Patient preparation for ICU bronchoscopy

Editor/ peer reviewer: Chris Nickson

OVERVIEW

Flexible bronchoscopy is a frequently performed bedside procedure in critical care, with both diagnostic and therapeutic indications.

• The bronchoscope occupies a significant portion of the tube lumen, provokes cough, bronchospasm, and laryngospasm, and often needs to be used in patients with minimal physiological reserve.
• The majority of adverse events – desaturation, haemodynamic instability, barotrauma, bleeding, loss of the airway – are predictable and preventable. They arise from inadequate preparation far more often than from the procedure itself.

Good preparation is key!

TIME OUT

Confirm the patient and the plan

• Patient identity, weight, allergies
• Procedure and indication
• Diagnostic samples required, and to where they are going (micro, cytology, AFB, virology, cell count, etc.)
• Consider transmission precautions (e.g. for aerosol-generating procedure)

Confirm the patient can tolerate it. Check:

• blood gas
  • borderline oxygenation and ventilation will likely worsen with a scope in the lumen
• Coagulation and platelets, recent anticoagulants/antiplatelets, and whether biopsy/brushing is planned
• Haemodynamics and vasopressor requirement
• Raised ICP/ open globe/ unstable spine and any other relative contraindication to a coughing, hypertensive response (see contra-indications to flexible bronchoscopy)

Confirm kit (and plan your escape!)

• Working scope, light source, processor, image on screen, suction tested
• BAL aliquots/syringes, specimen traps and labels are ready
• Bite block, swivel/bronchoscopy elbow with diaphragm, water-soluble lubricant
• Airway and resus trolley to hand; emergency drugs drawn (see Medications below)
• Vasopressor (push-dose or infusion) immediately available; defibrillator location known
• Roles assigned and the abort plan stated

CONSENT

ICU consent is rarely straightforward – most patients are sedated, encephalopathic, delirious or intubated.

Assess capacity

• Where the patient has capacity (e.g. awake, NIV/HFNC, planned diagnostic scope), take informed consent and document it.

When the patient lacks capacity

• Proceed on a best-interests basis, involving the substitute/medical treatment decision-maker and family per your jurisdiction (e.g. in Victoria, the Medical Treatment Planning and Decisions Act 2016; in Ireland, the Assisted Decision-Making (Capacity) Act 2015; elsewhere, your local legal framework).
• Check for an advance care directive or documented ceilings of care that bear on the procedure and on escalation if it goes badly.
• In emergency situations (i.e. life-threatening lobar collapse, soiling, haemoptysis, etc.) – proceed under emergency/necessity doctrine and document.

Risks to document and specifically discuss

• Transient hypoxaemia and hypoventilation/hypercapnia
• Bronchospasm, laryngospasm, cough
• Haemodynamic instability, i.e. arrhythmia, hypo-/hypertension
• Bleeding (markedly higher with biopsy/brushing), pneumothorax
• Raised ICP, raised intraocular pressure (if relevant)
• Need for escalation of sedation, paralysis, ventilation or intubation
• Infection transmission/cross-contamination

MONITORING

The standard set (continuous)

• SpO₂
  • desaturation is the commonest adverse event. Know your pre-oxygenation baseline and plan accordingly.
• ECG
  • arrhythmia from hypoxia, hypercapnia and vagal stimulation.
• Arterial line
  • beat-to-beat BP through sedation-induced hypotension, and on-demand ABGs if required
  • If NIBP only, cycle it frequently (e.g. q1-3 min)
• Capnography
  • continuous waveform in the ventilated patient confirms ongoing ventilation around the scope and flags hypoventilation/hypercapnia; use sampling EtCO₂ in awake/spont-vent cases.

Ventilator-related (see more in Ventilator Settings, below)

• Airway pressures
  • peak/plateau pressures will inevitably climb as the scope occupies the lumen.
• Delivered vs set tidal/minute volume
  • quantifies the leak around the scope and the expected volume drop.
• Flow-time waveform
  • expiratory flow not returning to baseline is indicative of gas trapping/auto-PEEP
  • Loss of PEEP signals derecruitment from suction.

