Effects of Fiberoptic Bronchoscopy During Mechanical Ventilation in a Lung Model*

R. Wayne Lawson, MS, RRT; Jay I. Peters, MD, FCCP; and David C. Shelledy, PhD, RRT

Study objectives: To evaluate the effects of fiberoptic bronchoscopy (FOB) on delivered volumes and pressures during mechanical ventilation, utilizing a lung model. Design: Bench study. Setting: Laboratory. Materials and methods: Using varying-sized endotracheal tubes (ETTs), we ventilated a lung model at two levels of compliance utilizing different modes and parameters of ventilation. After establishing baseline measurements, the bronchoscope was inserted and measurements repeated. Measurements and results: During controlled mechanical ventilation (CMV) with a preset high-pressure limit (HPL), tidal volumes (VTs) were reduced from 700 mL to 0 to 500 mL following insertion of the bronchoscope. Increasing the HPL to 120 cm H2O resulted in a VT of 40 to 680 mL. Changing from square to decelerating flow waveform resulted in no consistent difference in VT. Auto-positive end-expiratory pressure (auto-PEEP) of 0 to 41 cm H2O was present under most conditions. Higher rates and lower peak inspiratory flows were associated with higher levels of auto-PEEP. In the pressure-control (PC) mode, using a preset inspiratory pressure level (IP), VT was reduced from 700 mL to 40 to 280 mL following insertion of the bronchoscope. Maximum IP (100 cm H2O) increased VT to 260 to 700 mL. Auto-PEEP was less in the PC mode. Conclusions: Extreme care must be taken when bronchoscopy is performed on a patient receiving mechanical ventilation. Extremely low VT and significant auto-PEEP may develop unless flow, respiratory rate, mode, and ETT size are carefully selected. The PC mode delivered more volume than did the CMV mode. When performing FOB during mechanical ventilation, the inside diameter of the ETT should be > 2.0-mm larger than the outside diameter of the bronchoscope to maintain volume delivery and minimize the development of auto-PEEP. (CHEST 2000; 118:824 831)
Key words: auto-positive end-expiratory pressure; bronchoscopy; mechanical ventilation; peak inspiratory pressure Abbreviations: CMV controlled mechanical ventilation; ETT endotracheal tube; FOB fiberoptic bronchoscopy; ID inside diameter; I:E inspiratory to expiratory; OD outside diameter; Palv alveolar pressure; PC pressure control; PEEP positive end-expiratory pressure; PIF peak inspiratory flow; PIP peak inspiratory pressure; Te expiratory time; Ti inspiratory time; Vt tidal volume

bronchoscopy (FOB) is performed on F iberoptic both spontaneously breathing patients and pa-

tients receiving mechanical ventilation to accomplish both diagnostic and therapeutic objectives.1 4 Many

