAL results? Include normal values and patterns suggesting specific diagnoses. (6 marks)

Model Answer:

a) Types of bronchoscopes and specifications (6 marks)

Flexible Video Bronchoscopes (most common ICU use):

• Standard adult: OD 5.0-5.5mm, working channel 2.0-2.2mm, 600mm length
• Slim/diagnostic: OD 3.5-4.2mm, channel 1.2-2.0mm (for small ETTs, paediatrics)
• Therapeutic/large channel: OD 6.0-6.4mm, channel 2.8-3.2mm (large suction, interventions)

Video technology: Chip-on-tip CMOS sensors, HD resolution (1920×1080), superior to older fiberoptic

Rigid Bronchoscopes:

• Stainless steel, OD 7-14mm
• Indications: Massive hemoptysis, central airway obstruction
• Rarely used at bedside (requires OR, general anesthesia)

Single-Use (Disposable) Bronchoscopes:

• OD typically 5.0mm, channel 2.2mm
• Eliminates cross-contamination risk (PMID: 32066163)
• Immediately available without reprocessing delay
• Particularly indicated in immunocompromised patients (like this case)

Light Sources:

• Xenon (300W, tower-based) - high intensity
• LED (portable, integrated) - lower heat, instant on
• Color temperature 5000-6500K for tissue visualization

b) Approach to BAL in this patient (8 marks)

Pre-procedure optimization:

• Platelet transfusion to >50 × 10⁹/L (for biopsy) - BAL alone lower threshold acceptable (>20 × 10⁹/L)
• Pre-oxygenate with FiO2 1.0 for 5 minutes
• Ensure adequate sedation (propofol + fentanyl infusion)
• Consider neuromuscular blockade to prevent coughing
• Use single-use bronchoscope (immunocompromised, infection risk)
• Select scope ≤5.0mm OD (to ensure adequate ventilation through ETT)

Equipment preparation:

• Bronchoscopy swivel adapter to maintain ventilation
• Sterile saline warmed to body temperature
• Specimen traps for microbiology/cytology
• Suction apparatus ready

Procedure technique:

• Increase set PEEP to compensate for leak around scope
• Advance scope to affected lobe (based on CT findings)
• Wedge in subsegmental bronchus (4-5mm diameter)
• Instill 120-180mL sterile saline in 60mL aliquots (3 × 60mL)
• Aspirate with gentle suction after each aliquot
• Keep first aliquot separate (bronchial sample)
• Target >40% return of instilled volume
• Monitor SpO2 throughout - withdraw if SpO2 <90%

Safety considerations:

• This patient has severe hypoxemia (P/F ~134) - HIGH RISK
• Minimize procedure duration
• Maintain PEEP throughout procedure
• Have rescue equipment ready (bag-mask, emergency drugs)
• Abort if hemodynamic instability or sustained desaturation
• Post-procedure: return to previous ventilator settings, monitor for complications

Samples to send:

• Quantitative bacterial culture (>10⁴ CFU/mL threshold)
• Fungal culture and galactomannan
• PCP immunofluorescence and PCR
• CMV PCR and cytology
• AFB smear and culture
• Cell count and differential
• Cytology for malignancy

c) BAL interpretation (6 marks)

Normal BAL differential:

• Alveolar macrophages: 85-95%
• Lymphocytes: 5-15%
• Neutrophils: <3%
• Eosinophils: <1%
• Epithelial cells: <5%

Patterns suggesting specific diagnoses in this immunocompromised patient:

Additional interpretation:

• Recovery <40% may indicate technical failure (repeat may be needed)

• 5% squamous cells suggests upper airway contamination

• Combine BAL with clinical/radiological findings for diagnosis
• Consider empiric treatment while awaiting results given severity

---

SAQ 2: Bronchoscopy Complications and Infection Control

Question:

Your ICU performs approximately 150 bronchoscopies per year using reusable flexible video bronchoscopes. The infection control team has identified two cases of multidrug-resistant Pseudomonas aeruginosa pneumonia in patients who underwent bronchoscopy within the preceding 2 weeks.

a) Describe the potential mechanisms of bronchoscope-related cross-contamination. (5 marks)

b) Outline the essential steps in bronchoscope reprocessing and common failure points. (8 marks)

c) Discuss the evidence for single-use bronchoscopes and when you would recommend their use. (7 marks)

Model Answer:

a) Mechanisms of bronchoscope-related cross-contamination (5 marks)

Structural factors:

