|Year : 2018 | Volume
| Issue : 1 | Page : 26-31
Noninvasive ventilation with add-on fiberoptic bronchoscopy in patients with chronic obstructive pulmonary disease
Ahmed Sh Mohamed, Dalia E El-Sharawy
Chest Department, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||23-Aug-2017|
|Date of Acceptance||01-Oct-2017|
|Date of Web Publication||21-Mar-2018|
Dalia E El-Sharawy
Chest Department, Tanta University Hospitals, ElGeish Street, Tanta, 31911
Source of Support: None, Conflict of Interest: None
Introduction Noninvasive ventilation (NIV) is a valuable treatment for acute respiratory failure, which has many advantages and lessens the risk of tracheal intubation with its associated complications. Retained bronchial secretions are one of the most common causes of NIV failure and even can contraindicate its use.
Aim The aim was to assess the therapeutic utility of fiberoptic bronchoscopy as an add-on therapy in patients with acute respiratory failure on NIV, in a trial to decrease the possibility of invasive ventilation.
Patients and methods Patients with COPD were divided randomly into two groups: group I (20 patients) was subjected to NIV and medical therapy, and group II (20 patients) was subjected to NIV, medical therapy, and fiberoptic bronchoscopy for suctioning the retained secretions while on NIV. The cardiorespiratory parameters and complications were recorded during and after the procedure.
Results A total of 26 (65%) male and 14 (35%) female patients were enrolled in the study, with mean age of 47.55±11.56 years (range: 27–68 years). The mean duration of bronchoscopy was 3.5–7 min (range: 5.2±1.2 min) with no major complications. The amount of the aspirated secretions was 17.55±5.96 ml (range: 9–29 ml). There was significant difference on follow-up between the two groups regarding mean pH, PaO2/FiO2, and PaCO2, with more obvious improvement in group II than group I and with better outcome.
Conclusion Bronchoscopy on NIV in patients with COPD with acute respiratory failure and copious bronchial secretions can be an alternative to intubation with all its associated risks.
Keywords: chronic obstructive pulmonary disease, fiberoptic bronchoscope, noninvasive ventilation, retained secretions
|How to cite this article:|
Mohamed AS, El-Sharawy DE. Noninvasive ventilation with add-on fiberoptic bronchoscopy in patients with chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc 2018;67:26-31
|How to cite this URL:|
Mohamed AS, El-Sharawy DE. Noninvasive ventilation with add-on fiberoptic bronchoscopy in patients with chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc [serial online] 2018 [cited 2020 Apr 3];67:26-31. Available from: http://www.ejcdt.eg.net/text.asp?2018/67/1/26/228131
| Introduction|| |
Respiratory failure is defined as a failure to maintain adequate gas exchange and is characterized by abnormalities of arterial blood gas (ABG) tensions. Respiratory failure may be acute, acute or chronic, or chronic .
NIV is a valuable treatment for acute hypercapnic respiratory failure, with a number of potential advantages , particularly the avoidance of tracheal intubation with its associated mortality and morbidity from problems such as pneumonia. Intermittent ventilatory assistance is possible with NIV allowing gradual weaning and also normal eating, drinking, and communication. Breaks from ventilatory support can be used for giving nebulized medication, physiotherapy, and expectoration .
Some patients treated for acute respiratory failure may require diagnostic or therapeutic bronchoscopy  for many indications such as suctioning retained secretions to treat lobar collapse/atelectasis, diagnosis and treatment of persistent nonresolving endotracheal hemorrhage, diagnosis of suspected ventilator-associated pneumonia, and also transbronchial needle aspiration may be used for histological diagnosis .
| Aim|| |
The aim of this study was to assess the therapeutic utility of fiberoptic bronchoscopy as an add-on therapy in patients with chronic obstructive pulmonary disease (COPD) with acute infective exacerbation presented by mucous hypersecretion while on noninvasive ventilation (NIV) in a trial to decrease the possibility of invasive ventilation.
