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Role of Bronchoscopy in Prompt Discharge From the Intensive Care Unit

Verma, Akash MD, MRCP; Sim, Wen Yuan MRCP; Tai, Dessmon Y.H. FCCP; Goh, Soon Keng FRCP; Kor, Ai Ching FRCP; Phua, Chee Kiang MRCP; Ho, Benjamin FCCP; Lim, Albert Y.H. MD; Lew, Sennen J.W. MRCP; Xu, Huiying MRCP; Puah, Ser Hon MRCP; Abisheganaden, John FRCP

Journal of Bronchology & Interventional Pulmonology: April 2016 - Volume 23 - Issue 2 - p 123–130
doi: 10.1097/LBR.0000000000000271
Original Investigations
Free

Background: Intensive care unit (ICU) stays are 2.5 times more costly than other hospital stays, and 93.3% of ICU use is for respiratory disease with ventilator support. The aim of this study was to assess the role of bronchoscopy on discontinuation of mechanical ventilation, and prompt discharge from ICU in our institution.

Methods: Retrospective review of medical records of patients referred for bronchoscopic intervention for acute respiratory failure from malignant or benign central airway diseases requiring ICU admission.

Results: Twelve critically ill patients were studied. Median (range) age was 63 years (range, 35 to 85 y). Nine (75%) had endotracheal tube, and 3 (25%) had tracheostomy tube. Nine (75%) of 12 patients admitted to ICU could be transferred to general ward after median (range) interval of 2 days (range, 1 to 7 d) after the day of intervention. Median (range) prebronchoscopy and postbronchoscopy PaO2/FiO2 ratio was 102.8 (range, 99.2 to 328) and 180 (range, 129 to 380), respectively, with significant improvement postintervention (P=0.002). Radiologically, all 8 patients with lung atelectasis on presentation experienced complete reexpansion of the lung on the day after bronchoscopic intervention.

Conclusion: The majority of patients in our cohort (75%) of benign and malignant etiology could be promptly (within 2 d postbronchoscopy) transferred out from ICU to general ward after successful discontinuation of mechanical ventilation and extubation after bronchoscopic intervention. We advocate early recognition and bronchoscopic intervention in suitable patients.

Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Jalan Tan Tock Seng, Singapore

Disclosure: There is no conflict of interest or other disclosures.

Reprints: Akash Verma, MD, MRCP, Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433 (e-mail: akash_verma@ttsh.com.sg).

Received November 17, 2015

Accepted February 9, 2016

Intensive care imposes a substantial financial burden on the US health care system, with spending on critical illness exceeding $80 billion per year, approximately 3% of all health care spending and nearly 1% of the gross domestic product.1 The intensive care costs have been rising for decades, reaching 13.4% of hospital costs by 2005.2 From 2002 through 2009, intensive care unit (ICU) stays rose at 3 times the rate of general hospital stays without an increase in severity of illness.3 It has been reported that hospital stays that involve time in an ICU are 2.5 times more costly than other hospital stays, and the highest rate of ICU use (93.3%) is for respiratory disease with ventilator support.4 This necessitates constant reevaluation to identify and eliminate waste in the ICU management of respiratory diseases requiring ventilator support, and adoption of practices that optimize intensive care resources.

Liberation from mechanical ventilation (MV) and extubation of their patients is the ultimate desirable outcome for every ICU physician. However, this outcome in patients who require ICU stay for respiratory failure from neurological cause, pneumonia, acute respiratory distress syndrome, asthma and chronic obstructive pulmonary disease exacerbation, cardiac failure, or systemic sepsis with multiorgan dysfunction is not modifiable by bronchoscopic intervention. In such patients the therapy is targeted at the underlying disease.

However, patients who require intubation and MV for respiratory failure from central airway diseases, carry the potential to be liberated from MV and extubated immediately after bronchoscopic intervention.5 Such early discontinuation of MV and extubation carries both the clinical benefits such as reduced chance of ventilator associated pneumonia, need for sedation, and critical care neuropathy, and economic benefits with it. We did the current study to assess the role of bronchoscopy in prompt discontinuation of MV, extubation, and discharge from ICU in our institution.

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PATIENTS AND METHODS

We performed a retrospective analysis of 14 critically ill patients in the ICU or high dependency unit (HDU) for the management of “respiratory failure from central airway obstruction (CAO)” from August 2014 to September 2015. Our primary end point was: the proportion of patients in whom MV could be discontinued, the proportion of patients who could be extubated, and the proportion of patients who could be discharged from ICU to general wards after the bronchoscopic intervention. We collected data on oxygenation, radiographic changes, bronchoscopic appearance, type of intervention, complications of intervention, and duration of ICU or HDU stay. Approval from our institutional review board was obtained.

