Pulmonology

Bronchoscopy in the emergency department

a b s t r a c t

Background: Flexible bronchoscopy has been safely used for decades in ambulatory and critical care settings to aid in the diagnosis and treatment of tracheobronchial tree disorders. Although emergency physicians have the requisite skills to operate and interpret flexible bronchoscopy, no reports exist on the use of bronchoscopy by emergency physicians apart from endotracheal tube placement and confirmation.

Objective: The primary goal of this study was to describe the indications, outcomes and complications of flexible bronchoscopy performed by emergency physicians in an urban academic emergency department.

Methods: This was a single-center retrospective cohort study involving chart and video review of 146 patients over a 10.5-year study period. Patients of any age were included if they had been tracheally intubated or mechan- ically ventilated and underwent flexible bronchoscopy in the emergency department. After patients were identified, manual chart and video review was used to collect data on patient demographics, indications for intubation, indications for bronchoscopy, details of the bronchoscopy procedure, procedural findings, outcomes of the procedure, complications, provider training levels, and additional bronchoscopies performed after admis- sion. The data was analyzed using descriptive statistics.

Results: 146 patients were included in the study and all bronchoscopies were performed or supervised by attend- ing emergency physicians. After bronchoscopy, 24% of patients displayed improvement in oxygenation or lobar collapse while most patients had no change in clinical status. One patient had temporary hypoxemia after bronchoscopy. When another physician performed a subsequent bronchoscopy during admission, the findings were in agreement with the ED bronchoscopy 86% of the time.

Conclusion: At our institution, emergency physicians can safely and effectively use flexible bronchoscopy to diagnose and treat critically ill patients.

Introduction
1. Background

Flexible bronchoscopy, developed in its modern form in the late 1960s, is an important tool to diagnose and treat disorders of the tra- cheobronchial tree and the lung parenchyma [1]. In awake patients

* Corresponding author at: Department of Emergency Medicine, 4647 Zion Ave, San Diego, CA 92120, USA.

E-mail address: [email protected] (D.H. Lee).

after topical upper airway anesthesia, the bronchoscopist can inspect the large airways, sample the alveolar space, and suction or otherwise remove obstructing material in bedside procedures that are generally well-tolerated [2,3]. Tracheal intubation over a flexible bronchoscope is a useful technique for elective or emergent airway management in a spontaneously breathing patient [4]. Furthermore, flexible bronchos- copy is a straightforward diagnostic and potentially therapeutic proce- dure in critically ill patients who are receiving mechanical ventilation through an endotracheal tube, as the risk of hypoxemia, upper airway injury, or procedural intolerance are decreased [5-7]. The most common indications for emergency bronchoscopy include evaluation and

https://doi.org/10.1016/j.ajem.2022.05.040

potential treatment for lobar collapse, pulmonary edema, structural ob- struction or stenosis, pneumonia, hemoptysis, traumatic airway injury, and difficult endotracheal intubation [8].

1. Importance

Flexible bronchoscopy is a rapid diagnostic and potentially life-saving procedure with few complications, using equipment (i.e., a flexible endoscope) that is familiar to emergency physicians [6,8]. Tradi- tionally, the high cost of reusable bronchoscopes made them unavail- able to most emergency physicians, but now several manufacturers offer disposable bronchoscopes at a lower cost. No literature exists to describe flexible bronchoscopy performed in the emergency depart- ment (ED) by emergency physicians, outside of endotracheal tube placement and confirmation [4,9,10].

1. Goals of investigation

The aim of this retrospective study was to describe the indications, outcomes, and complications of flexible bronchoscopy performed by emergency physicians at an Urban academic ED.

Material and methods
1. Study design

This was a single-center retrospective cohort study of patients who underwent ED bronchoscopy during a 10.5-year study period. The study was performed at an urban academic ED with approximately 100,000 patient encounters annually. Approximately 85,000 patients are adults and the remaining are pediatric patients. The local institu- tional review board approved this study.

