Welcome to this video on the bronchoscopic management of bleeding. In this video, we will demonstrate multiple techniques to manage bleeding following biopsies of a lingular mass. I'm Laura Frey and I'm faculty at the University of Wisconsin and a member of the Bronchoscopy Domain Task Force. I am Abdul Agreyes, faculty at Tarzana Franklin University. I am at the Innovation Subcommittee, Education Committee, CHEST. Hi, I'm Tim Orgo, I work at the University of Chicago and I'm the current chair of Education Committee for CHEST. At the conclusion of this video, you should know how to demonstrate the installation of cold saline, how to safely wedge the bronchoscope in the airway, how to place your patient in the safety position, and multiple techniques to block the airway while your patient receives definitive management of bronchial bleeding. This is your introduction to the Cooke-Arndt Bronchial Blocker. This kit is a 7-inch, 65-centimeter bronchial blocker. We will quickly review the key components of this kit and the essential items you will need to place a bronchial blocker in the setting of airway bleeding. You will notice multiple pieces in this kit. The two that will be essential for your placement of your bronchial blocker are the bronchial blocker itself and then the multiport adapter. You also have a syringe to inflate the pilot balloon. These two additional pieces are often used by our anesthesia colleagues and are a suction adapter and a CPAP adapter. You have a three-port adapter that connects to the endotracheal tube, allowing you to pass the bronchial blocker through one port, your bronchoscope through the second port, and then connect your patient to ventilation through the third port. These will be your primary components for the placement of your bronchial blocker and the setting of bronchial bleeding. Prior to our procedure, we've reviewed our imaging and identified a peripheral mass in the superior segment of the lingula. Dr. Murga is currently located in the left main stem and will drive his scope to the lingular segment for his biopsy. Scope in the lingula. Forceps. Venting. Venting forceps in the superior segment of the lingula. Venting the scope and staying wedge there. Open. Open. Close. Close. Forceps up. Forceps down. Following acquisition of the biopsy, Dr. Murga will maintain his scope in a wedge position. He can verify this both by direct visualization or using fluoro for his biopsy. He can also verify his scope position based on fluoro. He will maintain a wedge position for approximately two minutes and in a normal airway will avoid suctioning the airway to allow clot formation distally. Sometimes in a patient with a very decreased elastic recoil, easily collapsible, segmental airway, it may be valuable to suction, like I'm doing right now, and that will create a seal and likely prevent the blood from spilling into the normal lung. After two minutes, we will then reassess the airway and evaluate whether or not we have accomplished cessation of bleeding. Under direct visualization, Dr. Murga will slowly withdraw his scope. And with the return of bright red blood, we will re-wedge. Re-wedge. With our scope still wedged in the lingula, we now begin to use the topical administration of cold saline for vasoconstriction and hopeful cessation of bleeding. It is encouraged to have cold saline available in your bronch suite anytime you are doing biopsies of the airway or the lung parenchyma. Laura, how cold should it be? Ice cold. Ice cold. Thank you. All right. Cold saline. If you're working in a bronch suite, that cold saline out at the beginning of the day does encourage that you re-evaluate that temperature as your day proceeds, as that ice cold saline may become room temperature saline. You can also use multiple large aliquots of saline, as studies have shown that volumes up to 500 cc of saline have been successful in alleviation of bleeding. We discourage the use of topical vasoconstrictants like epinephrine, as these have been associated with fatal arrhythmias. Of course, we're not leaving 500 ml of cold saline in the airway. We inject, we suction, we inject, we suction. We just want to take advantage of the cold temperature of the saline for vasoconstriction properties. It's still bleeding. And we re-wet. If you are doing biopsies of the airway or the lung parenchyma, we encourage you to have cold saline available throughout the day. This would be ice cold saline available for all of your cases. So if you're somebody who sets aside a basin of cold saline at the beginning of the day, know that that cold saline is going to be room temp by the time that you're doing your afternoon cases. Dr. Mergu is still wedged in the airway, as we have evidence of ongoing bleeding. We are now going to place our patient in the safety position while we, as a team, proceed with next steps for stabilization of the airway. Dr. Alreyes and I will now work to place the position with the bleeding side down, rotating the patient to the left