Fibroscopie bronchique sous ventilation non invasive chez des patients atteints de bronchopathie chronique obstructive avec hypoxémie et hypercapnie

Abstract

Objectives: To assess the feasibility and safety of non invasive positive-pressure ventilation (NIPPV) via a face mask to performing fiberoptic bronchoscopy (FOB) in patients with COPD contraindicating FOB in spontaneous ventilation. Study design: Clinical, prospective, open, non comparative trial of feasibility. Patients: Ten consecutive COPD patients (71 ± 5 year-old, PaO 2 = 53 ± 13 mmHg and PaCO 2 = 67 ± 11 mmHg), without any sign of acute respiratory failure, admitted to the intensive care unit for pneumonia requiring a bronchoalveolar lavage (BAL). Including were : PaO 2 < 70 mmHg despite nasal O 2 delivered at 3 L·min –1, PaCO 2 > 50 mmHg, improvement of SpO 2 with NIPPV before FOB. Methods: Topical anaesthesia of the nose and pharynx was obtained with a 5% lidocaine spray. NIPPV was administred using a ventilatory support system Evita 4™ (Dräger) applied through a full facial mask secured to the patient with elastic straps. Patients were first allowed to acclimate for 5 min with NIPPV (IPAP = 16 cmH 2O, EPAP = 0 and trigger of 0,3 cm H2O while a FIO 2 kept at 0.7). A T-adapter Medisize™ (Péters) was attached to the facial mask. The tip of the FOB was inserted through the nose. Topical anaesthesia of the vocal cords was obtained with 1% lidocaine solution (3 mL). The FOB was inserted into the trachea up to a bronchial subsegment. BAL was performed by instillation of 100 mL of saline solution. After FOB, the NIPPV was maintained for 5 min. Heart rate, SpO 2 were measured continuously and arterial pressure at 2 min intervals. Arterial blood gas values were obtained just prior NIPPV and after 15 min and 60 min NIPPV disconnection Results: FOB duration was 11 ± 4 min. SpO 2 significantly improved during FOB (from de 91 ± 4,7% to 97% ± 1,7) without decrease of oxygen saturation lower than 90%. There were no changes in PaCO 2 and PaO 2 during the hour following the end of procedure. FOB under NIPPV was performed in all patients without complications and was very well tolerated in eight patients. After NPPV disconnecting, one patient required again NIPPV for 15 min. No patient required endotracheal intubation within 24 hours. All patients survided. Conclusion: Application of NIPPV during FOB is a safe technic for maintaining adequate gas exchange in hypoxaemic and hypercapnic COPD patients not in acute respiratory failure. After the end of the procedure a close surveillance in the intensive care unit is essential.