1. Study setting and procedure details
  1. Physician training

At the institution where this study was performed, flexible bron- choscopy has been used in the ED since 1982. Although initially used to facilitate endotracheal intubation of patients with upper airway ob- struction, the indications for flexible bronchoscopy expanded in subse- quent years to include diagnosis and treatment of tracheobronchial pathology. The first emergency physicians to use flexible bronchoscopy at this institution were self-taught and subsequent generations of ED physicians learned in an informal manner from their predecessors.

Currently, the majority of airway procedures in our ED, including flexible bronchoscopy, are performed by senior emergency medicine residents; the remainder are performed by junior emergency medicine residents and attending emergency physicians. All residents undergo annual hands-on manikin-based training with flexible endoscopes, and these skills are able to translate directly when resident physicians are performing bronchoscopy under faculty supervision. Emergency physicians at this institution are solely responsible for the decision- making around, and performance of, ED tracheal intubation.

- 1. Procedure details

During the study period, all ED bronchoscopy was performed with either a reusable Flexible Video Intubation Endoscope (11,301 BNX, Karl Storz Endoscopy-America Inc., Culver City, CA) connected to a stan- dard C-MAC monitor or a disposable Ambu aScope 3 (Ambu Corp, Ballerup, Denmark) connected to an Ambu aView monitor. The distal tip outer diameter of the reusable Storz endoscope is 5.5 mm and

5.0 mm for the disposable Ambu aScope regular size. These are the en- doscopes we routinely use for bronchoscopy as opposed to slim or pediatric endoscopes, which are not as useful for suctioning. These bronchoscopes have separate ports for suction and irrigation which both access the working channel of the instrument. After a swivel

adapter is connected between the endotracheal tube and the ventilator circuit, a bronchoscope can be inserted into the side port of the swivel adapter and passed into the endotracheal tube (Fig. 1). This allows for oxygenation and ventilation during the procedure. In the majority of ED bronchoscopies, Respiratory therapists provide assistance by setting up suction tubing connected to the bronchoscope, attaching the swivel adapter, and managing Ventilator settings and alarms during the procedure.

1. Selection of participants

A hospital data analyst identified ED patients of any age seen be- tween January 1st, 2009 through June 30th, 2019, who were docu- mented to have been tracheally intubated or mechanically ventilated in the ED and had any of the following words in an ED provider note: en- doscope, endoscopy, endoscopic, bronchoscope, bronchoscopy, bronch, scope, fiberoptic, fiber optic. Each chart resulting from this automated search was reviewed to determine if bronchoscopy was performed while the patient was already receiving mechanical ventilation in the ED. Those determined to have undergone bronchoscopy from this re- view underwent a full structured chart review.

1. Methods of measurement

A senior investigator met with medical student abstractors to train them in structured chart review and use of the electronic data collection form. The abstractors reviewed the electronic medical record using Epic (Verona, WI) for each patient and entered data into a standardized form using REDcap [11]. Our institution maintains video archives of critical resuscitations for quality improvement and education. These are stored separately from the electronic medical record. In addition to chart re- view for each patient, abstractors were also trained to review video, when available, to assist in collecting study variables. The initial data collection form was refined after review of the first 10 patients. The study team met periodically to re-train and answer questions about data collection to ensure data uniformity.

Using manual chart review, abstractors collected data on patient demographics, indications for intubation, indications for bronchoscopy, and details of the bronchoscopy procedure. Bronchoscopy details in- cluded: equipment used, procedural target, subsequent findings as de- scribed in the procedure note, procedural findings, procedures performed, and outcome of the procedure, including documented com- plications during and immediately after the procedure. Characteristics of the ED provider performing and supervising the procedure were re- corded, including training level, and in the case of attending physician, additional formal critical care Fellowship training. Data on additional bronchoscopies performed after patient admission to the hospital were collected and compared with the ED bronchoscopy report.