• Complex internal channels difficult to clean (narrow lumens, bifurcations)
• Working channel diameter 2.0mm provides surfaces for biofilm adherence
• Elevator mechanisms and biopsy channel ports harbor organisms
• Internal scratches and defects create protected niches

Biofilm formation:

• Organisms adhere to channel walls within minutes
• Biofilm matrix (extracellular polysaccharide) protects from disinfectants
• Pseudomonas aeruginosa particularly prone to biofilm formation
• Mature biofilm resistant to high-level disinfection

Reprocessing failures:

• Inadequate pre-cleaning allows organic matter to dry and protect organisms
• Insufficient brushing leaves debris in channels
• Incomplete immersion or inadequate contact time with disinfectant
• Failure to flush all channels
• Inadequate drying promotes bacterial regrowth
• Contaminated rinse water (Pseudomonas common in water systems)

Storage issues:

• Wet storage allows bacterial growth
• Horizontal storage traps moisture
• Non-ventilated cabinets promote humidity
• Prolonged storage before use

Human factors:

• Protocol deviations under time pressure
• Inadequate training of reprocessing staff
• Lack of supervision and quality monitoring
• Equipment maintenance neglected

b) Essential reprocessing steps and failure points (8 marks)

Quality monitoring:

• Regular microbiological surveillance of processed scopes
• ATP testing of channel effluent
• Borescope inspection of internal channels
• Documentation of all reprocessing steps
• Traceability (link patient-procedure-scope)

c) Evidence for single-use bronchoscopes (7 marks)

Key Evidence:

Mouritsen 2020 systematic review (PMID: 32066163):

• Compared single-use vs reusable bronchoscopes
• Single-use eliminates cross-contamination risk
• Clinical performance comparable for most ICU procedures
• No significant difference in procedural success rates

Ofstead 2018 (PMID: 30041876):

• Found 60% of "ready-to-use" reusable bronchoscopes had visible debris/fluid
• 95% had positive microbial cultures or elevated ATP/protein
• Demonstrated failure of HLD to achieve sterility

Contamination rates in literature:

• 14-28% of reprocessed bronchoscopes contaminated
• Multiple outbreak reports (PMID: 28231131) - CRE, MDR Pseudomonas transmitted

Single-use advantages:

• Zero cross-contamination risk (sterile-packed, single patient)
• Immediate availability (no reprocessing delay)
• Consistent quality (no degradation over time)
• No reprocessing infrastructure required
• Eliminates human error in reprocessing
• Cost transparency (predictable per-procedure cost)

Single-use disadvantages:

• Higher per-procedure cost (~$200-350 per scope)
• Environmental impact (plastic waste)
• Working channel generally 2.0-2.2mm only (not therapeutic)
• Some early models had inferior image quality (now comparable)

Recommendations for single-use in your ICU:

Immediate action (outbreak situation):

• Switch to single-use bronchoscopes immediately
• Quarantine and investigate reusable scopes
• Enhanced surveillance for additional cases
• Review reprocessing compliance

Ongoing indications for single-use:

• Known MDRO colonization/infection in patient
• High-risk immunocompromised patients
• Emergency/after-hours procedures
• When reprocessing quality cannot be assured
• Pandemic settings

Cost-effectiveness analysis:

• Your volume: 150 procedures/year (~3/week)
• If single-use prevents 1 HAI per year, likely cost-effective
• HAI cost: $10,000-50,000 per episode
• Single-use cost: $30,000-52,500/year at 150 procedures
• Consider hybrid model: single-use for high-risk, reusable for others

---

Viva Scenarios

Viva 1: Bronchoscopy Equipment and BAL

Scenario:

You are the ICU consultant on call. A 45-year-old woman with recently diagnosed systemic lupus erythematosus (SLE) is intubated with acute hypoxemic respiratory failure. CT chest shows bilateral ground-glass infiltrates. The medical team is requesting diagnostic bronchoscopy.

Opening Question: "Tell me about the bronchoscopes available in your ICU and which one you would choose for this patient."

---

Examiner: "Tell me about the bronchoscopes available in your ICU and which one you would choose for this patient."

Candidate: "In our ICU we have flexible video bronchoscopes and single-use disposable bronchoscopes available.

For this patient - an immunocompromised woman with SLE and bilateral infiltrates - I would choose a single-use bronchoscope. The main reasons are:

First, she is immunocompromised, so the risk of healthcare-associated infection from any contaminated equipment would be particularly concerning. Single-use scopes eliminate any risk of cross-contamination.

Second, single-use scopes are immediately available without waiting for reprocessing.