*From the Department of Respiratory Care (Mr. Lawson and Dr. Shelledy), and Department of Medicine, Division of Pulmonary and Critical Care Medicine (Dr. Peters), University of Texas Health Science Center at San Antonio, San Antonio, TX. Support was provided by departmental funds. Manuscript received February 17, 1999; revision accepted March 22, 2000. Correspondence to: R. Wayne Lawson, MS, RRT, Department of Respiratory Care, MSC-6248, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229-3900; e-mail: LAWSON@uthscsa.edu
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retrospective studies have been done examining the adverse effects and complications of bronchoscopy during the procedure, almost all focusing directly on alterations in arterial blood gas values and hemodynamics, occurring secondary to BAL and transbronchial biopsy procedures.515 Tension pneumothorax and death have been reported as complications of bronchoscopy in patients receiving mechanical ventilation.1,8,14 Ricou et al5 compared BAL results, tidal volume (Vt) reduction, and intratracheal pressure changes in a group of 20 adult patients receiving mechanical ventilation, in whom paired bronchoscopies were performed using an adult (5.9-mm outside
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diameter [OD]) vs a pediatric (3.4-mm OD) bronchoscope. BAL recovery compared favorably between the two bronchoscopes, Vt was reduced 46% with the adult bronchoscope and 38% with the pediatric bronchoscope, while intratracheal pressure increased 16% with the adult bronchoscope vs 0% with the pediatric bronchoscope. Aside from Ricou et al,5 only two prospective studies examined complications during bronchoscopy on patients receiving mechanical ventilation.6,7 Lindholm et al6 evaluated the use of FOB in 55 patients, 38 of whom were receiving mechanical ventilation, to assess diagnostic and therapeutic implications as well as complications, and influence on cardiorespiratory function. They found no mortality or serious complications related to FOB, but did observe mild complications, including cardiac arrhythmias in two patients, and tachycardia as a common finding. In a follow-up analysis of the original work, Lindholm et al7 discussed the cardiorespiratory effects of FOB on those 38 patients. All were receiving mechanical ventilation using volumetargeted ventilation with Vt set at 10 to 15 mL/kg and ventilator frequencies between 12 and 18 breaths/min, via orotracheal or tracheostomy tubes. Tube size varied between 7.5-mm inside diameter (ID) and 9.5-mm ID (mean, 8.7-mm ID). Intratracheal pressure was monitored in 25 of these patients at the distal tip of the bronchoscope by using a manometer connected to the suction channel. During the procedure, peak tracheal pressures varied between 18 and 60 cm H2O, while peak inspiratory pressure (PIP) varied between 28 and 80 cm H2O. These values were limited by the fact that the safety pop-off valve of the ventilator was set at 60 to 80 cm H2O. Exhaled Vt fell dramatically in all cases during bronchoscopy and returned to prebronchoscopic values immediately on its removal. Even though positive end-expiratory pressure (PEEP) was discontinued during the procedure, auto-PEEP was present in all but five patients immediately on insertion of the bronchoscope through the tracheal airway, averaging 10.4 cm H2O for those 25 patients. Arterial blood gas analysis was performed on a small subgroup of the patients receiving mechanical ventilation. Although the mean arterial oxygen tension remained stable, the mean Paco2 rose during the procedure. In their conclusions, Lindholm et al7 listed a series of recommendations for bronchoscopy in patients receiving mechanical ventilation. These included use of a tracheal tube no smaller than 8.0-mm ID, discontinuance of PEEP, increasing the fraction of inspired oxygen to 1.0, monitoring for adequate chest excursion, suctioning for short periods only, frequent arterial blood gas analysis, and ruling out mediastinal emphysema and pneumothorax by chest

radiograph after FOB. This study did not examine the effects of ventilator frequency, ventilatory mode, inspiratory flow rate, or inspiratory flow waveform on delivered volumes and pressures. And while they reported that exhaled Vt decreased drastically in all cases, numbers were not reported. Because so little clinical information is known about the effect of bronchoscopy on mechanical ventilation, we used a lung model to address this issue. This model is designed to realistically simulate the mechanics of the adult ventilatory system. It uses two elastomer bellows-type lung compartments with a total residual volume of 1.84 L. Lung compliance is independently adjustable for each lung utilizing steel springs with a range of 0.01 to 0.15 L/cm H2O for each lung, while airway resistance can be altered using fixed orifice resistors calibrated to simulate 5, 20, or 50 cm H2O/L/s for each lung. These features allow the lung model to simulate a wide variety of pulmonary conditions. Our study examines the effect of FOB on peak pressure and alveolar pressure (Palv), auto-PEEP, and exhaled Vt during mechanical ventilation, and how they can be effectively dealt with during the procedure to ensure the adequacy of ventilation. The objectives were as follows: (1) to determine the effect of FOB on delivered volumes, PIP, Palv, and auto-PEEP during mechanical ventilation of a lung model utilizing three common-sized adult endotracheal tubes (ETTs) and two levels of lung compliance, and (2) to determine how changes in respiratory rate, peak inspiratory flow (PIF), and mode of ventilation would affect these parameters.

