Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position

Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position Kalchiem-Dekel et al. Critical Care (2018) 22:54 https://doi.org/10.1186/s13054-018-1983-3 LETTER Open Access Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position 1* 1 2 1 1 Or Kalchiem-Dekel , Carl B. Shanholtz , Jean Jeudy , Ashutosh Sachdeva and Edward M. Pickering Prone positioning (PP) was shown to reduce mortal- complications were documented. Figure 1 illustrates ity in mechanically ventilated (MV) patients with se- evolution of the PaO :FIO ratio over time for each 2 2 vere ARDS [1]. Despite its common use, safety subject. Six subjects had antibiotics modified based concerns inhibit use of flexible bronchoscopy (FB) in on FB-obtained cultures. Consistent with previous patients with ARDS, and there are few reports of FB data [3], 4/7 subjects survived 30 days following performed in PP [2]. We reviewed all adults receiv- discharge from the ICU. ing FB in PP in one institution between April 2016 Although PP is lung-protective, it may result in and September 2017. The study was approved by the mobilization of secretions into the airways, impairing institutional review board. Four men and three oxygenation and providing nidus for infection [4]. women were identified (Table 1). In five patients, FB Despite documented risks [5], FB maybebeneficialin was indicated for clearance of thick secretions, and this situation. in two patients for microbial analysis. The mode of Several limitations need to be addressed when mechanical ventilation was not changed for FB, but interpreting our data. This is a retrospective analysis. FIO was universally set to 100%. All subjects had Although physiologic monitoring was automatically invasivehemodynamicand pulseoximetrymonitor- captured, ventilator data were not and ventilator ing. End-tidal carbon dioxide (EtCO )was monitored output during FB could not be accurately analyzed. in 3/7 subjects. With the subject’s head tilted to the Additionally, EtCO was not measured in all cases side, the bronchoscope was advanced into the air- during FB.Finally,PPwas showntoreducemortality ways, repeatedly, and in short cycles, allowing time in patients with moderate to severe ARDS, however, for oxygenation, ventilation, and lung recruitment our study subjects’ oxygenation had started to im- between insertions. Therapeutic aspiration was provebythe time FB wasperformed (Fig. 1,T1). performed in 6/7 subjects. Bronchoalveolar lavage This likely reflects reluctance to perform FB in sub- was performed in two subjects. No significant jects with severe hypoxemia due to excessive risks. hemodynamic compromise was observed during any Our report demonstrates the feasibility of FB of the procedures. Significant oxygen desaturation performed in brief increments in carefully monitored and rising EtCO were observed in one case (patient patients with ARDS ventilated in PP. Further studies 4). Both derangements resolved with withdrawal of are needed to better delineate optimal ventilator the bronchoscope and recruitment. No additional management during FB in PP. * Correspondence: orkalchiemdekel@umm.edu Division of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD 21201, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kalchiem-Dekel et al. Critical Care (2018) 22:54 Page 2 of 3 Table 1 Individual patient parameters, flexible bronchoscopy performance, and outcomes (n =7) Variable Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Age (years) 63 18 44 79 53 23 61 Sex Female Female Male Male Male Female Male Ethnicity Black Caucasian Caucasian Asian Caucasian Black Caucasian Etiology of ARDS MRSA sepsis Massive Fulminant Pneumonia Massive Massive Pneumonia pulmonary hepatic failure, aspiration aspiration embolism Klebsiella sepsis Total ICU LOS (days)/day 27/9 30/13 97/32 35/29 9/2 49/11 16/1 of FB Prone-positioning protocol 28 18 16 236 20 133 18 (total hours) 30-day survival post ICU No Yes Yes No Yes Yes No discharge Ventilator-related parameters at FB Mode PRVC PC/AC VC/AC PRVC VC/AC PC/AC PC/AC Peak pressure (cmH O) 32 29 24 37 30 20 32 Plateau pressure (cmH O) 27 NA NA 30 26 NA 27 PEEP (cmH O) 11 12 15 8 10 10 14 FIO (%) 100 100 100 100 100 100 100 FB-related data Δ-diameter ETT to 1.7 2.0 1.7 2.0 2.0 4.0 3.1 bronchoscope (mm) Therapeutic aspiration Yes Yes Yes No Yes Yes Yes Bronchial washings / BAL Yes Yes Yes Yes Yes Yes Yes Monitoring data MAP Baseline 69 67 87 68 72 67 