The standard single-use scope has an outer diameter of 5.0-5.5mm and a 2.2mm working channel, which is adequate for BAL. I would confirm her ETT size is at least 7.5mm to allow adequate ventilation around the bronchoscope."

---

Examiner: "What are the key specifications I should know about bronchoscope sizing?"

Candidate: "The critical specifications are:

Outer diameter (OD): This determines which ETT the scope can pass through. The general rule is the scope OD should be no more than 66% of the ETT internal diameter to prevent dangerous auto-PEEP. For example:

• ETT 7.5mm → maximum scope OD 5.0mm
• ETT 8.0mm → maximum scope OD 5.3mm
• ETT 8.5mm → maximum scope OD 5.6mm

Standard adult scopes are 5.0-5.5mm OD. Slim scopes are 3.5-4.2mm for smaller ETTs or paediatric use.

Working channel diameter: Standard is 2.0-2.2mm, adequate for suction, BAL, and small biopsy forceps. Therapeutic scopes have 2.8-3.2mm channels for larger instruments.

Bending angle: Typically 180° up and 130° down for full airway navigation.

Working length: 600mm standard adult length.

Modern video bronchoscopes use chip-on-tip CMOS technology providing HD resolution, which has replaced older fiberoptic technology in most ICUs."

---

Examiner: "How would you perform the BAL procedure safely in this hypoxemic patient?"

Candidate: "This is a high-risk procedure given her hypoxemia. My approach would be:

Pre-procedure:

• Pre-oxygenate with FiO2 1.0 for 3-5 minutes
• Confirm adequate sedation - I would use propofol infusion with fentanyl bolus, and consider neuromuscular blockade to prevent coughing
• Check platelet count and coagulation - for BAL alone, platelets >20,000 acceptable; if biopsy planned, aim for >50,000
• Prepare equipment: bronchoscopy swivel adapter, warmed sterile saline, specimen traps
• Increase set PEEP to compensate for the leak that will occur around the bronchoscope

During procedure:

• Use the bronchoscopy adapter to maintain ventilation
• Advance to the most affected lobe based on CT findings - for bilateral disease, I would target the right middle lobe or lingula as they are most accessible
• Wedge the scope in a subsegmental bronchus
• Instill 60mL aliquots of warmed saline, typically 3 aliquots (180mL total)
• Aspirate gently after each aliquot
• Keep the first aliquot separate as it represents the bronchial sample
• Monitor SpO2 continuously - if it falls below 90% I would withdraw and allow recovery

Abort criteria:

• Sustained SpO2 <90%
• Hemodynamic instability
• Significant bleeding
• Arrhythmias"

---

Examiner: "The BAL returns 80mL of slightly blood-tinged fluid. The laboratory calls to report the cell differential shows 65% neutrophils, 20% lymphocytes, 10% macrophages, and 5% eosinophils. How do you interpret this?"

Candidate: "This is an abnormal BAL with significant neutrophilia (65%, normal <3%) and moderate lymphocytosis (20%, upper limit of normal 15%), with mild eosinophilia (5%, normal <1%).

In this SLE patient with acute respiratory failure, I would consider several diagnoses:

Neutrophilia interpretation:

• Could indicate infection (bacterial, viral, fungal)
• Could represent ARDS-type inflammatory response
• Lupus pneumonitis can cause neutrophilic inflammation

Lymphocytosis interpretation:

• May suggest viral infection (particularly in immunocompromised)
• Could indicate drug-induced lung injury
• May be seen in lupus pneumonitis

Eosinophilia interpretation:

• Drug-induced lung disease is a consideration
• Acute eosinophilic pneumonia if higher (>25%)
• Can be seen in some SLE flares

The blood-tinged nature is important - if this was progressively more bloody with each aliquot, I would be concerned about diffuse alveolar hemorrhage (DAH), which is a known complication of SLE vasculitis. I would ask for hemosiderin-laden macrophage count - if >20% of macrophages contain hemosiderin, this confirms chronic/subacute hemorrhage.

Additional tests I would request:

• Quantitative bacterial culture (threshold >10^4 CFU/mL for VAP)
• Fungal culture and galactomannan (immunocompromised)
• PCP staining and PCR
• CMV PCR
• Hemosiderin stain on cytology
• ANA on BAL (research use - may support lupus pneumonitis)

Given SLE, I would particularly consider lupus pneumonitis, DAH secondary to lupus vasculitis, and opportunistic infection. Treatment may include high-dose corticosteroids pending further results."

---

Examiner: "You mentioned single-use bronchoscopes. What is the evidence supporting their use?"

Candidate: "The evidence for single-use bronchoscopes has grown substantially over the past decade.