Hypoxemia was defined as an oxygen saturation less than 90% based on pulse oximetry. Improved oxygenation after bronchoscopy was de- fined as either the resolution of hypoxemia or an increase in oxygen sat- uration by greater than 10%. Improved lobar collapse was defined by chest radiographic findings of improved aeration in the affected lobe. Worsened oxygenation after bronchoscopy was defined as any decrease in oxygen saturation compared to the start of the procedure. Persistent hypoxemia in this study refers to hypoxemia (oxygen saturation less than 90%) after intubation without a clear explanation despite the ad- ministration of 100% fraction of inspired oxygen. Bronchoscopy was performed in patients with persistent hypoxemia in order to rule out mucus plugging, aspirated foreign bodies, and to assess the location of the endotracheal tube.

In some instances, data were not able to be collected from chart re- view and were recorded as missing with no assumed value. We tabu- lated the number of observations with missing data for each variable and displayed them as table footnotes.

Image of Fig. 1

Fig. 1. (A) A swivel adapter connected between an endotracheal tube and a ventilator circuit. (B) Setup demonstrating a bronchoscope loaded into the port and through the connected endotracheal tube. The ventilator circuit is still connected to the endotracheal tube via the swivel adapter and provides continuous ventilation during bronchoscopy.

1. Primary data analysis

Baseline patient and Operator characteristics and procedural process measures and outcomes were analyzed using descriptive techniques; frequencies, proportions, and medians are presented as appropriate. Stata version 15.1 (Statacorp, College Station, TX) was utilized for data analysis.

Results

In the initial database search, 160 patients were found who had bronchoscopy done in the ED. Fourteen of those patients were subse- quently excluded from the study because they were not intubated or mechanically ventilated and only underwent flexible endoscopy of the upper airway (evaluation of airway structures proximal to the vocal cords). This left 146 patients in the final analysis. Of these, 125 patients were orotracheally intubated in the ED and all patients were mechani- cally ventilated. The 21 patients who were mechanically ventilated in the ED but not intubated all had pre-existing tracheostomy tubes.

In order to calculate Interobserver agreement, a second abstractor reviewed 20% of the charts to review primary and secondary outcome values; an unweighted ? value was calculated. For outcome of bron- choscopy, agreement was 87% (k = 0.63); for occurrence of any compli- cation, agreement was 100% (k = 1).

Throughout the 10.5-year period of investigation, the number of ED bronchoscopy procedures generally increased with time. In the first half of the study period, 34 (23%) ED bronchoscopies were performed com- pared to 112 (77%) performed in the latter half of the study period. The bronchoscopy procedure itself did not change substantially and no trend in outcomes was detected over the study period.

All bronchoscopies were performed or supervised by attending emergency physicians; 10% of these physicians are board certified in both emergency and critical care medicine, with the remainder boarded solely in emergency medicine. Most patients (62%) were intubated for medical diagnoses, such as cardiac arrest, overdose, pneumonia, or air- way obstruction; 23% were intubated for trauma; 14% underwent bron- choscopy through a pre-existing tracheostomy tube. Table 1 displays patient demographics and the reason for intubation.

The indications for flexible bronchoscopy in the ED included removal of aspirated emesis (25%), persistent hypoxemia (24%), verification of endotracheal Tube location (23%), assessment of the extent of tracheo- bronchial injury after smoke inhalation (13%), diagnosis of the source of Pulmonary hemorrhage (11%), lobar collapse (8%) and removal of

foreign body (7%). The extent of ED bronchoscopy was largely limited to the trachea and mainstem bronchi, though a significant portion of pa- tients had segmental bronchi assessed as well. A majority of patients (83%) had at least one abnormal finding on bronchoscopy. Mucus plug- ging, emesis, debris, blood and soot accounted for most of the abnormal findings (Table 2).

