This is bronchoscopy using non-invasive positive pressure ventilation. I'm Laura Frey and I'm faculty at the University of Wisconsin and a member of the bronchoscopy domain task force. And I'm Tim Morgul, faculty at the University of Chicago, education committee chair. We're going to demonstrate how to perform a bronchoscopy in a patient in the ICU or in the bronch suite using non-invasive positive pressure ventilation. You may do this in a patient who's hypoxemic and you're worried about their ability to tolerate sedation and would prefer to avoid intubation or to patient at high risk of hypercapnia. We will demonstrate equipment setup and management of the ventilator or your non-invasive machine. If you see the ventilator behind us you'll notice that we already have basic settings. We're set at an FIO to 100% support of 15 with a PEEP of 5. As we are administering sedation you may also choose to set a backup rate to ensure continued ventilation and avoidance of hypercapnia. Dr. Murgul will demonstrate a couple of key pieces of equipment. So we use a full face mask in order to avoid leak and assure proper ventilation. We're securing the mask with the elastic straps and for the purpose of performing a bronchoscopy using non-invasive ventilation we use a bronchoscopy elbow adapter that has a one-way valve and then connect the hose from the ventilator. Now people could perform bronchoscopy either through the mouth or through the nose. If you go through the nose make sure that the elbow adapter is aligned with the nostril. Go through the mouth the same thing assure alignment and also use a wide block. We will now proceed with our bronchoscopy having been called to the bedside to perform a procedure for a hypoxemic immunosuppressed patient needing a BAL. The scope is inserted through the swivel adapter and we are using an insertion through the nose. Larynx, trichoid, trachea. We will begin with an airway inspection starting at the right main stem to the right upper lobe, anterior, posterior, and apical segments. We withdraw our bronchoscope proceed to the bronchus intermedius to the right middle lobe seeing the medial and the lateral segment. We again withdraw bronchoscope to the bronchus intermedius advancing to the superior segment of the right lower lobe. Withdraw our scope advance to the medial segment of the right lower lobe. Withdraw our scope and now can inspect the anterior, the lateral, and the posterior segments. We withdraw our scope to the trachea and now proceed with an airway inspection of the left side. Driving into the left main stem to the left upper lobe combined apical posterior segment. Withdraw slightly see our anterior segment of the left upper lobe. Withdraw slightly again to the lingula and evaluate our superior and our inferior segment. So we withdraw our scope directly across from the lingula in the left lower lobe. We will advance into the superior segment. Withdraw and advance into the lower lobe basilar segments to the combined anterior medial. Withdraw slightly into the lateral. Withdraw slightly and advance into the posterior segment and withdraw the trachea and we can now proceed with a BAL of our target site guided by imaging. Following completion of our bronchoscopy we would allow our patient to recover on non-invasive positive pressure ventilation for a period of approximately 30 minutes. This would allow the patient to recover from sedation and we could wean the non-invasive positive pressure ventilation with the patient maintaining a saturation of over 92%. If a longer period of recovery is needed then you would maintain similar settings weaning as able until you're able to wean the patient back to their prior supplemental oxygen requirement.

bronchoscopy

non-invasive positive pressure ventilation

hypoxemic patients

equipment setup

ventilator management