Materials and Methods

Using three different-sized ETTs, 7.5-, 8.0-, and 8.5-mm ID, we ventilated a two-chambered lung (Dual Adult TTL, Model 2600i; Michigan Instruments; Grand Rapids, MI) with an adult ventilator (7200ae; Nellcor Puritan Bennett; Carlsbad, CA). Experiments were done using two levels of compliance: a normal value of 100 mL/cm H2O and a reduced compliance value of 50 mL/cm H2O. Airway resistance was held constant at a value of 5 cm H2O/L/s for all experimental circumstances by utilizing a fixed orifice resistor with a calibrated pressure drop of 5 cm H2O/L/s for each lung. We chose not to look at changes in airway resistance and their effect on delivered volumes and pressures for this study. However, increasing airway resistance is associated with decreased delivered volumes and air trapping leading to the development of auto-PEEP. All experimental conditions are reflective of nonspontaneously breathing patients under the influence of heavy sedation. Two modes of ventilation were used: controlled mechanical ventilation (CMV) and pressure control (PC). A Vt of 700 mL was utilized as a baseline setting for all experimental conditions, at respiratory rates of 12 breaths/min and 24 breaths/min. In the CMV mode, PIFs of 40 L/min and 80 L/min were used under each experimental condition, as were square and decelerating inspiratory flow waveforms. The highpressure limit was initially set at 15 cm H2O above the average PIP. In the PC mode, the inspiratory pressure level was adjusted
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to deliver a Vt of 700 mL at an inspiratory to expiratory (I:E) ratio of 1:3.5, which corresponded to the I:E ratio obtained in the CMV mode under the following conditions: Vt, 700 mL; respiratory rate, 12 breaths/min; and PIF, 40 L/min. After establishing and recording baseline values, the 5.9-mm OD bronchoscope (Olympus B2 Fiberoptic Bronchoscope; Olympus; Tokyo, Japan) was introduced through a bronchoscope adapter at the y connector to a distance of 3 cm past the distal tip of the ETT. A time period of 10 to 15 s was allowed for equilibration of volumes and pressures prior to any measurements. Measurements were repeated three times, and the highest value was recorded. Palv was measured at end-inspiration while auto-PEEP was measured at end-expiration. Following insertion of the bronchoscope, in the CMV mode, the high-pressure limit was increased to the maximum value of 120 cm H2O. In the PC mode, the inspiratory pressure level was increased to its maximum value of 100 cm H2O in an effort to return delivered volumes to prebronchoscopic baseline values, and the resulting measurements were recorded. Exhaled volumes were measured at the y connector using a respirometer (Wright Mark 8; Ferraris Medical Limited; London UK), with an accuracy of 2% at a continuous flow of 16 L/min, and 5 to 10% at 60 L/min. PIP was recorded as measured by the ventilator system, while simulated Palv, including autoPEEP, was measured by the two-chambered adult test lung (Dual Adult TTL, Model 2600i; Michigan Instruments). As part of its standard configuration, the two-chambered adult test lung is equipped to directly measure pressure within each lung utilizing a pressure manometer built into each chamber.

Table 1CMV and PC Modes Prior to Readjusting the High-Pressure Limit Upward From the Baseline Setting in the CMV Mode, and Prior to Increasing the Inspiratory Pressure Level in the PC Mode*
Respiratory Rate, Breaths/min Variables CMV mode Square inspiratory flow waveform 8.5-mm ETT 40 L/min PIF 80 L/min PIF 8.0-mm ETT 40 L/min PIF 80 L/min PIF 7.5-mm ETT 40 L/min PIF 80 L/min PIF Decelerating inspiratory waveform 8.5-mm ETT 40 L/min PIF 80 L/min PIF 8.0-mm ETT 40 L/min PIF 80 L/min PIF 7.5-mm ETT 40 L/min PIF 80 L/min PIF PC mode 8.5-mm ETT Vt, mL (%Vt) PIP, cm H2O Palv/Pauto 8.0-mm ETT Vt, mL (%Vt) PIP, cm H2O Palv/Pauto 7.5-mm ETT Vt, mL (%Vt) PIP, cm H2O Palv/Pauto 12 24

290 (41) 90 (13) 70 (10) 50 (7) 0 (0) 0 (0)

290 (41) 90 (13) 70 (10) 50 (7) 0 (0) 0 (0)

500 (71) 60 (9) 60 (9) 40 (6) 0 (0) 0 (0)

340 (49) 60 (9) 380 (54) 40 (6) 0 (0) 0 (0)