Key evidence:

The Mouritsen 2020 systematic review (PMID 32066163) compared single-use and reusable bronchoscopes and found:

• Single-use scopes completely eliminate cross-contamination risk
• Clinical performance is now comparable for standard ICU procedures
• No significant difference in procedural success rates

The concern about reusable scopes comes from contamination studies. The Ofstead 2018 systematic review (PMID 30041876) found:

• 60% of 'patient-ready' reusable bronchoscopes had visible debris or fluid in channels
• 95% had positive microbial cultures or elevated ATP/protein levels
• 14-28% contamination rate despite following reprocessing protocols

There have been multiple outbreak reports (PMID 28231131) documenting transmission of multidrug-resistant organisms via contaminated bronchoscopes, including carbapenem-resistant Enterobacteriaceae and MDR Pseudomonas.

The reason reprocessing fails is the complex internal channel design promotes biofilm formation, which is resistant to high-level disinfection. Human factors in reprocessing also contribute.

Indications I use for single-use bronchoscopes:

• Immunocompromised patients (like this SLE patient)
• Known MDRO colonization
• Emergency/after-hours when scope may not be reprocessed
• Outbreak situations
• When I cannot confirm reprocessing quality

The cost is higher per procedure (~$200-350), but this is offset by eliminating HAI risk, immediate availability, and no reprocessing infrastructure costs."

---

Viva 2: Bronchoscopy Complications and PDT

Scenario:

You are called to the ICU for a 72-year-old man with ARDS secondary to aspiration pneumonia. He has been ventilated for 10 days and the team is planning percutaneous dilational tracheostomy (PDT). The patient's SpO2 is 94% on FiO2 0.6 and PEEP 10.

Opening Question: "What is the role of bronchoscopy during percutaneous tracheostomy?"

---

Examiner: "What is the role of bronchoscopy during percutaneous tracheostomy?"

Candidate: "Bronchoscopy plays an important guidance and safety role during PDT. It is standard practice in most Australian ICUs.

The key roles of bronchoscopy during PDT are:

Confirmation of midline needle entry:

• The bronchoscope allows direct visualization of the needle entering between tracheal rings
• Ensures the needle is in the midline and not paratracheal
• Confirms entry through the anterior tracheal wall

Prevention of posterior tracheal wall injury:

• The scope can visualize if the needle or guidewire passes too posteriorly
• This is the most serious technical complication of PDT
• Posterior wall perforation can lead to tracheo-esophageal fistula

Optimal level selection:

• Confirms tracheostomy is placed between 2nd-4th tracheal rings
• Avoids too-high placement (subglottic stenosis risk)
• Avoids too-low placement (innominate artery erosion risk)

Final position confirmation:

• Visualizes the tracheostomy tube in the trachea
• Confirms the carina is visible at appropriate distance
• Excludes complications before completing procedure

ETT management:

• The scope allows the ETT to be withdrawn to just below the vocal cords
• The cuff can be visualized to ensure it's not punctured during the procedure"

---

Examiner: "What is the evidence comparing bronchoscopy guidance to ultrasound guidance for PDT?"

Candidate: "This is an evolving area with good systematic review evidence.

Gobatto 2016 (PMID 26848035) compared bronchoscopy to ultrasound guidance and found:

• Similar safety profiles for major complications
• Similar procedural success rates
• Bronchoscopy provides direct visualization of needle entry
• Ultrasound can identify blood vessels but not internal tracheal anatomy

Sanjuan 2021 (PMID 33819239) is the most recent comprehensive review:

• No significant difference between methods for procedural success
• No difference in major complications (bleeding, pneumothorax)
• Ultrasound may have slight advantage for minor complications in some subsets

Key differences:

• Bronchoscopy: sees inside the trachea (needle entry, posterior wall)
• Ultrasound: sees outside (vessels, tracheal rings, needle trajectory)

In practice, many centres use a combined approach:

• Ultrasound to identify vessels and tracheal midline before starting
• Bronchoscopy to guide the actual needle entry and dilation

For this patient with ARDS and relatively high PEEP, I would use bronchoscopy guidance but minimize the time the scope is in the airway to reduce the impact on ventilation."

---

Examiner: "This patient has ARDS. What are the ventilation considerations during bronchoscopy?"