Sedation depth & neuromuscular block

• Depth of sedation
  • RASS at minimum
  • consider processed EEG (e.g. BIS or Entropy) where deep sedation with or without paralysis risks awareness.
• Train-of-four/nerve stimulator whenever neuromuscular blockade is used – especially relevant for timing sedation wean post-procedure.
• In the paralysed patient, haemodynamic surrogates (HR/BP surges) can represent discomfort

Neuro (selected patients)

• ICP/CPP if a monitor is in situ – anticipate and treat the cough-driven surge; positioning, deep sedation and topical/IV lidocaine all contribute to blunting it.

Vigilance & human factors

• Assign a person dedicated to watch the monitor
  • call out monitoring concerns, e.g. hypoxia, and ensure closed loop communication with bronchoscopist while they are task-focused (literally tunnel vision down the scope!).
• Don’t stop at the end of the procedure.
  • Continue monitoring post-procedure for delayed desaturation/derecruitment, bleeding, and pneumothorax (especially after biopsy) – low threshold for a post-procedure CXR and a defined observation period.

POSITIONING

Default set-up

• Semi-recumbent (head up 30-45°), not flat, is the usual default.
  • This improves FRC and apnoeic reserve, reduces aspiration and VAP risk, and blunts ICP rises.
• The bronchoscopist usually stands at the head of the bed, scoping down the ETT (same orientation as intubation – right is right and left is left).
• Lower the bed to the operator (or use a step if required) to ensure the scope is under tension, and place the screen in their eyeline.
• Remove the head of the bed.

Head, neck and the tube

• Neutral-to-sniffing alignment aligns the airway axes and eases scope passage. Avoid excessive flexion (kinking the tube) or rotation.
• Remember: flexion advances the ETT tip toward the carina and extension withdraws it (~1-2cm each way). Repositioning can therefore risk endobronchial migration or inadvertent extubation.
• Secure the swivel elbow/circuit first (it adds weight and torque), and re-confirm tube depth and cuff after any move.

Lateral positioning

• Haemoptysis/unilateral bleeding: affected lung down (dependent) to protect the contralateral lung from soiling. This is the opposite of the “good lung down” instinct from oxygenation teaching.
• Gravity-dependent positioning can aid targeted BAL/sampling of a specific lobe.
• In an unstable ventilated patient, a full lateral is often impractical, but a lateral tilt can still be effective.

Cohort-specific

• Obese/high BMI: ramp (i.e. ear-to-sternal-notch) or reverse Trendelenburg to recruit FRC.
• Raised ICP/neuro: head up 30°, neck strictly neutral to preserve jugular venous drainage; no head-down. Works alongside deep sedation/paralysis and topical/IV lidocaine to blunt the cough-driven ICP spike.
• Severe hypoxaemia/ARDS: Maximise head-up FRC and keep a low threshold to abort.
• C-spine/trauma: manual in-line stabilisation and a fixed neutral neck make scope passage (and any nasal route) harder – be ready!
• Fresh tracheostomy (<7 days): immature tract – neck movement risks false passage or decannulation. Minimise movement; have a reintubation kit ready.

Human-factors

• Position as part of physiological optimisation before sedation — while the patient can still be moved safely and is still breathing.
• Anticipate a mid-procedure change (desaturating → sit up; bleeding → affected side down) and verbalise a plan for this in the prebrief.
• Ensure that lines, arterial line transducer, SpO₂ probe and the BP arm aren’t trapped or pulled on every move.

AWAKE vs INTUBATED

Awake/spontaneously breathing patient

• Oxygenation strategy is vital, as there is no closed circuit. Use HFNC or “THRIVE” for apnoeic/peri-procedural oxygenation, or scope through a dedicated NIV mask or CPAP helmet port.
• Success relies on excellent topicalisation (“spray-as-you-go”) ± light, titratable sedation that preserves airway reflexes and ventilation.
• Risks
  • loss of a marginal airway, aspiration, over-sedation, laryngospasm, agitation, and a hypertensive/coughing response.
• Benefits
  • maintained ventilation and (ideally) airway tone, avoids committing a borderline patient to an ETT, ideal for the difficult-airway plan.

Intubated/ventilated patient

• Secured airway means that controlled ventilation, deeper sedation ± neuromuscular blockade can be optimised to improve conditions.
• Tube size limits scope size. A standard adult scope (OD ~5.5–6.0 mm) needs the largest available tube – ideally ≥ 8.0 mm, minimum 7.5 mm – to leave room for ventilation around it. Use a slim/diagnostic scope (~4 mm) for tubes 6.5–7.0 mm; expect higher resistance and worse leak around larger scopes.
• Scope through a swivel bronchoscopy elbow so ventilation continues; insert via the diaphragm, well lubricated.
• Tracheostomy: shorter route, but be mindful of tube length/position and the false passage in the recently formed stoma.