side. As we do this, Dr. Mergu will maintain himself in a wedged position. Wedged in? This allows him to continue to wedge and suction the airway. We are also now able to open the airway or parenchyma and suction any secretions out of the mouth. The safety position may help with avoiding the blood from spilling into the normal lung, in this case the right lung, and also will promote blood formation. With evidence of ongoing bleeding, the decision is made to secure the airway with a cuff endotracheal tube. The patient is now placed into the supine position, and we withdraw our bronchoscope and proceed with a fiberoptic intubation using a 9-0 cuff endotracheal tube. The bite block is left in place. As the purpose of the selected intubation is to secure the good non-bleeding lungs, we are going to proceed with a right main stem intubation and allow the left lung to fill with blood. There's some blood in the B.I. Suction. Keep the bronchoscope in the B.I. If there is some resistance, we don't want to force it. We want to pull back the tube and gently advance. Dr. Merger will advance the endotracheal tube into the right main stem under direct visualization. And if possible, in an effort to maintain aeration of the right upper lobe, we will position the Murphy's eye over the right upper lobe takeoff. This, however, is not always possible. This is the B.I. Right upper lobe. Give me the cuff. Cuff is needed. Left lung isolated. Tube is at 26. Inflate the cuff. Connect ventilation. Now with the secure airway, we can proceed with preparation for next steps. With the tube in the right main stem, we are now going to proceed with placement of a bronchial blocker. We are now going to proceed with placement of a bronchial blocker. In this video, we're going to demonstrate placement of a 7-french-arm bronchial blocker. These blockers, however, come in a 5-french, a 7-french, and a 9-french. If you're working in the adult population, you will largely use the 7 and the 9. If you're working in pediatrics, you will likely use a 5. There are two key pieces of equipment in your kit. This includes the multiport adapter and the bronchial blocker. The multiport adapter is intended to allow you to connect the ventilator to one port, your bronchoscope is able to pass through the second port, and the third port allows your bronchial blocker to be placed. We would encourage you to maintain your tube in the selected intubation position while you prepare this equipment outside of your patient. We will demonstrate that preparation now. Alright. The bronchoscope is passed through one port of the adapter, while the blocker is passed through the second. We now secure the lasso along the end of the bronchoscope and secure this in place. Tighten the lasso. Good. Dr. Mergel and Dr. Alreyes will now proceed with placing the bronchial blocker in block through this patient's airway. Keep in mind that we are still in the position of a selected intubation, so once visualization is achieved, we will need to pull the endotracheal tube back to the trachea and out of the right main stem. This is from behind, to play the cuff of the AT tube. Okay. Cuff is down. Cuff of the AT tube. Okay. Cuff is down. And we are now withdrawing our endotracheal tube to the trachea. To the trachea. I'm going down the left. Okay. Release the lasso. We are demonstrating a technique of securing the lasso over the end of the bronchoscope. Some providers, however, prefer to secure the lasso using a forcep through the endotracheal tube to drive that into place. Once the lasso has been deployed into the left main stem, we will inflate the balloon to occlude the airway. Inflate. Under direct visualization, we will ensure that we have full occlusion of the airway and there's no spillage of blood around the bronchial blocker. And we will withdraw our bronchoscope from the airway. We are now able to connect our patient to mechanical ventilation and secure our blocker in place. So to secure the blocker in place, we tighten the third port of the adapter. Tighten. Also important to make note of the depth of the endotracheal tube and the depth of the blocker. 49. Blocker is a 49, and ED tube is a 22. These two points should be communicated to both the nurse and the respiratory therapist so that we are aware if there is any migration of the bronchial blocker. The bronchial blocker can be left in place, but if it is left in place overnight, we encourage you to return to the patient's bedside and deflate the blocker the following day for visualization of the airway and to assess if there's evidence of active bleeding. If there is still active bleeding, we would encourage you to pursue more definitive management of this patient's ongoing bronchial bleed. This could be IR embolization or surgical therapy. If there is no evidence of active bleeding, you can now proceed with therapeutic aspiration of clot and potentially removal of the blocker.

bleeding management

biopsy

lingular mass

Cooke-Arndt Bronchial Blocker

cold saline