Bronchoscopy in Critically Ill Patients

Pre-Procedural Considerations

The American Thoracic Society recommends bronchoscopy in critically ill patients should be performed with strict aerosol mitigation protocols, prioritizing cuffed endotracheal intubation with general anesthesia whenever possible, maintaining cuff pressures of 25-30 cmH2O, and clamping ventilation circuits immediately before scope insertion and withdrawal to minimize viral transmission and hemodynamic complications 1, 2
Risk-benefit assessment must be individualized based on local COVID-19 prevalence, ICU capacity, and clinical urgency, according to the Portuguese Pulmonology Society 3, 4

The European Respiratory Society recommends cuffed endotracheal tube is mandatory over supraglottic devices, with cuff pressure of 25-30 cmH2O, and FiO2 increased to 100% before and during procedure 1, 2, 7
General anesthesia with muscle relaxant is recommended to reduce aerosol production 1, 2

The American College of Chest Physicians recommends monitoring cuff pressure at every shift to prevent displacement, and recording tube depth prominently and verifying at each shift change 7, 8, 9
The Society of Critical Care Medicine recommends using HME filter close to patient instead of heated humidified circuit, monitoring for wetness and blockage 7, 8

The British Thoracic Society recommends avoiding nebulized medications before or after procedure, and using proper sedation to minimize cough reflex and increase cooperation 2, 3, 4, 5
The American Association for Bronchology and Interventional Pulmonology recommends using oral aspiration cannula available during procedure, and transparent protective box over patient's head may contain droplet particles 2, 3, 5

The World Health Organization recommends all bronchoscopy procedures in suspected or confirmed COVID-19 patients are aerosol-generating and require enhanced PPE with airborne precautions 1, 2, 6
The Centers for Disease Control and Prevention recommends 5% of COVID-19 patients develop respiratory failure requiring ventilatory support, and bacterial, viral, and fungal co-infections must not be neglected 1, 2, 5