MEDICATIONS

Draw everything up before you start – and tailor the sedation strategy to whether the patient is breathing for themselves or is ventilated. The rescue drugs are the same either way, so have them ready regardless.

Awake/ spontaneously breathing

• Goal: workable conditions without abolishing respiratory drive or airway reflexes
• Adequate topicalisation is key.

Purpose	Agents	Notes
Sedation	Dexmedetomidine (cooperative sedation, minimal respiratory depression); ketamine (preserves drive, bronchodilates); low-dose remifentanil (titratable, blunts cough)	Be patient. Titrate slowly – the enemy is apnoea/obstruction. Avoid stacking boluses – you may end up inadvertently down the intubation route.
Topical anaesthesia	Lidocaine – spray-as-you-go, nebulised, ± transtracheal; nasal co-phenylcaine for the nasal route	Keep total ≤ 9 mg/kg LBW across all routes; less in elderly/hepatic/cardiac impairment. Watch for LAST; have Intralipid 20% locatable
Antisialogogue	Glycopyrrolate	Dries the field → better topical contact and view; mind tachycardia
Cough suppression	Topical/IV lidocaine; remifentanil	—

Intubated / ventilated

• Goal: deep, still, cough-free conditions through a secured airway.

Purpose	Agents	Notes
Deepen sedation	Propofol ± opioid (fentanyl / remifentanil); midazolam	Bolus to deepen before instrumentation; anticipate hypotension
Neuromuscular blockade	Rocuronium/ Cisatracurium	Abolishes cough, breath-holding and breath-stacking, improves the view and limits barotrauma — ensure adequate sedation depth first (e.g. RASS -5)
Cough / reflex attenuation	Lidocaine instilled via the scope	Reduces reflex bronchoconstriction; still counts toward the lidocaine ceiling
Antisialogogue (optional)	Glycopyrrolate	Cleaner view

Rescue medications – always prepared

Purpose	Agents	Notes
Haemodynamic	Metaraminol / ephedrine bolus; noradrenaline running; atropine for vagal bradycardia	Sedation + vagal stimulation = a predictable BP/HR dip — worse with deep sedation
Bronchospasm	Salbutamol (± ipratropium); ketamine adjunct	Common with airway instrumentation
Bleeding / haemostasis	Cold saline, topical adrenaline (e.g. 1:10,000), topical tranexamic acid; position bleeding side down	Plan this before any biopsy/brushing

VENTILATOR SETTINGS

A scope in the lumen is a fixed obstruction. This increase in resistance impairs expiration and leads to auto-PEEP and intrinsic gas trapping, reduced tidal volumes, and increased airway pressures. Suctioning then de-recruits by removing PEEP and volume. Anticipate and address accordingly.

Before the scope goes in:

• FiO₂ to 1.0 and pre-oxygenate/denitrogenate.
• Pick your mode:
  • Volume control (commonly used)
    • guarantees minute ventilation, but peak/plateau pressures rise around the scope. Imperative to raise the high-pressure alarm limit so the breath isn’t truncated, and watch for barotrauma.
  • Pressure control
    • caps pressure (protects against barotrauma) but tidal volume falls around the scope. You will need to accept and anticipate hypoventilation and hypercapnia, and not be surprised by the volume drop.
• Raise the high-pressure alarm limit (volume control) so the ventilator keeps delivering; widen low–tidal-volume/low–minute-volume alarms.
• Consider a lower respiratory rate/longer expiratory time to give trapped gas time to escape and limit auto-PEEP.
• Expect a leak around the scope – you may need to increase set tidal volume to compensate.

During bronchoscopy

• Minimise suction time
  • each suction decreases PEEP and lung volume
  • prolonged suction can cause mucosal trauma
  • Intermittent, brief suctioning is preferred over continuous suctioning.
• Assess the flow–time curve for gas trapping (expiratory flow not returning to zero) and the pressure waveform.
• Re-recruit and restore PEEP/FiO₂ deliberately after withdrawal.

