Réanimation

, Volume 22, Issue 1, pp 100–106 | Cite as

La fibroscopie bronchique chez le patient de réanimation hypoxémique et non intubé: modalités pratiques

Note Technique / Technical Note
  • 330 Downloads

Résumé

Malgré le développement d’outils diagnostiques non invasifs, la fibroscopie bronchique avec lavage bronchoalvéolaire (FB-LBA) garde toujours une place déterminante dans la quête diagnostique devant un patient admis en réanimation pour insuffisance respiratoire aiguë hypoxémiante. C’est parfois le seul examen qui permet d’apporter le diagnostic final. Elle permet aussi de mieux cibler les traitements et donc d’en réduire les effets secondaires. Pour être bénéfique au patient, la FB-LBA doit s’intégrer dans une démarche diagnostique raisonnée, être réservée à des populations ciblées et être pratiquée par des équipes entraînées. De nombreux travaux ont démontré que, sous couvert d’un certain nombre de précautions, ce geste peut être réalisé en toute sécurité même chez des patients profondément hypoxémiques et non intubés. La réalisation de la FB-LBA sous ventilation non invasive est un moyen d’en réduire le retentissement respiratoire. Certains auteurs ont également montré que l’ajout d’une sédation permet d’en améliorer la tolérance.

Mots clés

Fibroscopie bronchique Lavage bronchoalvéolaire Sédation Ventilation non invasive Propofol Sédation Insuffisance respiratoire aiguë 

Modalities of fiberoptic bronchoscopy in the critically ill non-intubated hypoxemic patients

Abstract

Despite the development of non-invasive diagnostic tools, bronchoscopy with bronchoalveolar lavage (FB-BAL) still plays a key role in the diagnostic challenge faced while managing patients admitted to the intensive care unit with acute hypoxemic respiratory failure. FB-BAL often represents the most helpful test to assess the final diagnosis and to allow targeting treatments and reducing their side-effects. FB-BAL should be performed in selected patients by trained physicians. To be beneficial, FB-BAL should be integrated into a clear diagnostic strategy and its benefits balanced with its possible risks in the hypoxemic patients. Several studies have assessed that FB-BAL is safe even in spontaneously breathing hypoxemic patients. In these patients, non-invasive positive pressure ventilation has been shown to prevent any worsening in respiratory conditions and avoid tracheal intubation in comparison to conventional oxygen supply. Sedation was suggested to additionally improve FB-BAL safety.

Keywords

Fiberoptic bronchoscopy Bronchoalveolar lavage Sedation Non-invasive positive pressure ventilation Propofol Target-controlled infusion Acute respiratory failure 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

Supplementary material

13546_2012_535_MOESM1_ESM.pdf (210 kb)
Supplementary material, approximately 210 KB.

