The Effect of Bronchofiberscopic Examination on Oxygenation Status*

Chugai Dubrawsky, M.D.,' ' Robert I . Awe, M.D.,t and Daniel E . Ienkins, M.D., F.C.C.P.$
Arterial blood gases were measured in 62 patients, none of whom was critically ill, to determine the effect of transnasal fiberoptic bronchoscopy on oxygenation status. Blood samples were obtained at regular intervals during the procedure. Thirty-four patients who were bronche scoped while breathing room air had a significant drop in the arterial Po2 following saline solution lavage. Twenty-eight patients who were given 28 percent oxygen via a Ventima~kduring the procedure were protected from this hypoxemia Simultaneously measured arterial pH and Pcoz were Gchanged dnring the procedure. Premedication alone resulted in a minimal but insignificant drop in Pa02 in 7 patients. These 0b~e~ati0nS suggest that if the initial Pa02 i less than 70 mm H on room air, s g bronchoscopy by the transnasal approach is best performed with the administration of oxygen through an a p propriate mask. If the patient is at risk of developing hypercapnia with supplemental oxygen, a 28 percent Ventimask should be utilized to prevent signi6cant hypoxemia without causing hypercapnia.

described by Ikedal Bronchofiberoscopy was first of this instrument for in 1968. Since then the use visualization of the tracheobronchial system has been widely accepted and utilized. Initially Ikeda passed the bronchofiberscope through an endotracheal tube. More recently Smiddy,2~~ Wanner,' and others have described a transnasal method, obviating the need for endotracheal intubation. Due to its simplicity and minimal patient discomfort,%is latter method has been adopted by us and used as a first line approach. The older, widely used method of tracheobronchid visualization has utilized the rigid bronche scope (Jackson), a procedure which is usually uncomfortable and often requires general anesthesia. Studies of the oxygenation status during bronchoscopy with the rigid instrument have indicated the need for supplemental oxygen.gs Bronchofiberoscopy eliminates two possible reasons for the hypoxia seen during straight bronchoscopy: ( 1 ) heavy sedation to allay patient apprehension is no longer necessary, and ( 2 ) when performed in the sitting position there is less hypoxemia than when the supine position is used.g Discomfort during fiberoptic bronchoscopy has been negligible, and all patients in the study were observed to be relatively at ease during the procedure.
*From the Pulmonary Division, Jefferson Davis Hospital, and the Pulmonary Disease Section, Department of Medicine, Baylor College of Medicine, Houston, Texas. Presented in part at the 39th Annual Meeting of the American College of Chest Physicians, Toronto, Ontario, October *'Fellow in Pulmona Disease, Baylor College of Medicine. tAssistant Professor z ~ e d i c i n eBa lor College of Medicine. , ttProfessor of Medicine and Chief ohulrnonary Disease Section, Baylor Colle e of Medicine. Manuscript r e c e i v e f ~ e c e m b e rLO. 1973; revision accepted June 18. Reprint requests: D .Awe, Jderson Duois Hospital, Houston r 77019

This study was undertaken because of the well known fact that the laek of patient distress does not necessarily reflect satisfactory arterial oxygenation. We wished to evaluate whether or not the patient became hypoxemic during this procedure, to quantitate the degree of hypoxemia, and to find an appropriate way to protect the patient from changes in oxygenation status if such occurred.
Sixty-two patients whose ages ranged between 22 and 93 years were studied while undergoing fiberoptic bronchoscopy for a wide spectrum of pulmonary conditions (see Tables 1 and 2 ) . None of the patients was critically ill and in all cases the transnasal approach was used. Premedication consisted of pentobarbital 100 mg and meperidine 50 mg IM 45 minutes prior to starting the procedure and atropine sulfate 0.4 mg subcutaneously immediately prior to introduo tion of the bronchoscope. For 20 minutes prior to bronchoscopy, 15 ml of 4 percent lidocaine was administered by ultrasonic nebulization through a face mask. After spraying one nostril with 1 percent lidocaine, the fiberoptic bronchoscope was introduced through the nostril into the nasopharynx and then passed to the level of the glottis. At that point, 1 or 2 ml of 1 percent lidocaine was introduced through the bronchoscope to render more effective topical anesthesia to the vocal cords. Subsequent passage through the glottis was usually accomplished with ease and was followed by systematic inspection of the tracheobronchial tree. Each bronchus was then irrigated with 30-40 ml of normal saline instilled into the main bronchus of each side, and bronchial washings were aspirated through the bronchoscope. Approximately 10 ml of secretions were usually recovered from each side, but this was variable depending on the amount of secretions initially present, the degree of cough, etc. Following the termination of the bronchoscopic procedure, patients were routinely observed for 15 minutes. Arterial blood gases were obtained through an intra-arterial catheter inserted prior to premedication and samples of blood were drawn in the following order: ( 1 ) prior to preoperative medication; ( 2 ) following medication but before insertion of the bronchoscope into the tracheobronchial