Results Postbronchoscopic values for Vt, PIP, Palv, and auto-PEEP are reported in Tables 13. Table 1 shows the CMV and PC modes at a compliance of 100 mL/cm H2O prior to readjusting the highpressure limit upward from the baseline setting of 15 cm H2O above average PIP in the CMV mode, and prior to increasing the inspiratory pressure level in the PC mode. In the CMV mode, at a compliance of either 100 cm H2O or 50 cm H2O, the delivered Vt following insertion of the bronchoscope ranged from 0 to 500 mL (0 to 71% of baseline), with PIP from 8 to 24 cm H2O and auto-PEEP from 0 to 15 cm H2O, depending on ETT size, PIF, and waveform settings. In the PC mode at a compliance of either 100 mL/cm H2O or 50 mL/cm H2O, the delivered Vt following insertion of the bronchoscope ranged from 30 to 340 mL (4 to 49% of baseline), with PIP between 11 to 35 cm H2O and auto-PEEP from 0 to 4 cm H2O. In the CMV mode at a compliance of 100 mL/cm H2O, comparing the difference among the three tubes with the bronchoscope in place, moving from an 8.5-mm to an 8.0-mm to a 7.5-mm ETT resulted in an average loss of delivered Vt of 10, 20, and 52%, respectively. In the PC mode, comparing the difference among the three tubes with the bronchoscope in place, moving from an 8.5-mm to an 8.0-mm to a 7.5-mm ETT in the airway resulted in an average loss of delivered Vt of 4, 14, and 43%, respectively. When lung compliance was reduced to 50 mL/cm H2O, using
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280 (40) 11 4 /0 200 (29) 11 4 /0 40 (6) 13 2 /1

260 (37) 23 5 /2 200 (29) 24 5 /3 90 (13) 29 5 /4

*Data are presented as No. (%) unless otherwise indicated. Pauto auto-PEEP. Vt is 700 mL baseline, bronchoscope in place. High-pressure limit is 15 cm H2O above PIP prior to insertion of the bronchoscope, delivered Vt with percentage. The effect of rate on delivered Vt, PIP, and Palv using PC mode without readjustment of the inspiratory pressure level; Vt is 700 mL baseline; I:E 1:3.5, bronchoscope in place.

the 7.5-mm ETT, the average loss of delivered Vt rose to 87% in the CMV mode and 79% in the PC mode. The loss of delivered Vt using the 8.5-mm or 8.0-mm ETT can be compensated for by increasing the high-pressure limit or, in the case of the PC mode, by increasing the inspiratory pressure level. With the exception of experimental conditions done at a respiratory rate of 12 breaths/min, compliance of 100 mL/cm H2O, and decelerating inspiratory flow waveform, the loss of volume using the 7.5-mm ETT
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Table 2CMV Mode After Readjusting the High-Pressure Limit From the Baseline Setting to Its Maximum Value*
Respiratory Rate, Breaths/min 12 Variables Peak flow 40 L/min 8.5-mm ETT 8.0-mm ETT 7.5-mm ETT Peak flow 40 L/min 8.5-mm ETT 8.0-mm ETT 7.5-mm ETT Peak flow 80 L/min 8.5-mm ETT 8.0-mm ETT 7.5-mm ETT Peak flow 80 L/min 8.5-mm ETT 8.0-mm ETT 7.5-mm ETT square wave 630 (90) 580 (83) 500 (71) decelerating wave 610 (87) 540 (77) 450 (64) square wave 610 (87) 550 (79) 140 (20) decelerating wave 600 (86) 550 (79) 500 (71) 45 54 115 7/1 8/2 12/8 650 (93) 600 (86) 200 (71) 55 68 120 16/11 20/15 11/9 95 120 120 7/1 8/2 4/2 640 (91) 510 (73) 160 (23) 103 120 120 14/9 13/9 9/7 21 27 59 8/3 9/4 15/11 NVE NVE NVE NVE NVE NVE NVE NVE NVE 34 45 120 8/1 8/3 14/9 680 (97) 600 (86) 380 (54) 47 60 120 20/14 23/18 26/23 Vt (%Vt), mL PIP, cm H2O Palv/Pauto Vt (%Vt), mL 24 PIP, cm H2O Palv/Pauto

* Vt is 700 mL baseline, bronchoscope in place. NVE no volume equilibration; see Table 1 legend for abbreviation.

represents a critical loss in delivered Vt that cannot be compensated for by manipulating ventilator parameters. Table 2 shows the CMV mode at a compliance of 100 mL/cm H2O, after readjusting the high-pressure limit from the baseline setting of 15 cm H2O above average PIP to its maximum value of 120 cm H2O. Delivered Vt following insertion of the bronchoscope ranged from 140 to 680 mL (20 to 97% of baseline), with PIP from 21 to 120 cm H2O, and auto-PEEP from 1 to 23 cm H2O, depending on ETT size, PIF, and waveform settings. Changing ETT size demonstrates an average 10% drop in delivered Vt with the 5.9-mm bronchoscope inserted through the 8.5-mm tube (resulting in a 2.6-mm lumen), an average 20% drop when inserted through the 8.0-mm tube (resulting in a 2.1-mm lumen), and an average 52% drop when inserted through a 7.5-mm tube (resulting in a 1.6-mm lumen). The results at a compliance of 50 cm H2O demonstrate that delivered Vt following insertion of the