Among the 34 patients who underwent bronchoscopy for persistent

hypoxemia, abnormal findings were discovered in 26 patients and 23 patients had procedures performed during bronchoscopy. After proce- dural intervention, 11 of these patients had improved oxygenation and 1 patient had worsened oxygenation (this patient is also counted as the patient who had the complication of hypoxemia in Table 2.).

In total, 55% of patients underwent an intervention during the bron- choscopy procedure. Common interventions included suction of mucus, irrigation of airways, and collection of specimens for culture. Only one case involved the use of an airway basket through the working channel in an attempt to remove a foreign body. After bronchoscopy, most pa- tients demonstrated no change in clinical status while 24% demonstrated improved oxygenation or lobar collapse following the procedure.

Table 1

Patient characteristics.

Characteristic All Patients

(N = 146)

Age, median (IQR) - years 48 (31-61)

Pediatric - no. (%) 4 (3)

Female gender - no. (%) 46 (32)

Method of airway management

Oral tracheal intubation via laryngoscopy in the ED 125 (86) Bronchoscopy performed through pre-existing tracheostomy tube 21 (14)

Reason for intubation (if intubated)

Medical 91/125 (73)

Cardiac Arrest 18/125 (14)

Overdose 14/125 (11)

Airway Obstruction 12/125 (10)

Pneumonia 9/125 (7)

Seizure 4/125 (3)

Septic Shock 4/125 (3)

Non-overdose Altered Mental Status 3/125 (2)

Anaphylaxis 2/125 (2)

Asthma 2/125 (2)

Stroke 1/125 (1)

Cardiogenic Shock 1/125 (1)

Unspecified 21/125 (17)

Trauma 34/125 (27)

Table 2

Flexible Bronchoscopy Procedural Characteristics.

Procedure detail Value (N = 146)

Specialty of attending physician performing or supervising the procedure

Emergency medicine 131 (90)

Emergency medicine / critical care 15 (10)

Reason for bronchoscopy^a

Remove emesis or body fluids 37 (25)

Evaluation of persistent hypoxemia^b 34 (24)

Verify tracheal tube location 34 (23)

Smoke Inhalation 19 (13)

Evaluate the source of hemoptysis or pulmonary hemorrhage^c 16 (11)

Lobar Collapse 12 (8)

Foreign Body 10 (7)

Other diagnostic reason^d 22 (15)

Reason not specified 2 (1)

What anatomy was assessed?^a

Trachea and Mainstem Bronchi	133 (92)
Segmental Bronchi Left Lung	53 (36)
Segmental Bronchi Right Lung	55 (38)
Not specified	13 (9)
Findings Mucus plugging	40 (27)
Emesis or debris	28 (19)
Blood	20 (14)
Active bleeding in the airway	6 (4)
Blood from distal pulmonary site, source not visible	10 (7)
Bleeding from oropharynx	2 (1)
Not specified	2 (1)
Soot below larynx	15 (10)
Foreign Body	5 (3)
Frothy pink secretions	4 (3)
Anatomic abnormality, not specified	3 (2)
Endotracheal tube in a mainstem bronchus	2 (1)
Mucosal injury from aspiration	2 (1)
Other^e	2 (1)
No abnormalities seen Interventions performed^a	25 (17)
Suction of visible mucus, debris, soot, or blood	56 (38)
Irrigation and suction of airways	21 (14)
Reposition tracheal tube	13 (9)
Obtain cultures	9 (6)
Removal of bronchial foreign body^f	2 (1)
Other^g	6 (4)
No procedure	66 (45)
Outcome Improved oxygenation	28 (19)
Improved lobar collapse	7 (5)
Referral for rigid bronchoscopy or another procedure/consultant	7 (5)
Worsened oxygenation	1 (1)
No change in clinical status	103 (71)
Procedural complications Hypoxemia	1 (1)
Trauma to airways^h	1 (1)
Pulmonary barotrauma	0
Additional bronchoscopy in the hospital - no. (%)ⁱ	35 (24)
Subsequent report agrees with ED bronchoscopy	30 (86)
Subsequent report differs with ED bronchoscopy	4 (11)

^a A patient could have more than one reason for bronchoscopy, anatomic area assessed, or intervention performed.