TEAMWORK & PREBRIEF

The prebrief/huddle

• Indication & plan: what we’re looking for, what we’re sampling, how long we expect to take.
• Roles (task allocation may vary according to local practice), named out loud:
  • Bronchoscopist – drives the scope, narrates findings, documents procedure note
  • Airway/ventilation lead – responsible for sedation, the ventilator and oxygenation, watches monitor, and calls the abort (e.g. intensivist / anaesthetist)
  • Assistant/nurse – suction, BAL instillation/aspiration, specimens, syringes
  • Runner & scribe – drugs, kit, documentation during procedure
• Contingency/abort criteria, agreed in advance
  • desaturation threshold, sustained instability, significant bleeding, loss of airway
  • Explicitly outline a plan to withdraw, recruit and resuscitate.
• “Any concerns before we start?”

Teamwork during bronchoscopy

• Closed-loop communication for drugs and instructions
• The airway lead signposts physiological parameters, helping the proceduralist maintain situational awareness.
• Continuous monitoring: SpO₂, ETCO₂, ECG, BP, airway pressures/ waveforms.

After – debrief

• Did samples get sent correctly? Any complications? What would we change next time?
• A 60-second debrief is where most procedural learning (and most system fixes) occurs.

CLINICAL PEARLS & TRAPS

• Lower side rails of bed prior to setting up bronchoscopy – accidentally trapping a bronchoscope cable when lowering side rails can be an expensive, damaging mistake!
• Prepare the patient. Oxygenation reserve, coags and haemodynamics.
• Decide awake vs intubated explicitly.
• Anticipate auto-PEEP and de-recruitment; raise alarm limits, minimise suction, be ready to withdraw and reset.
• Tally your lidocaine. Know your LAST signs and where the Intralipid is.
• Vasopressor drawn up before sedation, every time.
• Brief before, debrief after. Name the abort criteria before the scope goes in.

CONCLUSION

Patient preparation is vital for performing bronchoscopy safely in the ICU. Key considerations include:

• Time out, consent, and patient monitoring
• Patient and equipment positioning
• Consideration of awake versus intubated & sedated bronchoscopy
• Medications
• Ventilator settings
• Effective teamwork, including prebrief

REFERENCES AND LINKS

LITFL

• CCC – Flexible Bronchoscope
• CCC – Bronchoscopic anatomy 
• CCC – Bronchoscopic Foreign Body Removal 
• CCC – Bronchoscopy for Percutaneous Tracheostomy
• CCC – Bronchial blockers 
• CCC – Bronchoalveolar lavage (BAL) 
• CCC – Double lumen endotracheal tube (DLT) 
• CCC – Flexible Nasopharyngolaryngoscopy 

Journal articles and Guidelines

• Du Rand IA, Blaikley J, Booton R, Chaudhuri N, Gupta V, Khalid S, Mandal S, Martin J, Mills J, Navani N, Rahman NM, Wrightson JM, Munavvar M; British Thoracic Society Bronchoscopy Guideline Group. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013 Aug;68 Suppl 1:i1-i44. doi: 10.1136/thoraxjnl-2013-203618. PMID: 23860341.
• Lemyze M, Marshall DC, Granier M, Laouki CE, Marzouk M, Mallat J. Ventilator settings for fiberoptic bronchoscopy during mechanical ventilation: a randomized adjudicator-blinded controlled trial VentSetFib. Crit Care. 2026 Jan 27;30(1):89. doi: 10.1186/s13054-026-05847-8. PMID: 41593766; PMCID: PMC12918189.
• Strohleit D, Galetin T, Kosse N, Lopez-Pastorini A, Stoelben E. Guidelines on analgosedation, monitoring, and recovery time for flexible bronchoscopy: a systematic review. BMC Pulm Med. 2021 Jun 10;21(1):198. doi: 10.1186/s12890-021-01532-4. PMID: 34112130; PMCID: PMC8193886.
• Wang M, Wang L, Zhou X, Ming W, Sheng C, Xu R, Wu Y, Chen Y, Zhang Y, Cao Y. High-flow nasal cannula oxygenation reduces desaturation risk during diagnostic flexible bronchoscopy under deep sedation: a randomized controlled trial. Front Med (Lausanne). 2026 Jan 8;12:1729660. doi: 10.3389/fmed.2025.1729660. PMID: 41585221; PMCID: PMC12823792.
• World Health Organisation. WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Geneva: WHO; 2009. [website]