Bronchoscopic Removal of Mucous Plugs

Pre-Procedure Preparation

The European Respiratory Society recommends flexible bronchoscopy as the primary method for removing mucous plugs causing atelectasis, with rigid bronchoscopy reserved for large, resistant plugs 1
Ensure continuous multi-modal physiological monitoring, including oxygen saturation, electrocardiogram, blood pressure, peak inspiratory pressure, and exhaled tidal volume throughout the procedure 2, 3
Assess the internal diameter of the endotracheal tube if the patient is intubated—the tube must be at least 1.5 mm larger than the external diameter of the bronchoscope to maintain adequate ventilation 2, 4
Administer 100% FiO2 and reduce positive end-expiratory pressure as much as tolerated before beginning 4
Provide adequate sedation with consideration of short-acting paralytic agents to prevent coughing during the procedure 4

Select a bronchoscope with a wide suction channel (preferably ≥2.8mm) for efficient mucus removal 5
Have sterile or bacteria-free saline (autoclaved or filtered through 0.2 μm filters) available for lavage 2, 3
Consider having acetylcysteine available for instillation to help break down thick secretions 5

Perform systematic inspection of the tracheobronchial tree to identify the location and extent of mucous plugging 1
Begin with direct suctioning through the bronchoscope's working channel to remove loose secretions and smaller plugs 1, 5
Use a wire basket retrieval device for larger or more cohesive plugs 5

If flexible bronchoscopy fails to remove large resistant plugs, rigid bronchoscopy becomes necessary 1
The barrel of the rigid bronchoscope itself can be used for mechanical removal of obstructing material 6

ICU patients should be considered at high risk for complications during bronchoscopy 2, 3
Patients with clotting abnormalities are at higher risk if biopsy is performed, though therapeutic suctioning alone carries lower risk 5
Neonates and infants require particular attention to sedation, analgesia, and airway monitoring 1
Maintain detailed records of which bronchoscope was used on each patient and clean and disinfect all reusable equipment according to institutional protocols 2, 3