A Case Series of Emergency Medicine Performed Bronchoscopy: A Single Centre Experience in A Tertiary Care Hospital

Gurjeet Singh a/l Harvendhar Singh*, Khirthika Ramasamy, Theysinthia Thivya Naidu a/p Rajendran Naidu, Thayaharan Subramaniam, Suhash Damodaran, Nabil Muhammad bin Haji Al Kuddoos

Department of Emergency Medicine, Hospital Selayang, Malaysia 68100 Rawang Selangor, Malaysia

*Corresponding Author’s Email: gurjeet.s@live.com

Abstract

Bronchoscopy has long been regarded as a specialized procedure done in settings other than the emergency department. However recent advancements have brought to light the signif icance of the use of bronchoscopy in emergency medicine situations and in emergency critical care. The indications, contraindications and techniques have been well documented in recent times. This article looks at real time data on bronchoscopy perf ormed in the emergency department in a case series format to look at on f ield and on site uses and data interpretation to help improve the service in the emergency setting.

Keywords: Bronchoscopy; Oxygenation; Mechanically; Emergency

Introduction

Emergency bronchoscopy is relatively new and not a routine procedure in ED (Singh, 2023). The objective is to attain airway assessment, adequate oxygenation, and ventilation, by perf orming bronchoscopy in mechanically ventilated patients (Sachdev et al., 2022). Its use is signif icantly being advocated in the setting of critical emergency care (Ho et al., 2022). In this article we discuss the annals of bronchoscopes over a year in a tertiary care hospital in the Klang valley and its data interpretation.

Methodology

Emergency physicians who have been trained in emergency bronchoscopy and who have been certif ied perf ormed bronchoscopy in the critically ill patients through a one-year period in 2023. Data was collected for all the cases who had emergency bronchoscopy performed on them via a standardized data collection sheet to minimize bias. The data f rom all the cases was then analyzed in each of its components which includes saf ety profiles and rate of complications, outcome of patient post bronchoscopy, most common f indings recorded in emergency bronchoscopy, medications commonly used and the indications to perf orm a bronchoscopy.

Results and Discussions

Figure 1: Complications Observed in Emergency Bronchoscopy

A total of 15 patients underwent bronchoscopy in Emergency department, Hospital Selayang by certif ied emergency physicians in the above-mentioned period.

In the total of 15 patients, who underwent procedure in our setting, none of them had any complications. The expected small risks of complications are bleeding, desaturation, arrythmias and pneumothorax can happen for various reasons, which can be avoided and tackled by expertise. Thus, making bronchoscopy relatively safe (Kops et al., 2023).

Figure 2: Methods of Outcome Analysis

Three types of methods were used to measure the outcome of our patients, direct visualization f rom the bronchoscopy, CXR and ABG. As our collective data results shows 72% (10) had direct visualization f rom bronchoscopy to measure the outcome and 21% (4) had CXR done to measure the outcomes and 7% (1) had ABG f indings to analyze the outcome. The best way to evaluate the outcome is not via CXR/ABG but by direct bronchoscopy post procedure itself. And almost all the patients displayed improvement in ventilation and oxygenation drastically.

In the 15 patients, the most common f indings documented were mucous plugs and secretions accounting for 87 %, (13) and 7% (1) noted to have pulmonary hemorrhage, all of which can be easily treated in ED by removing the plug, suction or by bronchial washing (Cheng & Goldf arb, 2023).

Figure 3: Common Emergency Bronchoscopy Findings

Pre procedure medications are rarely needed for bronchoscope. Among the 15 patients, 54% (8) required low doses of rocuronium as pre procedure do not require 13% (2) requiring low dose of rocuronium and midazolam, which are relatively saf e and the remaining 33 % (5) not requiring any medications.

Figure 4: Medications Pre-Bronchoscopy

Patient’s diagnosis to perf orm bronchoscopy varies largely and its evidence of its wide use in the EDar. In the 15 patients, most common indication was both diagnostic and therapeutic, 53% (8) for mucus plug clearance, 40% (7) suction therapy for lobar collapse/bronchial washing and in 1 polytrauma patient, it was used as an adjunct for difficult airway accounting for 7 %.

Figure 5: Common Indications of Emergency Bronchoscopy

Conclusion

In tertiary care settings, emergency physicians can saf ely and ef f ectively use bronchoscopy to diagnose and treat critically ill patients. Thus, becoming an important therapeutic and diagnostic tool for emergency airway management.

Limitation

Limited trained personnel, and the lack of critical care unit in Emergency department are some of our limitations. Further studies are warranted to establish bronchoscopy as a reliable and saf e strategy for routine use in emergency department.

Conflict of Interest

The authors declare that they have no conf lict of interests.

Acknowledgement

The authors would like to thank the Ipoh Emergency Critical Care society for initiating training in emergency bronchoscopy for emergency physicians that has lead to this procedure being done routinely in the emergency departments all across Malaysia.

References

Singh, G. (2023). Signif icance of Emergency Bronchoscopy; Signif icance in Essential Emergency Critical Care Setting. Malaysian Journal of Medical Research (MJMR), 7(2), 40-44. https://doi.org/10.31674/mjmr.2023.v07i02.006

Sachdev, A., Gupta, N., Khatri, A., Jha, G., & Menon, G. R. (2022). Utility and saf ety of f lexible f iberoptic bronchoscopy in mechanically ventilated children in pediatric intensive care unit. Pediatric Pulmonology, 57(5), 1310-1317. https://doi.org/10.1002/ppul.25863

Ho, E., Wagh, A., Hogarth, K., & Murgu, S. (2022). Single-use and reusable f lexible bronchoscopes in pulmonary and critical care medicine. Diagnostics, 12(1), 174. https://doi.org/10.3390/diagnostics12010174

Kops, S. E., Heus, P., Korevaar, D. A., Damen, J. A., Idema, D. L., Verhoeven, R. L., ... & van der Heijden, E. H. (2023). Diagnostic yield and saf ety of navigation bronchoscopy: a systematic review and meta-analysis. Lung Cancer, 107196. https://doi.org/10.1016/j.lungcan.2023.107196

Cheng, P. C., & Goldf arb, S. B. (2023). Bronchoscopy, Pediatric Pulmonology . https://doi.org/10.1542/9781610026536-8