| Patients and methods|| |
This prospective randomized comparative experimental study included a total number of 40 patients known to have moderate to severe COPD at their baseline assessment according to American Thoracic Society/European Respiratory Society guidelines  and Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 edition  and admitted to intensive care unit of Chest Department, Tanta University Hospitals, during the period (June 2016–March 2017) with acute exacerbation caused by respiratory tract infections. On admission, the patients had acute hypercapnic respiratory failure (levels II to III according to GOLD classification of exacerbations)  with PaO2/FiO2 less than 225, PaCO2 greater than 70 mmHg, and pH less than 7.30, with dyspnea at rest (respiratory rate above 22 breaths/min). All patients presented with bronchial hypersecretion with loose cough and inability to spontaneously clear airways from these excessive mucopurulent secretions as diagnosed clinically by auscultatory paninspiratory coarse nonconsonating crepitations and as evaluated by the lowest score of an arbitrarily graded expelled sputum volumes in cough efficiency scale after three hard coughing efforts (1: <2 ml; 2: between 2 and 6 ml, and 3: >6 ml) .
These patients were divided randomly (by sealed envelopes) into two groups: group I (20 patients) was subjected to NIV plus medial therapy according to GOLD recommendations of management  and group II (20 patients) was subjected to NIV, medical therapy, and add-on fiberoptic bronchoscopy for suctioning these retained secretions. Exclusion criteria were impaired conscious level (Glasgow coma scale ≤9), severe refractory hypoxemia (PaO2/FiO2 ≤100 on FiO2 of 0.8–1.0), acute coronary syndromes, hemodynamic instability (hypotension, myocardial infarction, or arrhythmia), presence of high-risk co-morbid conditions (e.g. congestive heart failure), and radiological evidence of consolidation (e.g. pneumonia, bronchiectasis, and cystic fibrosis).
A written informed consent was obtained from the legal representatives of all patients after providing sufficient explanation regarding the study protocol, and the research complied with our institutional ethical guidelines.
All patients were submitted to noninvasive positive pressure ventilation according to published guidelines ,; on pressure controlled mode (BiPAP A40; Respironics Philips, USA) on spontaneous-timed mode with inspiratory pressure ranged from 16 to 22 cm H2O (19.10±1.37 cm H2O) and expiratory positive airway pressure ranged from 6 to 10 cm H2O (7.50±1.28 cm H2O) for at least two hours. Oronasal masks (ComfortFull 2; Respironics) were used as interfaces secured to the patient’s face with elastic straps with added heated humidifier.
Fiberoptic bronchoscopy (EB-1975k; Pentax, Japan) was done just after entry to ICU, and the patients were subjected to NIV through a swivel connector between the ventilator tubing and the mask. Fiberoptic bronchoscopy (FOB) was inserted nasally under topical anesthesia of the nasopharynx (10% lidocaine spray solution) and larynx (2% xylocaine) with mild sedation according to individual response (5–10 mg midazolam in incremental doses in average 7.22±1.56 mg). The bronchoscopy was wedged at every segment ostium, and all retained secretions from this segment were aspirated in a period of 3–5 s. FiO2 was adjusted to maintain the arterial saturation of oxygen (SaO2) greater than 90% throughout the bronchoscopy. The duration of bronchoscopy was calculated.
ABGs were obtained at baseline (on entry of ICU) and at 30 min, 2 h, 4 h, and 24 h after initiation of NIV and fiberoptic bronchoscopy.
Add-on FOB was defined to be failed depending on diminished conscious level (nonimproved or deteriorated Glasgow coma scale ≤8), nonimproved or even worsening of ABG tensions within 2 h of bronchoscopy, unstable hemodynamic state without response to vasoactive drugs, and development of complications (e.g. pneumothorax, arrhythmia, alveolar hemorrhage, or aspiration pneumonia) during and within the first 24 h after the procedure.
Data were analyzed using statistical program for the social sciences, version 20.0 (SPSS; SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean±SD. Independent samples t-test of significance was used in comparing two means, and a one-way analysis of variance was used in comparing between more than two means. P value of less than 0.05 was considered to be significant.
| Results|| |
A total of 40 patients with COPD [26 (65%) male and 14 (35%) female patients], with mean age of 47.55±11.56 years (range: 27–68 years), were included in this study. All patients had acute respiratory failure necessitating NIV in accordance with published guidelines . All patients had retained secretions and were divided randomly into two groups.
