Currently there are no guidelines for the performance of flexible bronchoscopy (FFB)in patients with hypercapnia. This study describes an experience with FFB in 26 hypercapneic patients. All patients with Pco2 of >45 mmHg who required FFB between a 4-year period (July 1992-July 1996) at Eastern New Mexico Medical Center, Roswell, NM were prospectively evaluated in a community hospital located at an altitude of 3,500 feet. Arterial blood gases were obtained on patients being evaluated for FFB who had Spo2 < 90%. Patients with Pco2 >45 mmHg were selected for the study. Spirometry was performed if the patient was capable of performing the test. Obstructive lung disease was treated with beta-agonists, anticholinergics, ±methylxanthines, and corticosteroids before FFB. Oxygen was administered to achieve Spo2 of >90% at the start of FFB. Indications, duration, complications, and diagnostic yield of FFB were noted. Twenty-six patients with hypercapnia underwent FFB. The first 2 patients were intubated over the bronchoscope for FFB and did not encounter any problems. The subsequent 24 patients underwent FFB without intubation. Primary etiology of hypercapnia was chronic obstructive pulmonary disease (COPD) (n = 20), retained airway secretions (n = 4), pneumonia (n = 1), and lung atelectasis (n = 1). Sixteen patients had more than one cause for hypercapnia. The mean + SD values were: pH (7.37 ± 0.038), Pco2 (52 ± 6.46 mmHg), forced expiratory volume in 1 second (FEV1) (1 ± 0.3 L). Fraction of inspired oxygen (Fio2) requirements at the start of FFB varied from 28 to 100%. Indications for FFB were lung mass (n = 7), persistent atelectasis (n = 6), persistent infiltrate + hemoptysis (n = 5), retained pulmonary secretions (n = 3), acute atelectasis (n = 4), and peritracheal mass (n = 1). FFB was diagnostic of lung cancer (n = 9), upper airway obstruction (n = 1), and Mycobacterium avium intracellulare infection (n = 1). FFB excluded endobronchial obstruction (n = 6). FFB was therapeutic for removal of diffuse secretions (n = 3), mucous plugs(n = 3), and food (n = 2). FFB was nondiagnostic in 1 patient with a 2-cm left upper lobe lung nodule. Procedure duration was 16 ± 6 minutes. Desaturation (Spo2 < 90%) occurred in 7 of 26 (27%) patients. Post-FFB wheezing requiring bronchodilator therapy was noted in 16 of 26 (62%) patients. FFB was terminated before completion in 4 of 26 (15%) patients because of audible wheezing and desaturation. All 4 improved with bronchodilator; FFB was still helpful in diagnosis and therapy. Desaturation during FFB could not be predicted by FEV1, Pco2, or initial Fio2 requirements. 1) If selected appropriately, most patients with hypercapnia can undergo safe and efficacious FFB without intubation. 2) The bronchoscopist should be vigilant about audible wheezing and desaturation and be always ready to terminate the procedure and treat the patient. 3) FEV1, Pco2, and initial Fio2 requirements do not predict complications. 4) Post-FFB wheezing requiring bronchodilator therapy is common.
Journal of Bronchology7:226-232.
FFB, flexible bronchoscopy; Spo2, oxygen saturation measured by pulse oximetry; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; Fio2, percentage of oxygen in inspired air