Elsevier

Clinics in Chest Medicine

Volume 24, Issue 3, September 2003, Pages 511-516
Clinics in Chest Medicine

Management of hypoxemia during flexible bronchoscopy

https://doi.org/10.1016/S0272-5231(03)00050-9Get rights and content

Section snippets

Causes of hypoxemia during flexible bronchoscopy

The common causes of hypoxemia during bronchoscopy include upper airway obstruction (UAO), bronchoalveolar lavage, or pneumothorax secondary to transbronchial lung biopsy or an interventional bronchoscopic procedure, hypoventilation, oversedation, inadequate sedation, inadequate oxygen supplementation, bleeding, and laryngospasm.

Mechanisms of hypoxemia during flexible bronchoscopy

These include UAO, ventilation-perfusion imbalance, and hypoventilation [6], [7], [8]. UAO has been shown to be the dominant cause of hypoxemia during FB and this is successfully managed with nasopharyngeal tube insertion (Fig. 1) [6]. In our experience, acute hypoxemia secondary to UAO, despite supplemental oxygenation, in patients undergoing FB under local anesthesia and sedation was successfully treated in 88.2% of procedures with insertion of a nasopharyngeal tube in lung transplant

Management of hypoxemia during flexible bronchoscopy

A survey of bronchoscopy practices in North America found that 84.2% of respondents routinely use oximetry and 88.9% routinely administered supplemental oxygen [12]. A recent survey in United Kingdom, however, reported that only 48% of bronchoscopy units had a policy of giving oxygen to all patients [13]. Jones et al report that supplemental oxygen is not mandatory when moderate doses of benzodiazepines are used, provided that the patient is suitably monitored [14]. They argue that the use of

The St. Vincent's stepwise approach for the management of hypoxemia during flexible bronchoscopy

We have developed the following stepwise approach for the management of hypoxemia during FB:

  • 1.

    Bronchoscopist's hypnosis is a real phenomenon! Another appropriately trained nurse/colleague should continuously monitor the vital parameters of the patient during the entire procedure.

  • 2.

    SaO2, electrocardiogram, and blood pressure are monitored throughout the procedure.

  • 3.

    All patients receive supplemental oxygen at 4 L/minute via nasal prongs for FB via the oral route.

  • 4.

    Snoring in association with oxygen

Bronchoscopy in the hypoxemic patient

The American Thoracic Society recommends avoiding FB and BAL in patients with hypoxemia that cannot be corrected to at least a partial pressure of arterial oxygen (PaO2) of 75 mm Hg or to a SaO2>90% with supplemental oxygen [17]. In high-risk patients with severe hypoxemia in whom FB is believed to have an acceptable risk-benefit ratio, the option that is commonly followed is to intubate the patient and to apply mechanical ventilation to ensure adequate gas exchange during FB. If this cannot be

Myocardial ischemia or infarction

Bronchoscopy should not be performed during acute ischemia [26]. Hypoxemia during bronchoscopy has been linked to an increased risk of arrhythmia. Bronchoscopy can produce ischemic changes, especially in those over 60 years of age [27]. The occurrence of arrhythmia during FB and the increased risk of hypoxemia have led to extreme caution in carrying out the procedure soon after myocardial infarction. FB induces significant hemodynamic changes that are maximal during passage of the FB through

Summary

Under controlled conditions, FB is a safe procedure that has few significant adverse events. Significant hypoxemia may sometimes occur during FB despite the use of supplemental oxygen. UAO has been shown to be the dominant cause of hypoxemia during FB, and this is successfully managed with nasopharyngeal tube insertion. Other strategies that may need to be implemented include oxygen supplementation with intratracheal catheter, administration of sedation reversal medication, removal of the

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