^b Persistent hypoxemia was an indication for bronchoscopy in clinical scenarios where an intubated patient remained hypoxemic without a clear explanation and bronchoscopy was performed to rule out mucus plugging, aspirated foreign bodies and assess endotracheal tube location.

^c These patients were not primarily intubated for airway hemorrhage and had a different indication for intubation.

^d These included assessment of suspected mucus obstruction (7), pneumonia (7), airway trauma (2), airway edema (2), unspecified respi- ratory failure (2), high airway pressures (1), and atelectasis (1).

^e One patient had tracheal stenosis. The other patient had elevated airway pressures and clinicians were unable to pass a bronchoscope through the distal end of the endotracheal tube (placed at an outside hospital). This was exchanged and the old tube was found to have an ab- normal narrowing at the distal end of the tube.

^f Both patients had large amounts of aspirated food contents removed from the main airway tracts with subsequent improvement in oxygenation.

^g These included replacement of an artificial airway (2), use of the endoscope to manually displace a mucus plug (1), and unspecified (1). One patient had both a fogarty balloon catheter and airway basket attempted, but both were unsuccessful.

^h This patient had small erythematous lesions on the lateral tracheal wall consistent with suction catheter trauma. No active bleeding was present.

ⁱ One patient had a subsequent bronchoscopy performed in the ICU solely for procedural purposes and did not agree or disagree with the ED bronchoscopy.

Complications from bronchoscopy included one patient (the same patient that had the outcome of worsened oxygenation) with post- procedural hypoxemia several minutes after bronchoscopy with an

oxygen saturation nadir between 70 and 80%. This was quickly corrected by disconnecting the patient from the mechanical ventilator and ventilating using a manual resuscitator bag; the etiology of the

hypoxemia was unclear. One patient was found to have minor tracheal wall lesions consistent with suction catheter trauma.

Out of the 146 patients that underwent ED bronchoscopy, 35 patients went on to have a subsequent bronchoscopy performed by another phy- sician during the hospitalization. Of these 35 cases, 30 (86%) had agree- ment between the findings of the initial ED bronchoscopy and the subsequent bronchoscopy, 4 cases showed differences between the re- ports, and 1 patient underwent bronchoscopy in the ICU solely to aid in percutaneous tracheostomy tube placement. Among the cases with dif- fering reports, in one case the ED report indicated “thin frothy fluid in the bronchial tree” whereas the subsequent bronchoscopy reported “thick mucopurulent secretions seen obstructing the RLL segments”. In another case, the ED report indicated “minimal carbonaceous material” whereas the subsequent bronchoscopy reported “diffuse erythema” and “mucoid secretions”. In the final 2 cases, the ED bronchoscopy report noted a small amount of blood in the distal airways whereas the ICU bronchoscopy reported “no active bleeding” in both cases. Based on chart review, it is unclear if these differences were due to the natural course of disease and time or a true discrepancy.

Limitations

This study analyzed patient charts from an electronic medical re- cord, which may be prone to documentation bias that is inherent in ret- rospective data. While the results of this study may suggest that flexible bronchoscopy has utility in the ED, no causal conclusions can be made without prospective data. For example, while a number of patients had improved oxygenation after bronchoscopy, it cannot be said that this was directly due to the bronchoscopy procedural intervention or di- agnosis. We were unable to adequately capture how ED bronchoscopy affected patient outcomes later in their hospitalization. It is unclear whether or not earlier Diagnosis and referral for procedures for some patients resulted in changed outcomes. Data regarding complications and adverse events from bronchoscopy were collected retrospectively from the electronic medical record and may be subject to reporting bias. Thus, the incidence of complications from ED bronchoscopy in this study may be underreported. This study was performed at an aca- demic ED with a well-established and autonomous program of airway management; therefore the results may not be generalizable to all emergency departments.