The mean pH, PaO2/FiO2, and PaCO2 of all patients were recorded at baseline (on entry of ICU) and at 30 min, 2 h, 4 h, and 24 h after initiation of NIV in group I ([Table 1] and [Figure 1]), and after performing fiberoptic bronchoscopy on NIV in group II ([Table 2] and [Figure 1]).
|Table 1 The arterial blood gases of group I patients at baseline (on entry of ICU), and at 30 min, 2 h, 4 h, and 24 h after initiation of noninvasive ventilation|
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|Figure 1 (a–c) The arterial blood gases of group I in comparison with group II patients at baseline (on entry of ICU), and at 30 min after initiation of noninvasive ventilation (in group II after FOB on noninvasive ventilation), 2 h, 4 h, and 24 h later.|
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|Table 2 The arterial blood gases of group II patients at baseline (on entry of ICU), and at 30 min, 2 h, 4 h, and 24 h after performing FOB on noninvasive ventilation|
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As shown, in group I, there was slight improvement in the levels of pH from 7.11±0.08 on entry of ICU to 7.14±0.06 30 min after initiation of NIV, reaching significant level 4 h later (7.20±0.09) (P=0.001); PaCO2 from 87.90±12.91 at baseline to 85.65±10.33 at 30 min after initiation of NIV, and then significantly to 81.50±13.43 at 4 h later (P=0.038); and PaO2/FiO2 from 169.35±16.39 at baseline reaching significant level only after 24 h (203.57±20.71) (P=0.013). However, in group II, the significant changes were obvious after 2 h from FOB [regarding pH, its level increases from 7.14±0.06 at baseline to 7.21±0.05 after 2 h (P=0.001) reaching 7.28±0.03 after 24 h (P=0.001 on comparing with 2 h results); PaCO2 also improves from 86.70±12.17 at baseline to 78.00±8.18 2 h later (P=0.004) reaching 71.12±7.31 after 24 h (P=0.028 on comparing with 2 h results); and PaO2/FiO2 improves from 175.10±20.62 at baseline to 193.75±17.82 after 2 h (P=0.012), reaching 225.47±16.70 after 24 h (P=0.003 on comparing with 2 h results)].
On comparing the ABG results of the two groups, the baseline data (on entry of ICU) of the two groups had no significant difference, and then there was significant difference between the two groups (group II had better results) starting from 2 h (i.e. in 2 h, 4 h, and 24 h) regarding pH and PaCO2, whereas PaO2/FiO2 showed the significant difference after 4 h (i.e. 4 and 24 h) ([Table 3]).
|Table 3 The comparison between the two groups regarding pH, PaO2/FiO2, and PaCO2|
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In group II, the mean duration of bronchoscopy was 5.2±1.2 min (range: 3.5–7 min). The amount of the aspirated secretions was 17.55±5.96 ml (range: 9–29 ml). The procedure was well tolerated with no major complications encountered during and after FOB up to 24 h, except for one case, which expressed sinus tachycardia up to 140 b/min with multiple premature ventricular contractions on monitoring during FOB and was controlled on additive sedation with 5 mg midazolam, disappearing completely 2 h after procedure.
Before the procedure, the mean SpO2 was 83.90±3.11 (range: 79–89) which elevated significantly to 92.55±2.26 (range: 90–97) during the procedure and was still high at 88.30±3.59 (range: 83–95) 15 min after the procedure; the mean respiratory rate was 29.75±4.36 breathes/min (range: 22–39 breathes/min), the mean heart rate was 83.60±7.10 beats/min (range: 70–96 beats/min), and the mean arterial blood pressure was 85.30±4.35 mmHg (range: 78–92 mmHg), which increased significantly to 34.60±3.98C/min, 91.80±6.78 beats/min, and 89.15±4.25 mmHg, respectively, during FOB, and reached to 30.55±3.86C/min, 86.35±6.68 beats/min, and 85.60±4.16 mmHg, respectively, 15 min after FOB, with no significant changes relating to the baseline ([Table 4]).
|Table 4 The cardiorespiratory parameters of group II patients during FOB|
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On clinical bases, the cough efficiency scale was improved significantly before procedure versus 2 h after it [from 1±0.73 (range: 0–2) to 2.05±0.76 (range: 1–3)] (P=0.001) ([Figure 2]).
|Figure 2 The cough efficiency scale in patients undergoing FOB (preoperatively compared with 2 h after the procedure).|
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On comparing the outcome of two groups, NPPV had failed, with necessity of intubation in six patients in group I (four within the first 2 h from entry to ICU, one at 6 h, and one at 17 h) versus three patients in group II (one each at 18 h, 21 h, and 23 h). These three cases expressed deterioration of the ABGs with lowering of the cough efficiency scale; on recurrence of FOB, there was significant improvement in postprocedure results in two cases with no need for intubation and only one case was in need.