bronchoscope ranged from 40 to 650 mL (6 to 93% of baseline), with PIP between 23 to 120 cm H2O, and auto-PEEP from 0 to 41 cm H2O, depending on ETT size, PIF, and waveform settings. Changing ETT size demonstrates an average 12% drop in delivered Vt with the 5.9-mm bronchoscope inserted through the 8.5-mm tube (resulting in a 2.6-mm lumen), an average 30% drop when inserted through the 8.0-mm tube (resulting in a 2.1-mm lumen), and an average 87% drop when inserted through a 7.5-mm tube (resulting in a 1.6-mm lumen). Comparing delivered Vt between the two compliance values using the 7.5-mm ID ETT in the CMV mode, at a respiratory rate of 12 breaths/ min, using the square inspiratory flow waveform at a PIF of 40 L/min, the delivered Vt was 500 mL at a compliance of 100 mL/cm H2O and 100 mL at a compliance of 50 mL/cm H2O. With the decelerating inspiratory flow waveform at a PIF of 40 L/min, delivered Vt was 450 mL at a compliance of 100 mL/cm H2O, and 200 mL at a compliance of 50 mL/cm H2O. Using a square wave inspiratory flow

Table 3Effect of Rate on Delivered VT, PIP, and Palv During PCV With the Inspiratory Pressure Level Increased in an Attempt to Achieve 100% Volume Recovery*
Respiratory Rate, Breaths/min 12 Variables 8.5-mm ETT 8.0-mm ETT 7.5-mm ETT Vt (% Vt), mL 700 (100) 700 (100) 540 (77) PIP, cm H2O 32 45 95 Palv/Pauto 9/2 10/3 15/10 Vt (% Vt), mL 640 (91) 500 (71) 260 (37) 24 PIP, cm H2O 88 90 95 Palv/Pauto 14/9 13/9 14/1

* Vt is 700 mL baseline; I:E, 1:3.5, bronchoscope in place. See Table 1 legend for abbreviation.
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waveform at a PIF of 80 L/min, delivered Vt was 140 mL at a compliance of 100 mL/cm H2O, and 0 mL at a compliance of 50 mL/cm H2O. With the decelerating inspiratory flow waveform at a PIF of 80 L/min, delivered Vt was 500 mL at a compliance of 100 mL/cm H2O, and 40 mL at a compliance of 50 mL/cm H2O. Comparing delivered Vt between the two compliance values using the 7.5-mm ID ETT in the PC mode, at a respiratory rate of 12 breaths/min, delivered Vt was 540 mL at a compliance of 100 mL/cm H2O, and 190 mL at a compliance of 50 mL/cm H2O. Figure 1 shows the average delivered Vt from all experimental circumstances in the CMV mode for each ETT size at respiratory rates of 12 breaths/min and 24 breaths/min, after the high-pressure limit was increased in an effort to recover volume delivery. Table 3 shows the PC mode at a compliance of 100 mL/cm H2O, after readjusting the inspiratory pressure level in an attempt to compensate for volume loss caused by the presence of the FOB in the airway. At a compliance of 100 mL/cm H2O, delivered Vt following insertion of the bronchoscope ranged from 260 to 700 mL (37 to 100% of baseline), with PIP between 32 to 95 cm H2O and auto-PEEP from 2 to 10 cm H2O. At a compliance of 100 mL/cm H2O, changing the ETT size demonstrates an average 4% drop in delivered Vt with the 8.5-mm tube, an

average 14% drop when inserted through the 8.0-mm tube, and an average 43% drop when inserted through a 7.5-mm tube. At a compliance of 50 mL/cm H2O, delivered Vt following insertion of the bronchoscope ranged from 100 to 700 mL (14 to 100%) of baseline), with PIP between 41 to 100 cm H2O and auto-PEEP from 0 to 6 cm H2O. At a compliance of 50 mL/cm H2O, changing ETT size demonstrates an average 6% drop in delivered Vt with the 8.5-mm tube, an average 19% drop when inserted through the 8.0-mm tube, and an average 79% drop when inserted through a 7.5-mm tube. Figure 2 shows the effect of ETT size on delivered Vt in the PC mode at respiratory rates of 12 breaths/min and 24 breaths/min and a compliance of both 100 mL/cm H2O and 50 mL/cm H2O following insertion of the bronchoscope.