Discussion

Over a 10.5-year period, flexible bronchoscopy was successfully per- formed by emergency physicians on 146 patients in the ED, which yielded Clinically relevant findings in 83% of patients. Frequently en- countered findings such as mucus, debris, soot and blood are both diag- nostically valuable, and amenable to immediate point of care intervention through the use of suction to potentially improve oxygen- ation and ventilation. In addition, some patients were able to undergo critical and possibly life-saving procedures such as foreign body re- moval and exchange or repositioning of artificial airways. Although this study was not designed to establish causality between ED bron- choscopy and improved patient outcomes, it seems likely that some pa- tients benefited from the procedure. After ED bronchoscopy, 19% of patients had improved oxygenation and 5% had improvement of their lobar collapse. Another 9% had repositioning of their endotracheal tube and 5% were referred for an additional procedure based on the di- agnosis received from bronchoscopy. Only 1 patient had a worsening of oxygenation that was quickly reversed. Given that only 55% of the pa- tients had some intervention performed during bronchoscopy, these re- sults suggest that ED bronchoscopy may benefit ED patient care by improving oxygenation in select clinical scenarios. Other than studies assessing endotracheal tube placement and confirmation [4,9,10], there are no descriptions of diagnostic or therapeutic flexible bronchos- copy being performed by emergency physicians. The data in this study

demonstrates the value and relative safety of flexible bronchoscopy within the scope of ED resuscitation managed by emergency physicians. Severe hypoxemia is a relative contraindication to flexible bron- choscopy, as the procedure leads to some decrease in alveolar venti- lation [12]. However, patients with emergent pulmonary pathology that may benefit from flexible bronchoscopy are frequently hypox- emic. If the hypoxemia is secondary to pathology expected to be im- proved with suctioning during bronchoscopy (or due to a foreign body amenable to removal with suction), flexible bronchoscopy may be the primary modality of treatment for an otherwise life- threatening condition. Persistent hypoxemia, which is not classically an indication for bronchoscopy outside of acute respiratory distress syndrome, was the reason for bronchoscopy in 34 patients in this study with the expressed goal of ruling out mucus plugging, aspirated foreign bodies, and assessing endotracheal tube location. In this subgroup of 34 patients, 11 had improvement in oxygenation after bronchoscopy while 1 had worsened oxygenation. The patient with worsened oxygenation after bronchoscopy was a middle-aged adult with pneumonia who suffered a prehospital respiratory arrest and was resuscitated on arrival to the ED. After endotracheal intubation, flexible bronchoscopy was performed for persistent hypoxemia and emesis was suctioned from the proximal airways. Several minutes later the patient had worsening hypoxemia with an oxygen satura- tion fluctuating between 70% and 80%. The hypoxemia was quickly corrected by disconnecting the patient from the mechanical circuit and ventilating with a manual resuscitator bag. It is unclear whether this hypoxic event was secondary to the bronchoscopy procedure, critical cardiopulmonary illness, or a combination of both. Our data suggests that flexible bronchoscopy in hypoxic ED patients is rela- tively safe, however, clinical judgment is required in assessing whether or not a hypoxic patient will tolerate flexible bronchoscopy. To improve the safety of flexible bronchoscopy, most clinicians rec- ommend adequate sedation during the procedure, ventilation using a controlled mode, limiting suction to a few seconds at a time, and in- creasing the fraction of inspired oxygen to 1.0 before, during and after the procedure [7,14]. There are otherwise few contraindications to emergency flexible bronchoscopy, particularly in intubated patients [13]. Hemodynamic instability due to dysrhythmia can be secondary to hypoxemia [13]. No cases of hemodynamic instability were found during our retrospective review, likely due to the low rate of post proce- dural hypoxemia. Only one case of minor airway trauma was noted after ED bronchoscopy and this was thought to be related to suction catheter trauma. The low complication rate in this study is similar to what is reported in other studies of emergency bronchoscopy [6,15]. Further- more, the limited number of complications in this study may be because most ED bronchoscopies were limited to the trachea and major bronchi and few airway instruments were used. This allows the procedure to be

expeditious and focused on finding overtly identifiable pathology that

contributes to the acute care of patients. As long as care is taken to max- imize oxygenation during the procedure, ED bronchoscopy seems unlikely to cause harm to patients, even those who are critically ill.

