Does anyone know of a hospital where I could do a diagnostic bronch rotation and get a decent number of critical care bronchs? I am in a two year CC program but unfortunately we do not get that many opportunities due to pulm fellows. I was considering doing an IP rotation, but I won't ever be doing EBUS or navigational bronchs.
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Bronchoscopy Rotation
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Please tell me you are going to graduate with at least the ACGME required 50 bronchs +/- BAL/Brush. It's not that difficult to get 50 with just ICU rotations. I had 10 after my first 2 months in the unit as a fellow! It is unfortunate that your program is letting this happen.
Can you do a surgical or trauma ICU rotation? There are some patients we would bronch practically every other day. Same with Burn ICU, although those are much less common.
D
deleted171991
Classical example of bad medicine.
I will be doing a trauma rotation, but I am not sure how many bronchs are available during those rotations. Unfortunately, we don't have that many opportunities, both because not that many diagnostic bronchs are done in general and additionally because pulm/cc here seems less reluctant to share in order to maximize how many their fellows get. At most, there are 1-2 per week. I know some programs have dedicated ICU consult or Pulm consult services that do all of the inpatient diagnostic bronchs. I was hoping to do a rotation with one of those programs in order to get better exposure.
I did a CC fellowship and graduated with 150 critical care broncos with BAL, 25 bronch/bx and 25 EBUSes . It helped that my CC program was run by the pulm docs and I did a month of pulm and 2 half months of IP. My IP guy always needed a fellow to help which he didn't have and since I was willing to stay late if required I got the required number of bronchs. This EBUS/navigational/bronch with bx was definitely overkill but because of it I can handle the scope like a boss. If you have an IP guy get close to him and tell him you want some bronch practice.
Another potential bronch opportunity is perc trachs. Most of these are done with bronch guidance nowadays. Try approaching your perc trach service in your hospital, and ask if you can do the bronchoscopy portion. You can get a high volume of this in the neuro/stroke ICU.
I'm in the same boat. Maybe it's just a coincidence but all the ICUs i've worked in so far as a resident and now fellow very seldom do bronchs, outside of perc trachs and organ donor workups. For those of you in centres where you are doing lots of bronchs - what are your indications? And how is it changing your management?
D
deleted171991
Maximize the indications table and carefully read the footnotes, too: Bronchoscopy - Pulmonary Disorders - Merck Manuals Professional Edition
Most ICU bronchoscopies will not change outcomes, hence there is no reason to expose patients to their risks and unpleasantness. They should be almost a last resort, not first, as in the
Somebody bronching a lot of patients in the ICU is almost always an indicator of a bad/greedy doctor.
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Appropriate indications for ICU bronchs: unexplained non-improving patients with infiltrates (usually bilateral) needing BAL/brushing for diagnostic work up, hemoptysis, mucus plugging, and perc trachs. I have also several times bronched for removal of foreign body.
Bronchs on ICU patients usually isn't necessary. Mostly, obvious mucous plugging that is causing a significant worsening in hypoxia not resolving or not very likely to resolve with nebs and treatments. And that's about it really. Every once in awhile I'll bronch a new infiltrate on an intubated patient if I'm confident it's a new infection so I can get an idea about bugs for final abx. You have to bronch hemoptysis to get an idea about source and etiology even though it often doesn't clear much up. The BAL can help in these cases.
I'll generally only bronch patients with at least a lobar atelectasis. Otherwise there's better diagnostic/therapeutic modalities to use.
I might also bronch to visualize the airway mucosa sometimes. Direct visualization of normal looking airways can provide evidence against pneumonia, and help with antibiotic stewardship.
I might also bronch to visualize the airway mucosa sometimes. Direct visualization of normal looking airways can provide evidence against pneumonia, and help with antibiotic stewardship.
I once bronched this older guy who was a transfer from another hospital with non resolving PNA for 4-5 days and now got intubated. Regular guy, married, very decent wife a retired administrator. No h/o cancer or immunosuppressives . Our bronch test panel is kind of broad with mycobacteria/PCP/CMV.
Turned out he had PCP and from that we figured out he had HIV. Turns out this respectable old man with children and grandchildren was really fond of getting anal receptive sex from random strangers. We had to break this news to his wife as he wouldn’t tell her himself and she pulled the plug on him the next day.
Turned out he had PCP and from that we figured out he had HIV. Turns out this respectable old man with children and grandchildren was really fond of getting anal receptive sex from random strangers. We had to break this news to his wife as he wouldn’t tell her himself and she pulled the plug on him the next day.
Jesus. Was he unsavable?
He was pretty sick probably in the fibroproliferative state of ARDS from PCP. Didn’t help that he got Bactrim more than a week after developing PNA. Probably he was glad that we pulled the plug. It saved him from that confrontation with his wife and children about what he had been up to all these years.
So uncool to be holding the bronchoscope in a perc trach. Much better to have the attending hold the scope while you do the trach.
Ha. Bazinga!