Discussion In this study on the effects of FOB on delivered volumes and pressures during mechanical ventilation on a lung model, significant changes in various parameters were observed following insertion of a 5.9-mm OD bronchoscope. PIP was increased, delivered Vt was reduced under most experimental circumstances,

Figure 1. The average delivered Vt (VT) from all experimental circumstances in the CMV mode for each ETT size at respiratory rates (f) of 12 breaths/min and 24 breaths/min, after the high-pressure limit was increased in an effort to recover volume delivery. C compliance.
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Figure 2. The effect of ETT size on delivered Vt in the PC mode at respiratory rates of 12 breaths/min and 24 breaths/min and a compliance of both 100 mL/cm H2O and 50 mL/cm H2O, following insertion of the bronchoscope. See Figure 1 legend for abbreviations.

and under conditions of higher respiratory rates and lower inspiratory flows, significant auto-PEEP was observed. These problems were further aggravated by decreasing ETT size. Our findings also demonstrated that volume delivery was slightly higher using the PC mode at a respiratory rate of 12 breaths/min, compared to the CMV mode at the same rate. At a given set of ventilatory parameters, actual patient-delivered volume from a mechanical ventilator during bronchoscopy is limited by the size of the ETT and the bronchoscope. The obstruction offered by the bronchoscope limits flow and, as a consequence, delivered Vt into the lung, causing PIP to rise as volume is delivered to the ventilator circuit rather than the lung. Poiseuilles law states that flow is directly proportional to the pressure gradient, but in the case of a mechanical ventilator, the available pressure gradient necessary to maintain flow in the face of the obstruction is limited by the highpressure limit setting. The increased resistance offered by the bronchoscope in the airway limits expiratory flow as well as inspiratory flow, resulting in volume trapped within the lung (auto-PEEP). ETT size had a significant impact on volume

delivery. The reduction in delivered Vt was a direct result of obstruction of the airway by the bronchoscope and, if the high-pressure limit setting is reached, the ventilator prematurely cycles from the inspiratory to the expiratory phase, resulting in a further decrease in machine-delivered Vt. While the first of these phenomena was present to a greater or lesser extent in all of our experimental conditions, the second phenomenon was more closely associated with the 7.5-mm ETT, as evidenced by the maximum high-pressure limit being reached in six of the eight experimental conditions in the CMV mode using the 7.5-mm ETT. Meduri and Chastre,16 in an effort to standardize how a patient receiving mechanical ventilation should be managed during the peribronchoscopy period to ensure the maintenance of adequate ventilation and oxygenation while minimizing the risk of barotrauma and other untoward physiologic effects, recommended a series of guidelines designed to standardize ventilator management during that time. They include the use of an ETT 1.5-mm larger than the OD of the FOB, and ventilator settings to include a fraction of inspired oxygen of 1.0, respiraCHEST / 118 / 3 / SEPTEMBER, 2000

