What is the role of bronchoscopy in the workup of smoke inhalation injury?

Updated: Oct 15, 2021
  • Author: Keith A Lafferty, MD; Chief Editor: Joe Alcock, MD, MS  more...
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A significant number of patients may present with a paucity of upper airway signs or symptoms but may still have serious subglottic injury. The threshold for performing diagnostic bronchoscopy should be low. Bronchoscopy can be diagnostic as well as therapeutic, particularly when lobar atelectasis is present.

Bronchoscopy is the criterion standard for diagnosis of smoke inhalation injury. [43] This procedure examines the airways from the oropharynx to the lobar bronchi. Although it may be performed in the ED, the intensive care unit or burn unit may be a more appropriate setting, especially in patients who are intubated.

Erythema, charring, deposition of soot, edema, and/or mucosal ulceration may be present, although severe vasoconstriction from hypovolemia may mask significant injury. Impending airway obstruction may be inferred. Diagnostic accuracy is reported to be 86%. Fiberoptic bronchoscopy can also be used to facilitate endotracheal tube placement, even in the technically difficult airway.

Studies have shown up to a 96% correlation between bronchoscopic findings and the triad of closed-space smoke exposure, carboxyhemoglobin levels of 10% or greater, and carbonaceous sputum. In another study, serial bronchoscopy was twice as sensitive for diagnosing inhalation injury as clinical findings alone. Bronchoscopy is more sensitive and accurate than clinical examination alone in diagnosing inhalation injury and is, therefore, particularly useful in cases in which the decision to perform endotracheal intubation is unclear.

The use of bronchoscopy in patients with inhalation injury complicated by pneumonia is associated with a decreases in the duration of mechanical ventilation, length of intensive care unit stay, and overall hospital cost. [45] Serial bronchoscopy can help remove debris and necrotic cells in cases with aggressive pulmonary toilet or when suctioning and positive pressure ventilation are insufficient.

Bronchoscopy in children requires the use of a bronchoscope with a relatively small diameter, in order to accommodate the narrow pediatric airway. Extremely small diameter fiberoptic bronchoscopes with a suction port (capable of entering an endotracheal tube sized for a small toddler or infant) have only recently become available, and whether these limit the ability to remove heavy particulate matter is unclear.

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