Respiratory Therapist Role During Bronchoscopy

Bronchoscopy — flexible fiberoptic bronchoscopy (FOB) — is one of the most common invasive pulmonary procedures performed in the ICU and pulmonary practice. The respiratory therapist's role may range from pre-procedure setup and monitoring to actively assisting with airway management and sample collection, depending on the institution, the patient's clinical status, and the type of bronchoscopy being performed.

In the ICU, bronchoscopy is frequently performed at the bedside in mechanically ventilated patients. The RT is often the primary person managing airway safety, ventilator adjustments, and oxygenation support throughout the procedure — a critical role that requires preparation and anticipation.

Common indications for bronchoscopy encountered by RTs:

• Diagnostic: suspected infection, unexplained hypoxemia, hemoptysis, evaluation of masses or adenopathy
• Bronchoalveolar lavage (BAL) for infectious diagnosis (pneumonia in immunocompromised patients)
• Therapeutic: mucus plug removal, foreign body extraction, atelectasis management
• Guided intubation in difficult airways
• Endobronchial procedures (biopsy, cryotherapy) — typically in the endoscopy suite

Thorough preparation before the procedure begins reduces the risk of complications and allows the RT to focus on patient management rather than troubleshooting equipment.

RT preparation checklist for bronchoscopy in a mechanically ventilated patient:

• Review the patient's current ventilator settings, FiO₂, PEEP, and recent ABG or SpO₂ trends.
• Pre-oxygenate: increase FiO₂ to 1.0 (100%) 10–15 minutes before the procedure.
• Confirm ETT or tracheostomy size — the bronchoscope must pass through the airway without significantly obstructing ventilation. ETT sizes ≥8.0 mm are preferred for adult bronchoscopy through an ETT; smaller tubes significantly increase resistance during the procedure.
• Ensure a bronchoscopy swivel adapter is in place to allow scope insertion without circuit disconnection.
• Ensure suction is available and functional.
• Have an emergency airway kit accessible.
• Confirm monitoring: continuous SpO₂, ECG, and blood pressure are monitored throughout.
• Note current secretion character to assist with post-procedure comparison.

Oxygenation management is a primary RT responsibility during bronchoscopy. The scope occupies a significant portion of the ETT lumen, increasing airway resistance and reducing effective tidal volume delivery. In addition, BAL involves instillation and recovery of saline in the distal airways, temporarily flooding alveolar units.

Expected oxygenation changes during bronchoscopy:

• SpO₂ may decrease 5–10% during scope advancement and suction passes.
• BAL may cause more significant transient desaturation — particularly in patients with poor baseline oxygenation.
• PaO₂/FiO₂ ratio often worsens transiently post-procedure but typically recovers within 1–2 hours.

The RT communicates SpO₂ values to the bronchoscopist throughout the procedure. If SpO₂ falls below institution-defined thresholds (often <88–90%), the bronchoscopist is notified, and may need to withdraw the scope temporarily to allow recovery.

In the non-intubated patient, bronchoscopy is typically performed with high-flow nasal cannula supplementation or moderate sedation with monitored anesthesia care. RT management of oxygen delivery in this setting focuses on maintaining SpO₂ above 92% while minimizing respiratory depression risk.

For mechanically ventilated patients, the RT manages ventilator adjustments during and after bronchoscopy:

BAL is performed to collect cells and fluid from the distal airways and alveoli for diagnostic purposes — most commonly to identify infectious organisms (bacteria, fungi, viruses, mycobacteria) in immunocompromised patients or those with ventilator-associated pneumonia.

Procedurally: the bronchoscopist wedges the scope in a segmental bronchus, instills sterile saline (typically in 20–50 mL aliquots, total 100–300 mL), and aspirates the recovered fluid. Recovery is typically 40–60% of instilled volume. The remaining volume is absorbed by the lung over subsequent hours.

RT role during BAL:

• Continuous SpO₂ monitoring and communication
• Adjusting FiO₂ as needed to maintain target oxygen saturation
• Being prepared for sudden bronchospasm (have bronchodilator available)
• Ensuring sample containers are labeled and transferred appropriately to the lab

Post-bronchoscopy monitoring is as important as intra-procedure management. Many complications manifest in the 30–60 minutes following the procedure.

What to assess and document post-bronchoscopy:

• Return of SpO₂ to baseline — most patients recover within 30–60 minutes, but persistent hypoxemia warrants reassessment.
• Secretion character and volume post-procedure — BAL may produce increased secretion burden acutely.
• Breath sounds — new findings (decreased air entry, new wheeze) may indicate bronchospasm, pneumothorax, or lobar flooding.
• Ventilator parameters — ensure settings return to pre-procedure values unless physician orders a change.
• Monitor for hemoptysis if any biopsy was performed.
• Document procedure time, observations, and any significant events during the procedure.