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tory rate between 15 and 20 breaths/min, PIF 60 L/min, and high-pressure limit set to a level that allows adequate ventilation. Ventilator settings were then titrated to maximize exhaled Vt. These recommendations were not accompanied by supporting data. On the basis of our findings, to ensure 10 mL/kg-delivered Vt, we would recommend a minimum 2.0-mm difference between the ID of the bronchoscope and the OD of the ETT, rather than the 1.5-mm minimum difference recommended by Meduri and Chastre.16 This recommendation is supported by the substantial fall observed in delivered Vt when going from a 8.0-mm to a 7.5-mm ETT. The size difference between the ID of the 8.0-mm ETT and the OD of the 5.9-mm bronchoscope was 2.1 mm, while the size difference in the ID of the 7.5-mm ETT and the OD of the 5.9-mm bronchoscope was 1.6 mm. When the high-pressure limit was increased to its maximum value in an effort to recover patientdelivered Vt, dramatic increases in PIP were observed, the higher PIPs being the direct result of increased resistance due to the partial obstruction caused by the presence of the bronchoscope. However, despite PIPs that averaged 82 cm H2O at the proximal airway in the CMV mode, Palv remained low. The increased resistance offered by the presence of the bronchoscope in the airway protected the alveolar space from the excessively high PIPs. Measured within the lung model, Palv averaged 11 cm H2O at a compliance of 100 mL/cm H2O, and 17 cm H2O at a compliance of 50 cm H2O, compared to an average Palv of 8 cm H2O prior to insertion of the bronchoscope Decreasing ETT size was also associated with increasing levels of auto-PEEP, as shown in Table 2. Auto-PEEP is the product of an inappropriate combination of expiratory flow, expiratory time (Te), and expiratory resistance, resulting in a lack of complete exhalation prior to the beginning of the next inspiratory phase. A portion of the previous Vt remains trapped in the lung on which the next Vt is delivered. Expiratory flow is directly proportional to the elastic recoil potential of the respiratory system and inversely proportional to the resistance offered by the combination of the respiratory system and the artificial airway. With regard to Te, at a given inspiratory flow, because the length of one complete respiratory cycle decreases as ventilator rate increases, Te decreases as well. Also, depending on how the ventilator functions in terms of volume delivery and phase variables, Te may be fixed at a given respiratory rate or may change inversely with ventilator inspiratory flow. By way of explanation, some ventilators, at a given rate, time the length of each phase of the respiratory cycle independently, resulting in fixed inspiratory time (Ti)
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and Te. Other ventilators, however, time only the length of the total respiratory cycle, not its individual components, meaning that at a given respiratory rate and Vt, Ti is controlled by inspiratory flow, with Te comprising the time remaining in that cycle. The Puritan Bennett 7200 series ventilator functions in this manner. Because higher respiratory rates and lower inspiratory flows are both associated with shorter Tes, they are associated with an increased prevalence of auto-PEEP. Careful attention, therefore, must be given to the matching of PIF with ventilator rate. The partial obstruction caused by the presence of the bronchoscope in the airway can prolong the active component of the expiratory phase into the next inspiratory phase. Changing from square to decelerating inspiratory flow waveform had no consistent effect on delivered Vt and auto-PEEP. At low respiratory rates, this change had little effect on delivered volume and auto-PEEP, while at high respiratory rates, the decelerating waveform delivered more volume but at the expense of higher levels of auto-PEEP. With the combination of a respiratory rate of 24 breaths/min and PIF of 40 L/min, decelerating flow waveform was attempted and equilibration within the lung model failed to occur, causing the model to continually gain both volume and pressure until the volumetric capacity of the lung model was exceeded. The combination of low inspiratory flow and resultant short Te in the face of the resistance offered by the bronchoscope led to stacking of volume within the lung model. These findings suggest that when performing FOB on a patient who is receiving mechanican ventilation, careful adjustment of PIF and flow waveform is necessary. To prevent Ti from becoming too great a portion of respiratory cycle, square flow waveform at an appropriate PIF should be used in an effort to minimize volume trapping. In the PC mode, the presence of the bronchoscope in the airway resulted in a reduction in delivered Vt similar to that observed in the CMV mode when the high-pressure limit was not readjusted. Delivered Vt ranged from 6 to 40%. One strategy to maintain adequate ventilation during bronchoscopy is to increase the ventilator rate. We examined this strategy in an attempt to determine if it was effective based on our lung model. Assuming a constant dead space of 150 mL for the purpose of determining an estimated minute alveolar ventilation, this strategy results in an increase in estimated alveolar ventilation in all cases, except with a 7.5-mm ID ETT or when using a decelerating inspiratory flow waveform and a PIF of 40 L/min. While increasing the ventilator rate to 24 breaths/min was effective in increasing alveolar ventilation, the resultant calculated minute alveolar ventilation was often at a level that would result in
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hyperventilation for most patients. At a ventilator rate of 24 breaths/min and PIF of 40 L/min, using a decelerating inspiratory flow waveform resulted in Tes that were too short to allow for adequate exhalation. This caused stacking of volume and subsequent overdistention of the lung model for all size ETTs. We recommend using a square inspiratory flow waveform with an increased PIF whenever the ventilator rate is increased in an effort to maintain ventilation during the peribronchoscopy period. A common practice among bronchoscopists performing FOB on patients receiving mechanical ventilation is to transiently withdraw the bronchoscope for brief periods to allow the patient unobstructed ventilation, and therefore reduced physiologic stress. If the PC mode is used during the procedure, it is critically important that the inspiratory pressure level be reduced to prebronchoscopic values before the bronchoscope is removed from the ETT. Failure to do so would expose the lung to very high pressures, and thus the potential for barotrauma. Comparing our findings to that of Lindholm et al,6,7 we found similar increases in PIP and reductions in delivered Vt, as well as the development of auto-PEEP immediately on insertion of the bronchoscope, especially with the 7.5-mm ID ETT. Our directly measured Palvs were slightly lower than the tracheal pressures measured by Lindholm et al.6,7 Limitations to our study include the fact that ventilatory parameters were arbitrarily chosen, the study was done on a lung model, and only one brand of mechanical ventilator was utilized. This study does demonstrate that extremely low Vt and significant auto-PEEP will develop if an inappropriate-sized ETT and ventilatory settings are used during bronchoscopy on a patient receiving mechanical ventilation. Clinical studies should be undertaken to establish the optimal settings for both spontaneously breathing patients and those paralyzed during the procedure. Further studies are essential to validate recommendations already published in the literature. Conclusion FOB during mechanical ventilation should not be performed prior to careful readjustment of the highpressure limit in the CMV mode or the inspiratory pressure level in the PC mode. The PC mode delivered a greater percentage of baseline Vt, compared to the CMV mode. Despite extremely high PIPs, Palv remained low (from 1 to 23 cm H2O) during bronchoscopic occlusion of the ETT. Increasing the respiratory