Flexible and rigid bronchoscopies were performed using standard techniques.6 Nd-YAG laser resection (Laser sonic Model 8000; Heraeus Surgical, Milpitas, CA) was performed using 15 to 30 W pulses and pulse duration of 0.5 to 1.0 seconds at the discretion of the performing bronchoscopist. Flexible bronchoscopy through the rigid tube was used as necessary to help clear the airways of secretions and blood. In cases with extrinsic compression from malignant obstruction, when indicated ultra-flex self-expanding metal stents were deployed using standard technique. Immediately after the intervention, patients who were receiving MV in the ICU before intervention were transferred to ICU. Patients who were not receiving MV before intervention were transferred back to HDU for closer monitoring.

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RESULTS

Twelve (5 females and 7 males) critically ill patients, who were intubated, and mechanically ventilated were referred for bronchoscopic therapy. Median (range) age was 63 years (range, 35 to 85 y). Nine (75%) had endotracheal tube (ETT) that was inserted on an emergent basis to manage acute onset of respiratory failure, 3 (25%) had tracheostomy tube 1 of which was inserted on an emergent basis. The type of the disease, bronchoscopic appearance, and modality of treatment are described in Table 1. Patients’ outcomes are described in Table 2.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

Eight of 12 (66.6%) patients could be liberated from MV. This included 7 of 9 (77.7%) with ETTs and 1 of 3 (33.3%) with tracheostomy tubes. Of the 12 patients admitted to ICU, 9 (75%) could be transferred to general ward after median (range) interval of 2 days (range, 1 to 7 d) after the day of intervention (Fig. 1).

FIGURE 1

FIGURE 1

Physiologically, median (range) prebronchoscopy and postbronchoscopy PaO2/FiO2 ratio was 102.8 (range, 99.2 to 328) and 180 (range, 129 to 380), respectively, with significant improvement postintervention (P=0.002) (Fig. 2). Radiologically, all 8 patients with lung atelectasis on presentation, experienced complete reexpansion of the lung on the day after the bronchoscopic intervention.

FIGURE 2

FIGURE 2

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DISCUSSION

Rising medical intensive care costs with respiratory disease and ventilator support being a large contributor, emphasizes the need to evaluate current ICU practices to identify procedures and practices that optimize use of these resources. Majority of patients in our cohort (75%) with central airway diseases could be promptly (within 2 d postbronchoscopy) transferred out from ICU to general ward after successful discontinuation of MV and extubation after bronchoscopic intervention. These finding support existing literature on the role of bronchoscopy in reduction of the ICU length of stay in this group of patients. Correspondingly, early referral, and bronchoscopic intervention in such patients can help conserve ICU resources.

Three patients were admitted to ICU for respiratory failure from malignant CAO. Numerous studies have demonstrated the role of bronchoscopic intervention in patients with central airways diseases. Colt and Harrell5 described how bronchoscopic intervention allowed the immediate discontinuation of MV in 10 of 19 patients (52.6%) with both benign and malignant disease. Lo et al7 reported successful extubation of 7 patients with major airway obstruction within 48 hours of rigid bronchoscopy with endoscopic techniques. Five patients had malignant airway obstruction in this cohort similar to 3 patients with malignant central airway obstruction in our cohort who were successfully stented. Murgu et al8 reported immediate extubation and discontinuation of MV after bronchoscopic intervention in 9 of 12 (75%) patients with central airway obstruction from inoperable/unresectable lung cancer. The outcomes of patients in our cohort with malignant central airway obstruction are consistent with these findings. Three ICU patients with malignant CAO and indwelling ETT before intervention were successfully extubated, and discharged to general ward shortly after the intervention (Fig. 3).

FIGURE 3

FIGURE 3

Five patients were admitted to ICU for bleeding and clot formation in the central airways causing respiratory failure (Fig. 4). Airway obstruction secondary to a blood clot has been reported to complicate several pulmonary diseases, including bronchiectasis, tuberculosis, bronchial carcinoma, and pulmonary arterial venous malformations.9–11 Such blood clots can also arise iatrogenically as a result of damage to the mucosa from the use of a suction catheter, bronchoalveolar lavage, transbronchial biopsy, and tracheostomy placement.12–14 Arney et al15 reported 3 cases of airway obstruction arising from blood clots, by a comprehensive literature review. They suggested observation in a patient with adequate gas exchange and stable hemodynamics. Intervention, if necessary, should involve flexible bronchoscopic evaluation with suctioning, saline lavage, and clot removal using flexible biopsy forceps, either en bloc or piecemeal. If this fails, rigid bronchoscopy can be attempted as it allows greater access for suctioning and forceps extraction, and also offers superior airway management in an event of significant bleeding. In 3 of the 5 such ICU patients, clots were successfully removed leading to reversal of respiratory failure, extubation, and transfer out from ICU. One patient passed away, and the other refused intervention beyond change of tracheostomy tube to that with longer vertical limb to by-pass the obstructing granulation tissue in the trachea.

