2.8 CME

A Case Based Approach to Acute Care Bronchoscopy: Skills for the Intensivists

Speakers: Dr. med. Thushira Weerawarna, Dr. Manish Bharti, Dr. Rajesh Mishra, Dr. Ahsina Jahan Lopa, Dr. Ruth Evlin Margaretha, Dr. Sumara Maqbool

Description

A Case-Based Approach to Acute Care Bronchoscopy: Skills for the Intensivists focuses on enhancing practical bronchoscopy skills essential for managing critically ill patients. Through real-world case discussions, the session will cover key techniques, decision-making strategies, and troubleshooting during acute interventions. It aims to build confidence in handling airway emergencies, performing diagnostic procedures, and improving patient outcomes in the ICU. This interactive approach ensures intensivists are better prepared to apply bronchoscopy effectively in urgent care settings.

Summary

The session begins with a discussion on the necessity of acute care bronchoscopy skills, emphasizing the improved patient outcomes and its role as a valuable tool for intensivists. Dr. Toshira highlights the benefits observed over two decades, while Dr. Mishra emphasizes its significance in preventing complications in the ICU.
The importance of bronchoscopy in specific ICU scenarios is explored, focusing on its use in cases of sudden obstruction, hypoxia, and difficult airways. The ability to perform point-of-care bronchoscopy for immediate intervention is underscored.
The increasing incidence of community-acquired pneumonia and infectious diseases necessitates rapid and effective management strategies, including point-of-care bronchoscopy. This approach allows for faster diagnosis, targeted treatment, and potentially shorter ICU stays.
Panelists from various countries highlight the challenges in resource-limited settings, but emphasize the game-changing potential of bronchoscopy in critical situations. The need to empower bedside physicians with this skill is crucial for improving patient outcomes.
A clinical case is presented involving a young patient with severe community-acquired pneumonia, hypoxemia, and septic shock. Initial steps include resuscitation, intubation, and broad-spectrum antibiotics, with the goal of stabilizing the patient.
The debate on whether to intubate immediately or resuscitate first is discussed, with varying opinions from the panelists. The concept of "resuscitate before you intubate" is introduced, emphasizing the importance of optimizing the patient's physiology to minimize risks during intubation.
Ventilator settings are adjusted based on ultrasound findings, focusing on low tidal volume, personalized I:E ratio, and potentially higher PEEP. The discussion emphasizes the individualization of ventilation strategies based on patient-specific factors.
Driving pressure management becomes a key focus, with panelists discussing strategies to reduce it while balancing oxygenation and ventilation. The conversation delves into the complex interplay between PEEP, plateau pressure, and driving pressure, challenging traditional views.
A pleural effusion is identified and drained, leading to some improvement in airway pressures. The panel acknowledges that the ventilation is still not optimal, emphasizing the need for further adjustments to reduce driving pressure and optimize lung recruitment.
The debate shifts to the potential risks and benefits of PEEP in the context of ARDS and hemodynamic instability. The importance of optimizing hemodynamics and considering right ventricular function is emphasized when using higher PEEP levels.