--.-.
1R73

CHEST, 67: 2, FEBRUARY, 1975

EFFECT OF BRONCHOFIBERSCOPIC EXAMINATION ON OXYGENATION STATUS 137

Downloaded From: https://publications.chestnet.org/ on 02/26/2013

Table I--f'atientr
Patient No A@. Sex

Without Supplernell~alOxygen

Clinical Diagnosis Hemoptysis with negative chest x-ray Tuberculous effusion Carcinoma RUL Tuberculosis RUL Carcinoma RUL LLL pneumonia Tuberculous effusion COPD; right hilar mass Carcinoma LUL Carcinoma RUL Abscess RUL Tuberculosis LUL Bronchiectasis Carcinoma LUL Tuberculosie RUL Tuberculosis, bilateral COPD; RLL pneumonia LUL abscess RUL abscess Carcinoma LUL RUL abscess Carcinoma LLL Tuberculosis LUL COPD; Tuberculosis RUL Pneumonia LLL Tuberculosis RUL Carcinoma RUL Abscess RLL Nodule LUL Abscess RLL Sarcoid Tuberculosis RLL Tuberculosis, far adv. Left hilar carcinoma Tuberculosis LUL

P a G on Room Air

Pa02 After First Bronchial Wash

PaO, After P a G 10 Minutea Contralateral After Procedure Bronchial Wash Room Air

49

Not done
51

60
56 51 45 59 46 36 74 65 49 62 49 69 56 40 53

Not done 60
57

60
32 63 71 60 49
~ U L T S

tree; ( 3 ) after insertion of the bronchoscope into the tracheobronchial tree but prior to bronchial washing; ( 4 ) following the first bronchial washing; ( 5 ) following the contralateral bronchial washing; ( 6 ) ten minutes following termination of the procedure while the patients were breathing room air. In 34 patients the procedure was performed while breathing room air ( Table 1), and in 28 patients oxygen was administered by means of a 28 percent Ventimask applied after introduction of the bronchoscope into one of the main bronchi but prior to starting the bronchial inspection or lavage (Table 2 ) . In another group of seven patients used as controls, medication was given in the same order as mentioned above. The arterial blood samples were drawn at 15minute intervals for one hour while the patient was breathing room air. No bronchoscopy was performed in this group. All arterial gases were immersed in ice and measured within 30 minutes on a blood gas analyzer at 3 7 O C . O All statistics were calculated with a digital computer, IBM 360/50. Bonferroni t statistics10 were utilized in order to compute significance levels for individual variable comparisons. *Blood gas analyzer, model IL-113, Instrumentation Laboratories, Lexington, Mass.

In the 34 patients who underwent fiberoptic bronchoscopy while breathing room air, a s i m c a n t drop in arterial Poz was noted following the instillation of saline solution into one lung. A significant

IWl

WIT

mc
*A'"'*@

PnC
"COICAT,

rrotcrra*

rrIl
TOTAL OROUP

I NO O1

SEQUENCE OF EVENTS

>

FIGURE Sequential measurements of arterial Po2 shown 1. while patients were breathing room air. Marker (*+) indicates when fiberbronchoscope was passed through vocal cords into tracheobronchial tree.

