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Chapter 18. Diagnostic Flexible Bronchoscopy

Which of the following would benefit most from a diagnostic flexible bronchoscopy?

a. A 34-year-old man with HIV and low CD4+ count who developed fever and nonproductive cough over the past week; his chest x-ray reveals diffuse opacities.

b. A 60-year-old woman with hypertension who developed fever, cough productive of "rusty" sputum, and right-sided pleuritic chest pain over the past 4 days; her chest x-ray reveals an infiltrate in the right lower lobe.

c. A 28-year-old woman just admitted to the ICU with ARDS after nearly drowning in salt water; she is intubated and being ventilated at FIO2 = 1.00 and PPEAK = 30 cm H2O to maintain her SaO2 at 88%.

d. A 70-year-old diabetic man with worsening cough, frothy sputum and shortness of breath over the past 2 days; his chest x-ray reveals bilateral pleural effusions and bilateral perihilar infiltrates, and he is tachycardic with an irregular heart rhythm.

The most correct answer is a.

The 34-year-old man with HIV and a low CD4 count may have a typical community acquired pneumonia, but is at risk for a wide range of opportunistic infections. A diagnostic flexible bronchoscopy with BAL will help to determine the pathogen and most appropriate therapy. The 60-year-old woman likely has typical community acquired pneumonia and would not require a diagnostic bronchoscopy unless her sputum studies were not diagnostic and she failed to improve with appropriate therapy (answer b). The 28-year-old woman with ARDS after a near drowning will require appropriate ventilator therapy for her lung injury. Bronchoscopy may actually be contraindicated given her high FIO2 requirements and high airway pressures (answer c). The 70-year-old diabetic man likely has congestive heart failure and does not require bronchoscopy (answer d).

Which of the following is the most serious contraindication to performing diagnostic flexible bronchoscopy?

a. Arterial [Hb] = 7.5 g/dL

b. Implanted cardiac pacemaker and defibrillator

c. Intubated patient with severe obstructive sleep apnea

d. Hypercarbic respiratory failure requiring non-invasive mechanical ventilation

The most correct answer is d.

Hypercarbic respiratory failure would preclude a safe diagnostic bronchoscopy without the presence of a secured airway via endotracheal intubation. Moderate anemia (answer a), cardiac pacemakers and defibrillators (answer b), or severe obstructive sleep apnea in a patient with a secure airway via endotracheal intubation (answer c) ...

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