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indikasi bronkoskopi : Diagnostic indications There are


numerous diagnostic indications for flexible bronchoscopy, including the
following (table 3 and table 4):
Suspected pneumonia Specimens for microbiological analysis can be
collected by flexible bronchoscopy.

Parenchymal nodules or masses Flexible bronchoscopy is a reasonable


approach for the diagnostic evaluation of large central masses [8].
Mediastinal lymphadenopathy or masses Flexible bronchoscopy with
transbronchial needle aspiration is used to sample enlarged mediastinal
lymph nodes or mediastinal masses, potentially eliminating the need for
mediastinoscopy.

Hemoptysis Flexible bronchoscopy may identify the cause of bleeding,


which is important for determining appropriate therapy and prognosis
[9]. Even if the source of bleeding cannot be identified, flexible
bronchoscopy may localize the area of bleeding, which will guide
endobronchial balloon tamponade, angiographic embolization, or surgery
[10]. (See "Etiology and evaluation of hemoptysis in adults" and "Massive
hemoptysis: Initial management".)

Suspected airway obstruction

Persistent atelectasis

Persistent infiltrate Slow or incomplete resolution of presumed


pneumonia despite treatment is common.

Suspected lung transplantation rejection

Suspected tracheobronchomalacia

Smoke inhalation

Chest trauma

Suspected tracheoesophageal and bronchopleural fistula

For therapeutic :

Mucus accumulation to suction mucus through the working channel


(ie, pulmonary toilet) may be helpful in this situation.

Foreign bodies

Endotracheal tube management Flexible bronchoscopy may be used to


guide the insertion of an endotracheal tube or to confirm the position of
an endotracheal tube [24].
Laser therapy Lasers can be used during flexible bronchoscopy to
ablate endobronchial lesions

Photodynamic therapy Photodynamic therapy is a variation of laser


therapy [25]. First, a fluorescent dye (usually a hematoporphyrin
derivative) is administered into the airway, which accumulates within
neoplastic tissue. Then, during flexible bronchoscopy, light of a certain
wavelength is used to activate the fluorescent dye, leading to the death of
the neoplastic tissue. (See "Photodynamic therapy of lung cancer".)

Electrocoagulation During electrocoagulation, a catheter containing an


electrically heated tip is passed through the working channel of a flexible
bronchoscope and used to burn away targeted tissue within the airways
[25]. Some of the catheters are designed with metal snares heated by
electrical current that can snare and burn through tissue for removal.
(See "Endobronchial electrocautery".)

Cryotherapy During cryotherapy, a catheter containing a metallic tip


that is cooled by liquid nitrogen is passed through the working channel of
a flexible bronchoscope and placed onto the targeted tissue [25]. This
causes a low temperature thermal injury that kills the tissue.
(See "Bronchoscopic cryosurgery: Principles and technique".)

Balloon dilatation Catheters analogous to those used for endovascular


angioplasty can be passed through the working channel of a flexible
bronchoscope, placed adjacent to abnormal airway narrowing, and
inflated to a controlled pressure to expand the airway [25]. This is
generally followed by endobronchial stent placement to maintain the
enlarged airway lumen. (See "Flexible fiberoptic bronchoscopy balloon
dilation".)

Brachytherapy catheters Brachytherapy involves passing a catheter


with a radioactive pellet through the working channel of a flexible
bronchoscope and placing the radioactive pellet next to the targeted
malignant tissue [25]. The radioactive pellets emit short range
radiotherapy. (See "Endobronchial brachytherapy".)

Tracheobronchial stents Expandable stents are wrapped around


catheters that can be passed through the working channel of a flexible
bronchoscope into the airways obstructed by tumor or stricture [25]. The
stents are most commonly placed in conjunction with ablative therapies
or bronchoplasty. The operator positions the stent-catheter complex at
the desired site, after which the cord wrapping the stent is unwound,
allowing the stent to expand and slide off the catheter. (See "Airway
stents".)

Bronchial thermoplasty Bronchial thermoplasty uses a special catheter


with a heated coiled at the distal end. The catheter is passed through the
working channel of a flexible bronchoscope and the coil is placed in direct
contact with the airway wall. The coil is slowly moved along the airway
with the intent of using heat to weaken smooth muscle. This procedure is
directed towards severe asthmatics with the goal of limiting
bronchospasm by permanently weakening the smooth muscles of the
airway [26]. (See "Alternative and experimental agents for the treatment
of asthma", section on 'Bronchial thermoplasty'.)

2. kontraindikasi bronkoskopi : Most contraindications to


flexible bronchoscopy are related to the potential for bronchoscopy to
cause tachycardia, bronchospasm, or hypoxemia.