rate in either the CMV or PC modes resulted in significantly higher auto-PEEP. When performing bronchoscopy on a patient receiving mechanical ventilation using an adult bronchoscope, the ID of the ETT should be 2.0-mm larger than the OD of the bronchoscope to maintain volume delivery and minimize the development of auto-PEEP.

References
1 Dreisin RB, Albert RK, Talley PA, et al. Flexible fiberoptic bronchoscopy in the teaching hospital: yield and complications. Chest 1978; 74:144 149 2 Jolliet P, Chevrolet JC. Bronchoscopy in the intensive care unit. Intensive Care Med 1992; 18:160 169 3 Turner JS, Willcox PA, Hayhurst MD, et al. Fiberoptic bronchoscopy in the intensive care unit: a prospective study of 147 procedures in 107 patients. Crit Care Med 1994; 22:259 264 4 Adolf J, Bartels H, Feussner H, et al. Fiberoptic bronchoscopy in intensive care medicine-functional efficacy and methodological side effects. Langenbecks Arch Chir 1985; 1:37 46 5 Ricou B, Grandin S, Nicod L, et al. Adult and paediatric size bronchoscopes for bronchoalveolar lavage in mechanically ventilated patients: yield and side effects. Thorax 1995; 50:290 293 6 Lindholm CE, Ollman B, Snyder JV, et al. Flexible fiberoptic bronchoscopy in critical care medicine: diagnosis, therapy and complications. Crit Care Med 1974; 2:250 261 7 Lindholm CE, Ollman B, Snyder JV, et al. Cardiorespiratory effects of flexible fiberoptic bronchoscopy in critically ill patients. Chest 1978; 74:362368 8 Pereira W Jr, Kounat DM, Snider GL, et al. A prospective cooperative study of complications following flexible fiberoptic bronchoscopy. Chest 1978; 73:813 816 9 Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest 1995; 107:430 432 10 Papazian L, Colt HG, Scemama F, et al. Effects of consecutive protected specimen brushing and bronchoalveolar lavage on gas exchange and hemodynamics in ventilated patients. Chest 1993; 104:1548 1552 11 Montravers P, Gauzit R, Dombret MC, et al. Cardiopulmonary effects of bronchoalveolar lavage in critically ill patients. Chest 1993; 104:15411547 12 Hertz MI, Woodward ME, Gross CR, et al. Safety of bronchoalveolar lavage in the critically ill, mechanically ventilated patient. Crit Care Med 1991; 19:1526 1532 13 Trouillet JL, Guiguet M, Gibert C, et al. Fiberoptic bronchoscopy in ventilated patients: evaluation of cardiopulmonary risk under midazolam sedation. Chest 1990; 97:927933 14 Humbert M, Robinson DS, Assoufi B, et al. Safety of fiberoptic bronchoscopy in asthmatic and control subjects and affects on asthma control over two weeks. Thorax 1996; 51:664 669 15 Suratt PM, Smiddy JF, Gruber B. Deaths and complications associated with fiberoptic bronchoscopy. Chest 1976; 69:747 751 16 Meduri GU, Chastre J. The standardization of bronchoscopic techniques for ventilator-associated pneumonia. Chest 1992; 102:557S564S

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