Candidate: "Bronchoscopy in ARDS patients is challenging because of the pre-existing hypoxemia and high PEEP requirements. The key considerations are:

Impact of bronchoscope on ventilation:

• The scope occupies part of the ETT lumen, increasing airway resistance
• Using a 5mm scope through an 8mm ETT reduces effective lumen by >50%
• This causes increased peak pressures and potential auto-PEEP
• There may be a leak around the scope, reducing delivered PEEP

Pre-procedure optimization:

• Pre-oxygenate with FiO2 1.0 for 5 minutes
• Document baseline SpO2 and blood gas
• Ensure deep sedation, likely add neuromuscular blockade
• Consider recruiting maneuver before procedure

During procedure:

• Use a bronchoscopy swivel adapter to maintain circuit
• Increase set PEEP by 2-4 cmH2O to compensate for leak
• Accept higher peak pressures temporarily
• Extend expiratory time to minimize auto-PEEP
• Monitor SpO2 continuously

For PDT specifically:

• The scope only needs to be in the airway for brief periods
• Withdraw scope during dilation steps when not needed
• Once tracheostomy is placed, ventilate through that immediately

Abort criteria:

• SpO2 <88-90% sustained
• Hemodynamic instability
• Inability to maintain minute ventilation

For this patient with SpO2 94% on FiO2 0.6, I would be cautious but PDT should be possible. If oxygenation deteriorates significantly, I would pause the procedure and allow recovery."

---

Examiner: "What complications can occur during bronchoscopy in ICU patients?"

Candidate: "Complications range from common and transient to rare but serious.

Common complications (>5%):

• Transient hypoxemia (20-40%): Due to reduced ventilation, V/Q mismatch, and suction. Usually recovers quickly when scope removed.
• Transient hypercapnia (15-30%): Reduced minute ventilation. Accept permissive hypercapnia briefly.
• Coughing (10-30%): Stimulation of airway. Prevented by adequate sedation and topical anesthesia.
• Laryngospasm (5-10%): Particularly in non-intubated patients.

Infrequent complications (1-5%):

• Bleeding (1-5%): From biopsy sites or mucosal trauma. Usually minor, managed with cold saline or topical epinephrine.
• Bronchospasm (1-3%): Especially in asthma/COPD. Pre-treat with bronchodilators.
• Fever (1-5%): Transient cytokine release. Usually benign.
• Arrhythmias (1-3%): Usually related to hypoxemia.

Rare but serious complications (<1%):

• Pneumothorax (0.1-0.5%): Higher with transbronchial biopsy. Check CXR post-procedure.
• Airway fire: With laser and high FiO2. Reduce FiO2 before thermal procedures.
• Cardiac arrest (<0.01%): Usually in unstable patients who shouldn't have had bronchoscopy.
• Death (<0.01%): Extremely rare with appropriate patient selection.

PDT-specific complications via bronchoscopy:

• Accidental extubation during scope manipulation
• ETT cuff puncture
• Scope damage from surgeon's instruments

Prevention strategies:

• Appropriate patient selection (relative contraindications considered)
• Adequate pre-oxygenation
• Appropriate sedation and analgesia
• Correct bronchoscope size for ETT
• Continuous monitoring throughout
• Experienced operator
• Rescue equipment immediately available"

---

Examiner: "The patient's oxygen saturation drops to 85% during the procedure. What would you do?"

Candidate: "This is a significant complication requiring immediate action.

Immediate steps:

1. Stop the procedure - Communicate clearly with the team to pause

2. Withdraw the bronchoscope - Remove the scope from the airway to restore full ETT patency

3. Increase ventilation support:

   • FiO2 to 1.0 if not already
   • Consider manual bag ventilation for higher minute ventilation
   • Ensure PEEP is maintained

4. Check the basics:

   • ETT position (has it moved during the procedure?)
   • Circuit connections
   • Ventilator settings restored

5. Rule out immediate complications:

   • Bronchospasm - listen for wheeze, consider bronchodilator
   • Pneumothorax - especially if PDT or transbronchial biopsy performed
   • Mucus plugging - may need brief re-bronchoscopy to clear
   • Tension pneumothorax - decompress if suspected

6. Wait for recovery:

   • Most hypoxemia during bronchoscopy recovers within 5-15 minutes
   • Do not restart procedure until SpO2 >95% and stable

7. Reassess:

   • If hypoxemia recovers: decide whether to continue (shorten procedure, abandon, or modify)
   • If not recovering: investigate cause (ABG, CXR, ultrasound)

If this is during PDT:

• If the tracheostomy is partially complete, the team needs to make a rapid decision
• May need to complete urgently or remove equipment and manage the airway conventionally
• Clear communication with surgeon is critical

Documentation:

• Record the complication, management, and outcome
• Post-procedure CXR essential
• Consider ABG after recovery"

---