Contraindications include current or recent myocardial ischemia; poorly


controlled heart failure; significant hypotension, hypertension,
bradycardia, or tachycardia; exacerbation of asthma or chronic
obstructive pulmonary disease; severe hypoxemia; and life-threatening
cardiac arrhythmias.

Additional contraindications exist when brushing, biopsy, or needle


aspiration is planned, which are related to bleeding risk. They include
recent anti-platelet agents (eg, aspirin, clopidogrel), anticoagulant
therapy, thrombocytopenia, coagulopathy, elevated blood urea nitrogen
(BUN), or elevated serum creatinine.

We postpone non-emergent bronchoscopy in patients who are currently


having or have had any of the following events within the past six weeks:
myocardial ischemia (ie, unstable angina, myocardial infarction),
decompensated heart failure, an exacerbation of asthma or chronic
obstructive pulmonary disease, or life-threatening cardiac arrhythmias
[27].

We avoid non-emergent bronchoscopy in patients with severe


hypoxemia, which we define as a resting arterial oxygen tension (PaO2)
<60 mmHg or an oxyhemoglobin saturation (SpO2) <90 percent while
receiving a fraction of inspired oxygen [FiO2] 50 percent [27].

We avoid non-emergent brushing, biopsy, or needle aspiration in patients


who have taken an antiplatelet agent within the past five days or
subcutaneous low molecular weight heparin in the past 12 hours, or who
have a platelet count of 50,000 platelets/mm3 or lower, an international
normalized ratio (INR) of 1.3 or greater, or an elevated partial
thromboplastin time (PTT) [27,28]. For patients who receive platelets or
fresh frozen plasma to correct the abnormality, we repeat the relevant
laboratory study to confirm that the abnormality has been corrected,
before proceeding with the procedure.
Among patients whose BUN >30 or whose serum creatinine is >2 mg/dL,
we generally administer desmopressin (DDAVP) approximately 30
minutes before the procedure if brushing, biopsy, or needle aspiration is
anticipated [27].

3. Thorakoskopi : The major indication for diagnostic medical


thoracoscopy is an exudative pleural effusion of unknown etiology
(biopsy pleura). Often at the time of thoracoscopy, the etiology turns out
to be mesothelioma, lung cancer, tuberculosis, or a benign pleural
disorder. In some hands, medical thoracoscopy is used to evaluate
pulmonary parenchymal disease.

4. Pleurodesis : Indikasi Efusi pleura maligna, pneumothorax, efusi


pleura non maligna (rekuren; heart failure, renal failure). Kontraindikasi
Produksi cairan >150mL per hari (dari chest drain), Efusi pleura masih
tampak banyak pada rontgen thoraks, Curiga infeksi pleura, Kondisi
pasien tidak stabil

5. Weaning ventilator : Syarat lung disease is stable/ resolving,


low FiO2 (< 0.5) and PEEP (< 5-8cmH2O) requirement, haemodynamic
stability (little to no inopressors), able to initiate spontaneous breaths
(good neuromuscular function).

MANAGEMENT TO AVOID DELAYED WEANING


Optimize Respiratory Muscle Power
nutrition
avoid neuromuscular blocking drugs, decrease steroid use and
other contributors to critical illness-induced weakness
encourage spontaneous breathing but avoid exhaustion
normal electrolytes
normal FRC
physiotherapy
Decrease Respiratory Work
sit up
decrease respiratory demand:
decrease CO2: treat pyrexia, treat agitation, avoid overfeeding,
minimise dead space
correct metabolic acidosis
decrease resistance: large, short diameter ETT, treat disease,
decrease WOB
increase compliance: treat lung disease; decrease abdominal
distention (chest wall factors are not usually reversible)
Optimise ventilatory drive
stop sedation
consider causes from the brain to the neuromuscular junction
Increase oxygenation and carrying capacity
sit up and avoid atelectasis
correct anemia
correct acid-base disturbance (shift in Hb-O2 dissociation curve)
Address cardiac dysfunction
removal of PPV may unmask LV dysfunction
treat ischemia
Address sputum clearance
treat infection, chest physiotherapy, suction, bronchoscopy
mucolytics are controversial

PREDICTORS OF WEANING FAILURE


advanced age
prolonged mechanical ventilation
COPD
increased minute ventilation
positive fluid balance

TECHNIQUES OF WEANING
Techniques include:
gradual reduction in mandatory rate during intermittent
mandatory ventilation
gradual reduction in pressure support
spontaneous breathing through a T-piece
spontaneous breathing with ventilator on flow by and PS=0 with
PEEP=0

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