The mean interval from ICU admission up to discharge in group I was 53.85±32.28 h (range: 18–118 h), whereas the mean interval from ICU admission to discharge in group II was 23.35±17.53 h (range: 9–84 h) with significant value (P=0.001). The overall ICU mortality rate was 5% (1/20) in group I (after intubation owing to cardiorespiratory respiratory arrest), whereas no cases in group II.
| Discussion|| |
Noninvasive mechanical ventilation is used in the treatment of acute respiratory failure to improve gas exchange alterations and to reduce respiratory effort, dyspnea, and the activity of the accessory respiratory muscles, preventing the complications related to invasive mechanical ventilation with preservation of the airway defense mechanism . The published guidelines ,, recommended initial trial of NIV for 1–2 h and indicated intubation if there is intolerability or failure of NIV.
Retained bronchial secretions are one of the most common causes of NIV failure and even can contraindicate its use . The inefficient clearance of secretions caused 33 and 43% of all NPPV failures of COPD exacerbations in two studies, respectively ,.
Bronchoscopy has become a key element in modern pulmonology, and one of the most common therapeutic indications of FOB is suctioning of retained secretions to treat lobar collapse/atelectasis .
However, bronchoscope itself can cause gas exchange alterations, increases the resistance of the airway, and reduces tidal volume. The increased respiratory effort associated with increased resistive loading can precipitate acute respiratory failure in critical patients especially in addition of suction through the bronchoscope channel which lowers airway pressure at the end of expiration, facilitating early alveolar closure . Our study documented that PaCO2 level slightly improved from 86.70±12.17 to 84.45±10.49 mmHg 30 min after the procedure, nonsignificantly reaching 78.00±8.18 mmHg 2 h after procedure, with significant improvement; this may be because of the use of just local oronasal anesthesia with mild dose of sedation (average of 7.22±1.56 mg of midazolam) which aided in preserving the level of PaCO2 within the acceptable range, lessening the risk for intubation.
Moreover, these factors may cause arterial oxygen pressure (PaO2) to decrease between 10 and 20 mmHg during bronchoscopy (especially when bronchoalveolar lavage was added because of an altered ventilation–perfusion ratio). In a group of 107 mechanically ventilated patients undergoing FB, an average decline in PaO2 of 26% was observed at the end of the procedure compared with the baseline value . So the use of supplemental O2 must be justified in patients at risk for desaturation during bronchoscopy . In this study, the mean SpO2 was 83.90±3.11 (range: 79–89), which elevated significantly to 92.55±2.26 (range: 90–97) during the procedure and was still high at 88.30±3.59 (range: 83–95) 15 min after the procedure. This may be because of the efficient clearance of all retained secretions plus no bronchoalveolar lavage with its potential effects on lung compliance was done.
Performing bronchoscopy presents potential complications that can be related to the procedure itself and qualifications and experience of the bronchoscopist . The lack of major complications in our study is related mainly to the short duration of the FOB (5.2±1.2 min; range: 3.5–7 min) that was sufficient to clear all lung segments from these retained secretions with obvious effect on ABGs compared with the other group. These results were in accordance with several studies that demonstrated the safety of FBO performed under NPPV in critical patients with respiratory failure ,.
Limitation of this study is focused on the small sample size (only 20 cases in each group), but this occurs owing to the precise selection of cases matched with inclusion criteria, no response to initial medical therapy, and purely diagnosed as COPD on exacerbation, with no other pathologies explaining this bronchial hypersecretion. So, we recommend applying this technique on a larger scope to state its applicability as a standard efficient and safe procedure.
| Conclusion|| |
Bronchoscopy on NIV in patients with acute exacerbation of COPD patients with copious bronchial secretions can be a safe alternative to intubation with all its associated risks, but it should be performed as early as possible and by a skilled bronchoscopist, with meticulous monitoring.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]