ICU · Respiratory

Flexible bronchoscopy in the intensive care unit

Also known as Bronchoscopy in ICU · Flexible bronchoscopy · Diagnostic bronchoscopy · Therapeutic bronchoscopy · Bronchoalveolar lavage in ICU · BAL for VAP · Transbronchial biopsy · Mucus plug removal · Bronchial lavage · Rigid bronchoscopy

Flexible bronchoscopy in the ICU is one of the most frequently performed invasive procedures in critical care and has both DIAGNOSTIC and THERAPEUTIC roles. DIAGNOSTIC: (1) Bronchoalveolar lavage (BAL) for microbiology — quantitative culture for ventilator-associated pneumonia (significant greater than 10^4 CFU/mL), PCR for viruses (influenza, CMV, RSV, SARS-CoV-2), galactomannan and PCR for invasive aspergillosis, stains and culture for Pneumocystis jirovecii in the immunocompromised host, AFB for tuberculosis — and cytology (malignancy, alveolar proteinosis, eosinophilic pneumonia). (2) Biopsy — transbronchial lung biopsy for interstitial or disseminated disease, endobronchial biopsy for visible lesions. (3) Visualisation — foreign body, bleeding source in haemoptysis, airway patency, assessment post-extubation or for inhalational injury. THERAPEUTIC: (1) Mucus plug and retained secretion removal in atelectasis (especially post-operative, immobilised, or asthmatic patients). (2) Foreign body extraction. (3) Haemoptysis control — localise the source, ice-cold saline lavage, topical adrenaline, balloon tamponade, argon plasma coagulation. (4) Airway stenting, balloon dilation, and laser ablation for malignant or benign obstruction. The procedure is well tolerated in mechanically ventilated patients provided three rules are followed: maximise the inspired oxygen beforehand, use a swivel adapter with a bronchoscopy port, and anticipate the ventilatory impairment of the space-occupying scope (watch exhaled tidal volume and airway pressures). The dominant complication is HYPOXAEMIA (the scope partially obstructs the airway and the lavage fluid impairs gas exchange); other complications are bleeding (after biopsy), pneumothorax (after transbronchial biopsy — mandate a post-procedure CXR), laryngospasm/bronchospasm, arrhythmia, and transient bacteremia with post-procedure fever. Check coagulation before any biopsy - correct significant thrombocytopenia and coagulopathy.

Checked against its sources on 2 Oct 2026