Bronchoscopy in the ED

Emergency department bronchoscopy is uncommon but practical in selected airway emergencies. The highest-yield scenarios are suspected foreign body aspiration, complete hemithorax whiteout where mucus plugging is on the table, and unexplained hypoxemia or poor ventilation immediately after intubation.

When ED Bronchoscopy Changes Management

• Foreign body aspiration clues: Foreign body aspiration is usually a history-plus-exam diagnosis; the classic cough, wheeze, and decreased breath sounds triad appears in less than 40% of cases, so a convincing story can matter more than the textbook pattern.
• Adult aspiration risk profile: In adults, aspiration usually follows impaired consciousness or swallowing rather than bad luck alone, and small organic objects like nuts or beans are the realistic targets for an ED flexible scope.
• Whiteout tracheal position: A complete hemithorax whiteout with a midline trachea should raise mucus plugging alongside consolidation and edema, whereas tracheal shift away points more toward pleural effusion than a problem bronchoscopy will fix.
• Post-intubation rescue role: When oxygenation or ventilation worsens right after intubation, bronchoscopy can rapidly confirm the tube is above the carina and identify aspirate or mucus plugging among the immediate can’t-miss causes. We walk through that bedside differential in the episode.
• Flexible scope limitations: ED bronchoscopes have smaller suction channels than rigid scopes, so patient selection matters; bulky or smooth obstructing objects may exceed what a flexible bronchoscope can safely retrieve.

ED Bronchoscopy Setup And Pearls

• Respiratory therapist partnership: Your first call is respiratory therapy because scope diameter substantially narrows the endotracheal tube lumen, making ventilator adjustments and close coordination central to a safe procedure.
• Ventilator strategy changes: Pressure control is the preferred procedural mode, with FiO2 increased to 100% and baseline PEEP generally maintained; the practical reason is preserving ventilation despite the scope occupying tube space.
• Lidocaine through the scope: A headline move is endobronchial 1% lidocaine at the carina to blunt coughing and improve tolerance, paired with adequate analgesia and sedation before you start.
• Sampling every opportunity: Bronchoalveolar lavage should be sent whenever feasible because you are already in position to add microbiologic value, and the chapter gets into the practical collection sequence.
• Documentation that helps ICU: Procedure notes should specify what was seen, exactly where it was seen, secretion character and volume, lavage details, airway patency, bleeding, bilateral breath sounds, and the patient’s response afterward.

References:

1. Lee DH, et al. Bronchoscopy in the emergency department. Am J Emerg Med. 2022 Aug;58:114-119. PMID: 35679653.
2. White JJ, et al. Evaluation and Management of Airway Foreign Bodies in the Emergency Department Setting. J Emerg Med. 2023 Feb;64(2):145-155. PMID: 36806432.