It is important to note that all of the bronchoscopies in this study were performed using modern video bronchoscopes. These devices pro- ject images to a monitor in real-time and also allow for video recording of the procedure. Video bronchoscopes have significant advantages over older bronchoscopes containing only a single eyepiece that allow visual- ization of the procedure solely by the operator. Video systems allow all members of the care team to simultaneously view bronchoscopy im- ages. They also allow real-time guidance of the procedure by the super- vising attending physician, even when the bronchoscope is being operated by a resident physician or other less experienced provider. The use of video likely shortens the learning curve for bronchoscopy, as it does for laryngoscopy and nasal fiberoptic intubation [16,17]. In ad- dition, the advent of relatively inexpensive disposable video devices now makes it possible to have bronchoscopes available in most emer- gency departments.

Most of the clinicians (90%) in this study who oversaw or performed bronchoscopies are trained solely in emergency medicine. When a spe- cialist performed an additional bronchoscopy after hospital admission, the findings on both ED and subsequent bronchoscopy reports were in agreement 86% of the time. This suggests that emergency physicians can interpret bronchoscopy findings with reasonable accuracy despite a relatively low procedure rate compared to other ED procedures. There are limited indications for ED bronchoscopy but when it is re- quired as a part of ED resuscitation, our standard practice has been for ED physicians to perform the procedure. The skills and dexterity re- quired to operate a flexible bronchoscope are the same as those re- quired for any other flexible endoscope which ED physicians already utilize when performing endoscopic tracheal intubation or endoscopic visualization of upper airway anatomy. These are skills that all emer- gency physicians learn in accredited contemporary residency programs. Thus, although the rate of ED bronchoscopy in our study was approxi- mately one per month in the study period, the data from this study sug- gests that emergency physicians can be proficient in performing and interpreting bronchoscopies. These findings may not apply to all EDs given the training and cost requirements, but may prove feasible for most residency-trained emergency physicians.

Conclusion

At our institution, flexible bronchoscopy in the emergency depart- ment performed by emergency physicians appears to be safe and feasi- ble. Although the clinical impact of ED bronchoscopy on patient outcomes cannot be definitively stated, many patients in this study had important findings that led to a change in their management.

Financial disclosures

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Author contributions

BD, MEP, MAP, and RR conceived of and designed the study. EM, JCS, PD, and JLS abstracted and organized data based on chart and video re- view. DL and BD drafted the initial manuscript, and DL, BD, MEP, MAP, DP and RR contributed substantially to its revision. DL takes responsibil- ity for the manuscript as a whole.

Credit authorship contribution statement

Daniel H. Lee: Writing - original draft, Writing - review & editing. Brian E. Driver: Writing - review & editing, Writing - original draft, Supervision, Software, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Matthew E. Prekker:

Conceptualization, Supervision, Writing - review & editing. Michael A. Puskarich: Writing - review & editing, Supervision, Conceptualization. David Plummer: Conceptualization, Investigation, Supervision. Erika Y. Mojika: Data curation. Jennifer C. Smith: Data curation. Paige A. DeVries: Data curation. Jamie L. Stang: Data curation. Robert F. Reardon: Writing - review & editing, Supervision, Conceptualization.

Declaration of Competing Interest

None.

Acknowledgements

None.

References

AJEM

Bronchoscopy in the emergency department

a b s t r a c t

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