Références

  1. 1.
    Azoulay E, Alberti C, Bornstain C, et al (2001) Improved survival in cancer patients requiring mechanical ventilatory support: impact of non-invasive mechanical ventilatory support. Crit Care Med: 519–525Google Scholar
  2. 2.
    Azoulay E, Thiéry G, Chevret S, et al (2004) The prognosis of acute respiratory failure in critically ill cancer patients. Medicine 83:360–370PubMedCrossRefGoogle Scholar
  3. 3.
    Hilbert G, Gruson D, Vargas F, et al (2001) Non-invasive ventilation in immunosupressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 344:481–487PubMedCrossRefGoogle Scholar
  4. 4.
    Murray PV, OBrien M, Padhani AR, et al (2001) Use of the first line bronchoalveolar lavage in the immunosupressed oncology patient. Bone Marrow Transplant 27:967–971PubMedCrossRefGoogle Scholar
  5. 5.
    Azoulay E, Mokart D, Rabbat A, Schlemmer B (2008) Diagnostic bronchoscopy in hematology and oncology patients with acute respiratory failure: prospective multicenter data. Crit Care Med 36:100–107PubMedCrossRefGoogle Scholar
  6. 6.
    Spanavello A, Migliori GB, Satta A, et al (1998) Bronchoalveolar lavage causes decrease in PaO2, Increase in (A-a) gradient value and bronchoconstriction in asthmatics. Respir Med 92:191–197CrossRefGoogle Scholar
  7. 7.
    Bauer TT, Arosio C, Monton C, et al (2001) Systemic inflammatory response after bronchoalveolar lavage in critically ill patients. Eur Respir J 17:274–280PubMedCrossRefGoogle Scholar
  8. 8.
    Pugin J, Suter PM (1992) Diagnostic bronchoalveolar lavage in patients with pneumonia produces sepsis-like systematic effects. Intensive Care Med 18:6–10PubMedCrossRefGoogle Scholar
  9. 9.
    American Thoracic Society (1990) Clinical role of bronchoalveolar lavage in adults with pulmonary disease. Am Rev Respir Dis 142:481–486CrossRefGoogle Scholar
  10. 10.
    Trouillet JL, Guiguet M, Gibert C, et al (1990) Fiberoptic bronchoscopy in ventilated patients. Evaluation of cardiopulmonary risk under midazolam sedation. Chest 97:927–933PubMedCrossRefGoogle Scholar
  11. 11.
    Antonelli M, Conti G, Riccioni L, Meduri G (1996) Non-invasive positive pressure ventilation via face mask during bronchoscopy with BAL in high risk hypoxemic patients. Chest 110:724–728PubMedCrossRefGoogle Scholar
  12. 12.
    Maitre B, Jaber S, Maggiore SM, et al (2000) Continuous positive airway pressure during fiberoptic bronchoscopy in hypoxemic patients. Am J Crit Care Med 162:1063–1067CrossRefGoogle Scholar
  13. 13.
    Antonelli M, Conti G, Rocco M, et al (2002) Non-invasive positive-pressure ventilation versus conventional oxygen supplementation in hypoxemic patients undergoing diagnostic bronchoscopy. Chest 121:1149–1154PubMedCrossRefGoogle Scholar
  14. 14.
    Azoulay E, Mokart D, Lambert J, et al (2010) Diagnostic strategy for hematology and oncology patients with acute respiratory failure. Am J Respir Crit Care Med 182:1038–1046PubMedCrossRefGoogle Scholar
  15. 15.
    (2006) Ventilation non-invasive au cours de l’insuffisance respiratoire aiguë (nouveau-né exclu). In: 3e Conférence de consensus commune organisée par la SFAR, SPLF et la SRLF; 2006; ParisGoogle Scholar
  16. 16.
    Antonelli M, Alberto Pennisi M, Conti G, et al (2003) Fiberoptic bronchoscopy during non-invasive positive pressure ventilation delivered by helmet. Intensive Care Med 29:126–129PubMedGoogle Scholar
  17. 17.
    Heunks L, De Bruin C, Van der Hoeven J, Van der Heijden H (2010) Non-invasive mechanical ventilation for diagnostic bronchoscopy using a new fac mask: an observational feasibility study. Intensive Care Med 36:143–147PubMedCrossRefGoogle Scholar
  18. 18.
    Chiner E, Sancho-Chust JN, Llombart M, et al (2010) Fiberoptic bronchoscopy during nasal non-invasive ventilation in acute respiratory failure. Respiration 80:321–326PubMedCrossRefGoogle Scholar
  19. 19.
    Gonzalez R, De-la-Rosa-Ramirez I, Maldonado-Hernandez A, Dominguez-Cherit G (2003) Should by patients undergoing a bronchoscopy be sedated? Acta Anaesthesiol Scand 47:411–415PubMedCrossRefGoogle Scholar
  20. 20.
    Putanati S, Ballerin J, Corbetta L (1999) Patient satisfaction with conscious sedation for bronchoscopy. Chest 115:1437–1440CrossRefGoogle Scholar
  21. 21.
    Allen MB (1995) Sedation in fiberoptic bronchoscopy. BMJ 310:1333PubMedCrossRefGoogle Scholar
  22. 22.
    Silvestri G, Vincent B, Wahidi M, et al (2009) A phase 3, randomized, double-blind study to assess the efficacy and safety of fospropofol disodium injection for moderate sedation in patients undergoing flexible bronchoscopy. Chest 135:41–47PubMedCrossRefGoogle Scholar
  23. 23.
    Matot I, Kramer M (1997) Sedation in outpatient fiberoptic bronchoscopy: alfentanil-propofol vs meperidine-midazolam. Anesthesiology 87(Suppl 3):12 AGoogle Scholar
  24. 24.
    Maguire GP, Rubinfeld AR, Trembath PW, Pain MC (1998) Patients prefer sedation for fiberoptic bronchoscopy. Respirology 3:81–85PubMedCrossRefGoogle Scholar
  25. 25.
    British Thoracic Society Interventional Bronchoscopy Guideline group (2011) British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax 66(Suppl 3: iii):1–21Google Scholar
  26. 26.
    Wood-Baker R, Burdon J, MacGregor A, et al (2001) Fiber-optic bronchoscopy in adults: a position paper of the Thoracic Society of Australia new Zealand. Intern Med J 31:479–487PubMedCrossRefGoogle Scholar
  27. 27.
    Clouzeau B, Bui HN, Guilhon E, et al (2011) Fiberoptic bronchoscopy under non-invasive ventilation and propofol target-controlled infusion in hypoxemic patients. Intensive Care Med 37:1965–1975CrossRefGoogle Scholar
  28. 28.
    Clouzeau B, Bui HN, Vargas F, et al (2010) Target-controlled infusion of propofol for sedation in patients with non-invasive ventilation failure due to low tolerance: a preliminary study. Intensive Care Med 36:1675–1680PubMedCrossRefGoogle Scholar
  29. 29.
    Hilbert G, Clouzeau B, Bui HN, Vargas F (2012) Sedation during non-invasive ventilation. Minerva Anestesiol 78:842–846PubMedGoogle Scholar
  30. 30.
    Clouzeau B, Vargas F, Boyer A, et a (2011) Place et modalités de la sédation au cours de la ventilation non-invasive. Reanimation 20:389–396CrossRefGoogle Scholar
  31. 31.
    Dreher M, Ekkernkamp E, Hendrik Storre J, et al (2010) Sedation during flexible bronchoscopy in patients with preexisting respiratory failure: midazolam versus midazolam plus alfentanil. Respiration 79:307–314PubMedCrossRefGoogle Scholar
  32. 32.
    Baumann H, Klose H, Simon M, et al (2011) Fiber optic bronchoscopy in patients with acute hypoxemix respiratory failure requiring non-invasive ventilation: a feasibility study. Crit Care 15:R179PubMedCrossRefGoogle Scholar
  33. 33.
    Azoulay E, Mokart D, Rabbat A, et al (2008) Diagnostic bronchoscopy in hematology and oncology patients with acute respiratory failure: prospective multicenter data. Crit Care Med 36:100–107PubMedCrossRefGoogle Scholar
  34. 34.
    Chernik DA, Gillings D, Laine H, et al (1990) Validity and reliability of the Observer’s Assessment of Alertness/Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol 10:244–251PubMedCrossRefGoogle Scholar

Copyright information

© Société de réanimation de langue française (SRLF) and Springer-Verlag France 2012

Authors and Affiliations

  1. 1.Medical Intensive Care UnitPellegrin Teaching HospitalBordeaux cedexFrance

Personalised recommendations