FIGURE 4

FIGURE 4

One patient required ICU management for respiratory failure from aspiration pneumonia caused by bronchoesophageal stump fistula (Fig. 5). Malignant tracheoesophageal or bronchoesophageal fistulas can complicate advanced cancer of the esophagus, lung, or mediastinum.16 Patients may present with recurrent pneumonias and acute respiratory failure. The prognosis is poor if the fistula is left untreated. Burt et al17 reported that most patients succumb to respiratory failure within 6 weeks of diagnosis if the fistula is not sealed. Stenting is the management of choice, and this can involve esophageal, tracheobronchial, or parallel (both esophageal and tracheobronchial) stenting.16 Wang et al18 reported a case of failure of 2 esophageal stents to seal off the bronchoesophageal fistula, with dislodgement of 1 into the stomach in a patient with respiratory failure from esophageal cancer. Subsequent placement of the bronchial stent successfully stopped the air leak, allowing weaning from the ventilator in 1 week. One such patient with bronchoesophageal stump fistula in our cohort underwent parallel stenting of the “stomach” pulled up in the mediastinum (after resection of esophagus), and left main bronchus. Although lung infiltrates improved after stenting initially, patient eventually succumbed to aspiration pneumonia and passed away 2 months poststenting.

FIGURE 5

FIGURE 5

One patient required ICU management for misdiagnosis of excessive dynamic airway collapse (EDAC) as asthma. EDAC refers to the narrowing of the central airways during expiration as a result of excessive bulging of the posterior membrane into the airway lumen.19 It is more common in patients with obstructive airway diseases (asthma and chronic obstructive pulmonary disease), and obesity, and can present as difficulty in weaning from MV.20 In 1 patient in our cohort, bronchoscopy after failure of second extubation attempt confirmed the presence of EDAC (Fig. 6). She was hence extubated to continuous positive airway pressure the third time and did not require reintubation thereafter. Noninvasive positive pressure ventilation has been used to maintain airway patency in patients with EDAC.20 Lyaker et al21 described a morbidly obese patient who failed repeated attempts at extubation after elective hysterectomy. They suggested that while their patient may have tolerated a significant degree of airway collapse preoperatively, several factors such as reduced functional residual capacity, respiratory muscle dysfunction from a high abdominal incision, atelectasis, edema, secretions, and tracheal reactivity from intubation contributed to an increased work of breathing, shifting the balance toward respiratory failure in the postoperative period.21 Similarly, EDAC in our patient may have been asymptomatic before the stress caused by respiratory infection and prolonged intubation/ICU stay.

FIGURE 6

FIGURE 6

Two patients required ICU admission for foreign body (FB) aspiration. FB aspiration is rare in adults. The most common site is right lower lobe and the most common type of FB is peanut in children and food or garden pea in adults.22,23 Patients in our cohort aspirated a green pea and a peanut, respectively. FB was aspirated into the right upper lobe in both the patients and was retrieved successfully using the dormia basket in the one, and rat-tooth forceps in the other (Fig. 7).

FIGURE 7

FIGURE 7

Our study is limited by the lack of matched cohort for comparison of ICU length of stay and cost. Although it is conceivable that sparing of ICU resources as a result of prompt extubation and early discharge from ICU will translate into cost savings, our study did not involve true cost effectiveness analysis to support this. However, similarity between our findings and the existing literature strengthens the evidence in favor of the role of bronchoscopy in reduction of ICU length of stay with the potential saving effect on the ICU resources. Our study illustrates a “comprehensive” spectrum of central airway diseases that cause acute respiratory failure resulting in ICU admission and yet, can be reversed promptly by the bronchoscopic intervention.

In conclusion, early discontinuation of MV and extubation in ICU patients carry the potential benefits of reduced risk of ventilator-associated pneumonia, delirium associated with sedation in ventilated patients, and critical care neuropathy. Importantly, there are substantial cost savings and reduction in critical care resource utilization. Patients admitted to ICU for respiratory failure from central airway diseases are amenable to reversal by bronchoscopy. Recognizing this subgroup and carrying out bronchoscopy promptly can modify the course of their illness favorably fulfilling the ultimate goal of ICU, that is timely liberation from MV and extubation, and at the same time free up the scarce ICU resources.

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ACKNOWLEDGMENT

The authors thank Ms Ivy Yu Ling Ling for her valuable contribution in editing the figures and administrative work.

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Keywords:

cancer (lung); bronchoscopy; stenting; laser; central airway obstruction

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