138 DUBRAWSKY, AWE, J E N K I N S

CHEST, 67: 2, FEBRUARY, 1975

Downloaded From: https://publications.chestnet.org/ on 02/26/2013

Table 2--Pdentr on 28 Percent Yentimurk

Patient No Age, Sex Paor on Room Air Pa02 After First Bronchial Wash Pa01 Afbr PaOI 10 Minutes Contralateral After Procedure Bronchial Wash Room Air

Clinical Diagnosis Tuberculosis RUL Tuberculosis, bilateral Carcinoma RML Abscess RUL Tuberculosis LUL COPD; Pneumonia Tuberculosis, biapical Tuberculosis, biapical Hemoptysis Pneumonia RLL COPD; Carcinoma LUL Pneumonia RUL Tuberculosis RUL, minimal Carcinoma RUL Bronchiectasis Carcinoma RML Adenocarcinoma, bilateral COPD; Tuberculosis Left hilar maaa Carcinoma RUL Right hilar carcinoma COPD Abscess RUL Tuberculosis RUL Carcinoma RUL Carcinoma RUL Tuberculosis, biapical Carcinoma, RUL

further drop in Pa02 was noted after introducing saline solution into the other lung. When compared with pre-washing Pa02 levels, the ten minute postbronchoscopy arterial oxygen levels remained significantly lower ( Fig 1) . The drop in Pa02 was not accompanied by significant changes in arterial Pcoz or pH. When the 34 patients were subdivided into three groupso0 according to their initial PaOz values, the magnitude
"Group A=Arterial P@ more than 80 mm Hg. Group BArterial Po2 between 60-80 m m Hg. Group C=Arterial Po2 less than 60 mm Hg.
PRC T I POST T

after bronchial lavage was of drop in arterial POZ similar in all three ( Fig 2 ) . In the 28 patients given supplemental 0 2 via a 28 percent Ventimask prior to the bronchial washing, only two cases (Cases 47 and 50) had significant drop in the PaO2. The majority had no significant fall in the oxygenation status (Fig 3). Simultaneous measurement of arterial pH and Pcoz again showed no significant change in these patients. In the seven patients who were not bronchoPO~T

ME
-

loo
WAaHIUe

WA~HIUSq

POST -

POST

K) MI*

POST w~anl*o2 MI.. POST

' ..our

W.IS)

.
P
cWItro1

- - --

60

C /------(u.10)

pO
40..

40..

rczl
TOTAL GROUP

(NO O* 1

rzzl
TOTAL GROUP ( 2 8 % 0 , )

L
SEOUENCE OF EVENTS

>

SEQUENCE OF EVENTS

->

FIGURE Sequential measurements of arterial P w shown in 2. patients undergoing fiberbronchoscopic examination while breathing room air. In this figure total group is divided according to initial Po?: Group A=Po2 80 mm Hg; Group B= P m 60-80 mm Hg; Group C=Po2 < 60 mm Hg.

>

FIGURE Sequential measurements of arterial Po2 shown in 3. patients undergoing fiberbronchoscopic examination while breathing through a ventimask (28 percent &). The marker (O+) shows point at which bronchoswpe is passed into tracheobronchial tree, through a hole in ventimask. Marker (OO+) shows point at which supplemental O2 was started.

CHEST, 67: 2, FEBRUARY, 1975

EFFECT OF BRONCHOFIBERSCOPH: EXAMINATION ON OXYGENATION STATUS 139

Downloaded From: https://publications.chestnet.org/ on 02/26/2013

PIE YEDICATION MEDICATION

MEDICATION MEDlcATlon

E
U

60
Control

"
L

NO BRONCHOSCOPY

N = 7

SEaUENCE OF EVENTS > FIGURE 4. The control group. Arterial Po2 measurement shown before and after administration of medication without bronchoscopic examination. No significant drop occurred in were unchanged. arterial Poz. Arterial pH and P C O ~