80 Trough during FB 69 64 72 66 71 67 68 SpO Baseline 94 98 97 100 100 100 100 Trough during FB 94 92 97 87 99 99 100 EtCO Baseline 48 30 NA 43 NA NA NA Trough during FB 49 30 NA 51 NA NA NA Change in antibiotic regimen De-escalation De-escalation No Additional coverage De-escalation De-escalation De-escalation based on culture results ARDS adult respiratory distress syndrome, ICU intensive care unit, LOS length of stay, FB flexible bronchoscopy, MRSA methicillin-resistant Staphylococcus aureus, PRVC pressure-regulated volume control, PC/AC pressure-cycled assist-controlled, VC/AC volume-cycled assist-controlled, PEEP positive end-expiratory pressure, ETT endotracheal tube, BAL bronchoalveolar lavage, MAP mean arterial pressure as measured with an arterial line, NA not available, SpO oxygen saturation as measured with pulse oximetry, EtCO end-tidal carbon dioxide,FIO fractional concentration of 2 2 2 inspired oxygen As documented prior to first bronchoscope insertion Kalchiem-Dekel et al. Critical Care (2018) 22:54 Page 3 of 3 Fig. 1 Evolution of PaO to FIO ratio from pre bronchoscopy (T1) to 24 h (T2) and 72 h (T3) post bronchoscopy (n = 7). IQR interquartile range, 2 2 PaO partial pressure of arterial oxygen, FIO fractional concentration of inspired oxygen 2 2 Abbreviations Publisher’sNote ARDS: Acute respiratory distress syndrome; EtCO : end-tidal carbon dioxide; Springer Nature remains neutral with regard to jurisdictional claims in FB: Flexible bronchoscopy; FIO : Fraction of inspired oxygen; ICU: Intensive published maps and institutional affiliations. care unit; MV: Mechanical ventilation; PaO : Partial pressure of arterial oxygen; PP: Prone position Author details Division of Pulmonary, Critical Care, and Sleep Medicine, University of Acknowledgements Maryland School of Medicine, 110 South Paca Street, Baltimore, MD 21201, This manuscript was presented as a thematic poster during the American USA. Department of Diagnostic Radiology and Nuclear Medicine, University Thoracic Society International Conference, Washington DC, USA, May 2017. of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD 21201, USA. Funding This research received no specific grant from any funding agency in the Received: 31 January 2018 Accepted: 7 February 2018 public, commercial, or not-for-profit sectors. Availability of data and materials References The datasets used and/or analyzed during the current study are available 1. Guerin C, Reignier J, Richard J-C, Beuret P, Gacouin A, Boulain T, Mercier E, from the corresponding author on reasonable request. Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L. Prone positioning in severe Authors’ contributions acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68. OK-D, AS, and EMP contributed to the study concept and design. OK-D, CBS, 2. Guarracino F, Bertini P, Bortolotti U, Stefani M, Ambrosino N. Flexible AS, and EMP contributed to acquisition of data. OK-D, CBS, JJ, AS, and EMP bronchoscopy during mechanical ventilation in the prone position to treat contributed to analysis and interpretation of data. OK-D contributed to acute lung injury. Rev Port Pneumol. 2013;19(1):42–4. drafting of the manuscript. All declared authors contributed to critical revi- 3. Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, Gattinoni L, van sion of the manuscript for important intellectual content. All authors read Haren F, Larsson A, McAuley DF, Ranieri M, Rubenfeld G, Thompson BT, and approved the final manuscript. Wrigge H, Slutsky AS, Pesenti A. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive Ethics approval and consent to participate care units in 50 countries. JAMA. 2016;315(8):788–800. The study was conducted at University of Maryland Medical Center in 4. Graf J, Marini JJ. Do airway secretions play an underappreciated role in accordance with Good Clinical Practice (Declaration of Helsinki 2002) and acute respiratory distress syndrome? Curr Opin Crit Care. 2008;14(1):44–9. University of Maryland, Baltimore Campus Institutional Review Board 5. Steinberg KP, Mitchell DR, Maunder RJ, Milberg JA, Whitcomb ME, Hudson approvals (IRB reference number HP-00073462). Patients were included from LD. Safety of bronchoalveolar lavage in patients with adult respiratory April 2016 to September 2017. A waiver of consent has been approved per distress syndrome. Am Rev Respir Dis. 1993;148(3):556–61. 45 CFR 46.116(d). Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Critical Care Springer Journals

Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position

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Medicine & Public Health; Intensive / Critical Care Medicine; Emergency Medicine
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Abstract

Kalchiem-Dekel et al. Critical Care (2018) 22:54 https://doi.org/10.1186/s13054-018-1983-3 LETTER Open Access Feasibility, safety, and utility of bronchoscopy in patients with ARDS while in the prone position 1* 1 2 1 1 Or Kalchiem-Dekel , Carl B. Shanholtz , Jean Jeudy , Ashutosh Sachdeva and Edward M. Pickering Prone positioning (PP) was shown to reduce mortal- complications were documented. Figure 1 illustrates ity in mechanically ventilated (MV) patients with se- evolution of the PaO :FIO ratio over time for each 2 2 vere ARDS [1]. Despite its common use, safety subject. Six subjects had antibiotics modified based concerns inhibit use of flexible bronchoscopy (FB) in on FB-obtained cultures. Consistent with previous patients with ARDS, and there are few reports of FB data [3], 4/7 subjects survived 30 days following performed in PP [2]. We reviewed all adults receiv- discharge from the ICU. ing FB in PP in one institution between April 2016 Although PP is lung-protective, it may result in and September 2017. The study was approved by the mobilization of secretions into the airways, impairing institutional review board. Four men and three oxygenation and providing nidus for infection [4]. women were identified (Table 1). In five patients, FB Despite documented risks [5], FB maybebeneficialin was indicated for clearance of thick secretions, and this situation. in two patients for microbial analysis. The mode of Several limitations need to be addressed when mechanical ventilation was not changed for FB, but interpreting our data. This is a retrospective analysis. FIO was universally set to 100%. All subjects had Although physiologic monitoring was automatically invasivehemodynamicand pulseoximetrymonitor- captured, ventilator data were not and ventilator ing. End-tidal carbon dioxide (EtCO )was monitored output during FB could not be accurately analyzed. in 3/7 subjects. With the subject’s head tilted to the Additionally, EtCO was not measured in all cases side, the bronchoscope was advanced into the air- during FB.Finally,PPwas showntoreducemortality ways, repeatedly, and in short cycles, allowing time in patients with moderate to severe ARDS, however, for oxygenation, ventilation, and lung recruitment our study subjects’ oxygenation had started to im- between insertions. Therapeutic aspiration was provebythe time FB wasperformed (Fig. 1,T1). performed in 6/7 subjects. Bronchoalveolar lavage This likely reflects reluctance to perform FB in sub- was performed in two subjects. No significant jects with severe hypoxemia due to excessive risks. hemodynamic compromise was observed during any Our report demonstrates the feasibility of FB of the procedures. Significant oxygen desaturation performed in brief increments in carefully monitored and rising EtCO were observed in one case (patient patients with ARDS ventilated in PP. Further studies 4). Both derangements resolved with withdrawal of are needed to better delineate optimal ventilator the bronchoscope and recruitment. No additional management during FB in PP. * Correspondence: orkalchiemdekel@umm.edu Division of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD 21201, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kalchiem-Dekel et al. Critical Care (2018) 22:54 Page 2 of 3 Table 1 Individual patient parameters, flexible bronchoscopy performance, and outcomes (n =7) Variable Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Age (years) 63 18 44 79 53 23 61 Sex Female Female Male Male Male Female Male Ethnicity Black Caucasian Caucasian Asian Caucasian Black Caucasian Etiology of ARDS MRSA sepsis Massive Fulminant Pneumonia Massive Massive Pneumonia pulmonary hepatic failure, aspiration aspiration embolism Klebsiella sepsis Total ICU LOS (days)/day 27/9 30/13 97/32 35/29 9/2 49/11 16/1 of FB Prone-positioning protocol 28 18 16 236 20 133 18 (total hours) 30-day survival post ICU No Yes Yes No Yes Yes No discharge Ventilator-related parameters at FB Mode PRVC PC/AC VC/AC PRVC VC/AC PC/AC PC/AC Peak pressure (cmH O) 32 29 24 37 30 20 32 Plateau pressure (cmH O) 27 NA NA 30 26 NA 27 PEEP (cmH O) 11 12 15 8 10 10 14 FIO (%) 100 100 100 100 100 100 100 FB-related data Δ-diameter ETT to 1.7 2.0 1.7 2.0 2.0 4.0 3.1 bronchoscope (mm) Therapeutic aspiration Yes Yes Yes No Yes Yes Yes Bronchial washings / BAL Yes Yes Yes Yes Yes Yes Yes Monitoring