Bronchoscopy
Best of ATS Video Lecture Series: Bronchoscopy. Part of a larger collection of videos curated by ATS. These videos introduce strategies for preparation, examination, and bronchoalveolar lavage.
Weiss SM, Hert RC, Gianola FJ et al. Complications of fiberoptic bronchoscopy in thrombocytopenic patients. Chest 1993;104:1025-8. Established safety of transnasal bronchs for bronchoalveolar lavage in thrombocytopenic patients.
Criner GJ, Eberhardt R, Fernandez-Bussy S, et al. Interventional bronchoscopy. Am J Respir Crit Care Med. 2020; 202:29-50. Provides an excellent overview of advanced bronchoscopy, including bronchial thermoplasty, cryobiopsy, lung volume reduction and others. The review serves as an introduction for budding interventionalists and as a resource for non-interventionalists considering a referral.
Herth FJF, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest 2002;122:1461-4 Prospective study compared 285 patients taking ASA within 24 hrs of TBB to 932 non-ASA users and found no difference in the risk of minor, moderate, or major bleeding.
***See also Lung Cancer Staging
Endotracheal intubation
Mosier JM, Sakles JC, Law JA, et al. Tracheal intubation in the critically ill. where we came from and where we should go. Am J Respir Crit Care Med. 2020; 201:775-788. This review summarizes the relevant evidence and guideline recommendations, but the practical pearls are especially valuable.
Percutaneous tracheostomies
Ghattas C, Alsunaid S, Pickering EM, et al. State of the art: percutaneous tracheostomy in the intensive care unit. J Thorac Dis. 2021;13:5261-76. Provides a comprehensive overview including pre-procedural preparation, procedural technique, and post-tracheostomy management.
Thoracentesis
Swiderek J, Morcos S, Donthireddy V, et al. Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest 2010; 137:68-73. Prospective single center study of 103 patients with known or suspected malignant effusion. Three aliquots (10 mL, 60 mL, and >150 mL) were collected from each procedure and examined by direct smear/cytospin and by cell block analysis. Aliquots of 60 mL or >150 mL had significantly higher sensitivity and negative predictive value than aliquots of 10 mL, suggesting larger volumes are of diagnostic benefit. This is in contrast to earlier retrospective and smaller prospective studies suggesting diagnosis was independent of volume (See Chest 2002;122:1913-7, Chest 2009; 135:999-1001)
Lentz RJ, Lerner AD, Pannu JK, et al. Routine monitoring with pleural manometry during therapeutic large-volume thoracentesis to prevent pleural-pressure-related complications: a multicentre, single-blind randomised controlled trial. Lancet Respir Med. 2019; 7:447-455. This study randomized 124 patients with free-flowing effusions with estimated volume > 500 ml (63% with malignant effusion) to thoracentesis drainage based on symptoms alone vs. symptoms plus pleural manometry. There was no significant difference in chest discomfort, volume of fluid drained, proportion of patients with complete lung expansion, or clinically significant complications. Of note, the mean volume of fluid drained was 1,100 ml (SD 500 ml) and patients with known re-expandable lung, such as those with a large hepatic hydrothorax, were excluded.
Lentz RJ, Shojaee S, Grosu HB, et al. The impact of gravity vs suction-driven therapeutic thoracentesis on pressure-related complications: The GRAVITAS multicenter randomized controlled trial. Chest. 2020; 157:702-711. This study found no difference in chest discomfort or dyspnea during, or in the 48 hours following, thoracentesis.
Williams JG, Lerner AD. Managing complications of pleural procedures. J Thorac Dis. 2021; 13:5242-50. This article reviews the relevant anatomy followed by diagnosis and management of complications including pneumothorax, bleeding, re-expansion pulmonary edema, pain, and infection.
***For additional information, see Pleural disease section
General Procedural Safety
Wolfe K, Kress J. Risk of procedural hemorrhage. Chest 2016;150:237-46. Review article addressing the risk factors for hemorrhage associated with procedures commonly performed in the ICU, including central line placement, thoracentesis, paracentesis, lumbar puncture, and others.
Procedure Videos: The New England Journal of Medicine has developed and published a series of Videos in Clinical Medicine, intended to facilitate teaching and learning of common procedural techniques. Videos and accompanying text provide an excellent review of indications, pertinent techniques, and potential complications. Links to those procedures most applicable to critical care medicine are provided below. Access requires subscription.
- Arterial line insertion
- Arterial line insertion: ultrasound guided
- Bag-mask ventilation
- Central venous catheter insertion: internal jugular
- Central venous catheter insertion: femoral
- Central venous catheter insertion: subclavian
- Central venous catheter insertion: ultrasound guided subclavian
- Chest tube insertion
- Chest tube insertion: ultrasound guided
- Cricothyroidotomy
- Intubation: fiberoptic
- Intubation: standard orotracheal
- Lumbar puncture
- Paracentesis
- Percutaneous tracheostomy
- Prone positioning with elevated BMI
- Thoracentesis