scoped (control premedication group), an insignificant drop was observed in oxygenation status as a result of the premedication alone ( Fig 4). Simultaneous measurement of arterial pH and P a showed no significant change. DISCUSSION This study showed that during fiberoptic bronchoscopy bronchial lavage with relatively small quantities of saline solution in the range of 30 to 40 ml to each lung was usually followed by significant hypoxemia. This hypoxemia often persisted for at least ten minutes following termination of the procedure. The drop in Pa02 was not associated with significant change in the PaC02 or the pH. The control group demonstrated that premedication by itself may be followed by a slight drop in the arterial Poz but not of the magnitude which occurred following saline lavage. No significant bronchospasm was encountered in any of our patients. As shown in our study and previously reported," fiberoptic bronchoscopy by the transnasal approach without bronchial lavage does not cause a significant drop in the PaO2. It is suggested that the degree of hypoxemia which we observed to follow bronchial lavage probably results from an alteration of ventilation-perfusion balance, in that the liquid-filled terminal air units remain perfused and thus a transient increase in intrapulmonic shunting occurs. Since only small quantities of fluid were instilled into the lung, sufficient hydrostatic pressure was not created to diminish perfusion and to eliminate the shunt.12 Two recent articles have described methods of providing supplemental oxygen during fiberoptic bronchoscopy in patients who had previously undergone endotracheal intubation or tracheostomy.ls.14 We have not encountered in a review of the literature any description of a method of oxygenating patients during fiberoptic bronchoscopy by the transnasal approach. This study shows 140 DUBRAWSKY, AWE, JENKINS

that supplemental oxygen is clearly indicated in this type of procedure if the initial arterial Pop on room air is less than 70 mm Hg. Any oxygen mask which delivers at least 28 percent oxygen is probably adequate for patients who are not subject to Con retention with supplemental oxygen. In our opinion, however, the method herein described is a safe technique to prevent hypoxemia without causing hypercapnia, a point of considerable importance in patients suffering from severe chronic obstructive pulmonary disease. It is recommended that arterial blood gases be obtained prior to fiberoptic bronchoscopy. If the initial arterial Po2 on room air is less than 70 mm Hg, bronchoscopy is best performed with administration of oxygen through an appropriate mask in which a small port has been created to allow passage of the fiberoptic bronchoscope. If the patient is at risk of developing hypercapnia with supplemental oxygen, a 28 percent Ventimask usually allows adequate oxygenation without risk of hypercapnia.lS
1 Ikeda S: The flexible bronchofiberscope. Keio J Med 17:l16,1968 2 Smiddy JF, Ruth WE, Kerby GR, et al: The utility of the flexible fiberoptic bronchoscope. Chest 60:303, 1971 3 Smiddy JF, Ruth WE, Kerby GR, et al: Flexible fiberoptic bronchoscope. Ann Intern Med 75:971, 1971 4 Wanner A, Amikam B, Sackner MA: A technique for bedside bronchofiberoscopy. Chest 61 :287-288, 1972 5 Sackner MA: Bronchofiberoscopy: To intubate or not? Editorial, Chest 63:3, 1973 (Mar.) 6 Forke ME, Schoemperlen CB, Chemiak RM: Alveolar ventilation during bronchoscopy. Dis Chest 42:311-314, 1962 7 Morales ES, Krumperman LW, Cohen JG: Bronchoscopy under Diazepam anesthesia. Anesth Analg 52:414-421, 1973 8 Pender JW, Winchester LW, Jamplis RW, et al: Effects of anesthesia on ventilation during bronchoscopy. Anesth Analg 47:415-422, 1968 9 Bates DV, Macklem FT, Christie RV: Chapter 2, The normal lung: Physiology and methods of study. In Respiratory Function in Disease, 2nd ed. Philadelphia, W. B. Saunders Co, 1971, p p 59 10 Miller RG Jr: Simultaneous Statistical Inference. New York, McCraw Hill, 1966, pp 67ff 11 Kleinholz EJ, Fussell J: Arterial blood gas studies during fiberoptic bronchoscopy. Am Rev Resp Dis 108:1014, 1973 12 Rogers RM, Szidon JR, et al: Hemodynamic response of the pulmonary circulation to bronchopulmonary lavage in man. N Engl J Med 286(23) :1230-1233 (June 8 ) , 1972 13 Tahir AH: Ventilation during bronchofiberoscopy. Ann Thorac Surg 14:680-682, 1972 14 Harker AH, Schonmetzler HK, Rosenkainer SW, et al: Improved oxygenation during bronchoscopy. Ann Thorac Surg 14 :683-685, 1972 15 Beden GA, Black AJ, Ball WC: The 28 percent ventimask in obstnrctive airway disease. Arch Int Med 125: 106-113, 1970

CHEST, 67: 2, FEBRUARY, 1975

Downloaded From: https://publications.chestnet.org/ on 02/26/2013