data MAP Baseline 69 67 87 68 72 67 80 Trough during FB 69 64 72 66 71 67 68 SpO Baseline 94 98 97 100 100 100 100 Trough during FB 94 92 97 87 99 99 100 EtCO Baseline 48 30 NA 43 NA NA NA Trough during FB 49 30 NA 51 NA NA NA Change in antibiotic regimen De-escalation De-escalation No Additional coverage De-escalation De-escalation De-escalation based on culture results ARDS adult respiratory distress syndrome, ICU intensive care unit, LOS length of stay, FB flexible bronchoscopy, MRSA methicillin-resistant Staphylococcus aureus, PRVC pressure-regulated volume control, PC/AC pressure-cycled assist-controlled, VC/AC volume-cycled assist-controlled, PEEP positive end-expiratory pressure, ETT endotracheal tube, BAL bronchoalveolar lavage, MAP mean arterial pressure as measured with an arterial line, NA not available, SpO oxygen saturation as measured with pulse oximetry, EtCO end-tidal carbon dioxide,FIO fractional concentration of 2 2 2 inspired oxygen As documented prior to first bronchoscope insertion Kalchiem-Dekel et al. Critical Care (2018) 22:54 Page 3 of 3 Fig. 1 Evolution of PaO to FIO ratio from pre bronchoscopy (T1) to 24 h (T2) and 72 h (T3) post bronchoscopy (n = 7). IQR interquartile range, 2 2 PaO partial pressure of arterial oxygen, FIO fractional concentration of inspired oxygen 2 2 Abbreviations Publisher’sNote ARDS: Acute respiratory distress syndrome; EtCO : end-tidal carbon dioxide; Springer Nature remains neutral with regard to jurisdictional claims in FB: Flexible bronchoscopy; FIO : Fraction of inspired oxygen; ICU: Intensive published maps and institutional affiliations. care unit; MV: Mechanical ventilation; PaO : Partial pressure of arterial oxygen; PP: Prone position Author details Division of Pulmonary, Critical Care, and Sleep Medicine, University of Acknowledgements Maryland School of Medicine, 110 South Paca Street, Baltimore, MD 21201, This manuscript was presented as a thematic poster during the American USA. Department of Diagnostic Radiology and Nuclear Medicine, University Thoracic Society International Conference, Washington DC, USA, May 2017. of Maryland School of Medicine, 110 South Paca Street, Baltimore, MD 21201, USA. Funding This research received no specific grant from any funding agency in the Received: 31 January 2018 Accepted: 7 February 2018 public, commercial, or not-for-profit sectors. Availability of data and materials References The datasets used and/or analyzed during the current study are available 1. Guerin C, Reignier J, Richard J-C, Beuret P, Gacouin A, Boulain T, Mercier E, from the corresponding author on reasonable request. Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L. Prone positioning in severe Authors’ contributions acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68. OK-D, AS, and EMP contributed to the study concept and design. OK-D, CBS, 2. Guarracino F, Bertini P, Bortolotti U, Stefani M, Ambrosino N. Flexible AS, and EMP contributed to acquisition of data. OK-D, CBS, JJ, AS, and EMP bronchoscopy during mechanical ventilation in the prone position to treat contributed to analysis and interpretation of data. OK-D contributed to acute lung injury. Rev Port Pneumol. 2013;19(1):42–4. drafting of the manuscript. All declared authors contributed to critical revi- 3. Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, Gattinoni L, van sion of the manuscript for important intellectual content. All authors read Haren F, Larsson A, McAuley DF, Ranieri M, Rubenfeld G, Thompson BT, and approved the final manuscript. Wrigge H, Slutsky AS, Pesenti A. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive Ethics approval and consent to participate care units in 50 countries. JAMA. 2016;315(8):788–800. The study was conducted at University of Maryland Medical Center in 4. Graf J, Marini JJ. Do airway secretions play an underappreciated role in accordance with Good Clinical Practice (Declaration of Helsinki 2002) and acute respiratory distress syndrome? Curr Opin Crit Care. 2008;14(1):44–9. University of Maryland, Baltimore Campus Institutional Review Board 5. Steinberg KP, Mitchell DR, Maunder RJ, Milberg JA, Whitcomb ME, Hudson approvals (IRB reference number HP-00073462). Patients were included from LD. Safety of bronchoalveolar lavage in patients with adult respiratory April 2016 to September 2017. A waiver of consent has been approved per distress syndrome. Am Rev Respir Dis. 1993;148(3):556–61. 45 CFR 46.116(d). Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests.

Journal

Critical CareSpringer Journals

Published: Mar 2, 2018

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