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Primum Non Nocere: How To Cause Chaos With a Bronchoscope in the ICU

Andrew Bush, MD*
Author and Funding Information

Dr. Bush is Professor of Paediatric Respirology, Department of Paediatrics, Royal Brompton Hospital.

Correspondence to: Andrew Bush, MD, Department of Paediatrics, Royal Brompton Hospital, Sydney St, London, SW3 6NP, UK; e-mail: a.bush@imperial.ac.uk

The author has no conflict of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


The author has no conflict of interest to disclose.

The author has no conflict of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(1):2-4. doi:10.1378/chest.08-2160
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Extract

Chevalier Jackson, the father figure of bronchoscopy, once famously remarked that if doubt existed whether a bronchoscopy should be performed, then a bronchoscopy ought to be performed. Had he the opportunity to perform fiberoptic bronchoscopy in pediatric and neonatal ICUs, he may well have sung a different song. The performance of a bronchoscopy is deceptively easy: the patient is intubated, there is no upper airway to traverse, no esophagus lying in wait for the inexperienced to enter by mistake, coughing or agitation (except in the bronchoscopist) is unlikely to be an issue; but in no other context is there the need to carefully weigh risk vs benefit. These children are by definition critically ill and may be easy to destabilize. They may be at risk of pulmonary hypertensive crises, systemic hypotension, and intracranial hemorrhage, any of which may be adversely impacted by blocking part of the endotracheal tube with a solid telescope.1 There are benefits for sure,2,3 but in one series,2 10% of children desaturated by ≥ 20%, and 17% required a fluid bolus for resuscitation as a result of bronchoscopy in ICU. Depending on the patient group, important diagnoses were made in 44 to 90% of the patients.

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