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(Chest. 2001;119:670-671.)
© 2001 American College of Chest Physicians

Bronchoscopy via Continuous Positive Airway Pressure for Patients With Respiratory Failure

Gregory McGrath, MD; Mike Das-Gupta, MD and Geoffrey Clarke, MD

Royal Perth Hospital WA, Australia

Correspondence to: Gregory McGrath, MD, ICU Royal Perth Hospital, Wellington St, Perth, WA, Australia 6000; e-mail: gregory.mcgrath{at}rph.health.wa.gov.au

To the Editor:

Bronchoscopy during noninvasive ventilation of patients with poor gas exchange was described by Antonelli et al (September 1996),1 whose technique overcame the need for intubation and prevented hypoxia and hypercapnea. Antonelli et al1 used a Bard full face mask, attached via a T-seal adaptor and biological filter to a Servo 900C ventilator (Siemens-Elema; Solna, Sweden) to provide pressure support (PS) of 17 cm H2O over continuous positive airway pressure (CPAP) of 4 cm H2O. Delivery of some PS is desirable for the following reasons: to overcome the increased work of breathing caused by the increased airway resistance due to the bronchoscope reducing the effective airway diameter; to ease the resistive load in this ventilator and filter; and to compensate for the deadspace of the mask and extension tubing and compressible volume loss of the circuit.

CPAP (without PS) has recently been described2 as a method to avoid endotracheal intubation and mechanical ventilation in patients with severe nonhypercapnic oxygenation failure secondary to causes other than cardiogenic pulmonary edema.3 CPAP reduces the work of breathing by improving compliance subsequent to increasing functional residual capacity, which is especially valuable when sedation is required for invasive procedures in patients with high breathing work rates. CPAP also splints airways open, overcoming dynamic collapse, and optimizes the bronchoscopist’s view.

Our unit has performed flexible bronchoscopy in a patient with type 1 respiratory failure receiving CPAP via a Vital Signs face mask (Vital Signs; Totowa, NJ) with a flow of 80 L/min oxygen/air mix and the CPAP valve applied at the mask (Fig 1) , allowing appropriate sedation without hypoxia and without the possibility of CO2 rebreathing.



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  		Figure 1.. Face mask with CPAP valve applied at the mask.

 
This technique can be performed outside the ICU and avoids the health risks and cost associated with endotracheal intubation and mechanical ventilation on the ICU.4

Rothfleisch et al5 applied CPAP by a nasal pillow via the naris contralateral to the naris bronchoscopically intubated in a difficult-to-intubate obese patient. Although mouth leak could be overcome with a chin strap, it is improbable that the bronchoscope could tamponade the naris, and some air leak would be inevitable. A high flow through a single naris via an Adams circuit in a naive patient is unlikely to be well tolerated and would require increased sedation to allow diagnostic bronchoscopy.

References

  1. Antonelli, M, Conti, G, Riccioni, L, et al (1996) Noninvasive positive-pressure ventilation via face mask during bronchoscopy with BAL in high-risk hypoxemic patients. Chest 110,724-728[Abstract/Free Full Text]
  2. Kindgen-Milles, D, Buhl, R, Gabriel, A, et al (2000) Nasal continuous positive airway pressure: a method to avoid endotracheal reintubation in postoperative high-risk patients with severe nonhypercapnic oxygenation failure Chest 117,1106-1111[Abstract/Free Full Text]
  3. Bersten, AD, Holt, AW, Vedig, AE, et al (1991) Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med 325,1825-1830[Abstract]
  4. Sandur, S, Stoller, JK (1999) Pulmonary complications of mechanical ventilation. Clin Chest Med 20,223-247[Medline]
  5. Rothfleisch, R, Davis, LL, Kuebel, DA, et al (1994) Facilitation of fibreoptic nasotracheal intubation in a morbidly obese patient by simultaneous use of nasal CPAP. Chest 106,287-288[Abstract/Free Full Text]




This Article
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