Diagnostic samples required, and to where they are going (micro, cytology, AFB, virology, cell count, etc.)
Consider transmission precautions (e.g. for aerosol-generating procedure)
Patient’s tolerance of the procedure
Blood gas
borderline oxygenation and ventilation will likely worsen with a scope in the lumen
Coagulation and platelets, recent anticoagulants/antiplatelets, and whether biopsy/brushing is planned
Haemodynamics and vasopressor requirement
Raised ICP/ open globe/ unstable spine and any other relative contraindication to a coughing, hypertensive response
Equipment and resuscitation
Working scope, light source, processor, image on screen, suction tested
BAL aliquots/syringes, specimen traps and labels are ready
Bite block, swivel/bronchoscopy elbow with diaphragm, water-soluble lubricant
Airway and resus trolley to hand; emergency drugs drawn (see Medications below)
Vasopressor (push-dose or infusion) immediately available; defibrillator location known
Roles assigned and the abort plan stated
Positioning
Default set-up
Semi-recumbent (head up 30-45°), not flat, is the usual default.
This improves FRC and apnoeic reserve, reduces aspiration and VAP risk, and blunts ICP rises.
The bronchoscopist usually stands at the head of the bed, scoping down the ETT (same orientation as intubation – right is right and left is left).
Lower the bed to the operator (or use a step if required) to ensure the scope is under tension, and place the screen in their eyeline.
Remove the head of the bed.
Head, neck and the tube
Neutral-to-sniffing alignment aligns the airway axes and eases scope passage. Avoid excessive flexion (kinking the tube) or rotation.
Remember: flexion advances the ETT tip toward the carina and extension withdraws it (~1-2cm each way). Repositioning can therefore risk endobronchial migration or inadvertent extubation.
Secure the swivel elbow/circuit first (it adds weight and torque), and re-confirm tube depth and cuff after any move.
Lateral positioning
Haemoptysis/unilateral bleeding: affected lung down (dependent) to protect the contralateral lung from soiling. This is the opposite of the “good lung down” instinct from oxygenation teaching.
Gravity-dependent positioning can aid targeted BAL/sampling of a specific lobe.
In an unstable ventilated patient, a full lateral is often impractical, but a lateral tilt can still be effective.
Cohort-specific
Obese/high BMI: ramp (i.e. ear-to-sternal-notch) or reverse Trendelenburg to recruit FRC.
Raised ICP/neuro: head up 30°, neck strictly neutral to preserve jugular venous drainage; no head-down. Works alongside deep sedation/paralysis and topical/IV lidocaine to blunt the cough-driven ICP spike.
Severe hypoxaemia/ARDS: Maximise head-up FRC and keep a low threshold to abort.
C-spine/trauma: manual in-line stabilisation and a fixed neutral neck make scope passage (and any nasal route) harder – be ready!
Fresh tracheostomy (<7 days): immature tract – neck movement risks false passage or decannulation. Minimise movement; have a reintubation kit ready.
Medications
Awake/ spontaneously breathing
Goal: workable conditions without abolishing respiratory drive or airway reflexes
Bolus to deepen before instrumentation; anticipate hypotension
Neuromuscular blockade
Rocuronium/ Cisatracurium
Abolishes cough, breath-holding and breath-stacking, improves the view and limits barotrauma — ensure adequate sedation depth first (e.g. RASS -5)
Cough / reflex attenuation
Lidocaine instilled via the scope
Reduces reflex bronchoconstriction; still counts toward the lidocaine ceiling
Antisialogogue (optional)
Glycopyrrolate
Cleaner view
Rescue medications – always prepared
Purpose
Agents
Notes
Haemodynamic
Metaraminol / ephedrine bolus; noradrenaline running; atropine for vagal bradycardia
Sedation + vagal stimulation = a predictable BP/HR dip — worse with deep sedation
Bronchospasm
Salbutamol (± ipratropium); ketamine adjunct
Common with airway instrumentation
Bleeding / haemostasis
Cold saline, topical adrenaline (e.g. 1:10,000), topical tranexamic acid; position bleeding side down
Plan this before any biopsy/brushing
Ventilator Settings
A scope in the lumen is a fixed obstruction. This increase in resistance impairs expiration and leads to auto-PEEP and intrinsic gas trapping, reduced tidal volumes, and increased airway pressures. Suctioning then de-recruits by removing PEEP and volume. Anticipate and address accordingly.
Before the scope goes in:
FiO₂ to 1.0 and pre-oxygenate/denitrogenate.
Pick your mode:
Volume control (commonly used)
guarantees minute ventilation, but peak/plateau pressures rise around the scope. Imperative to raise the high-pressure alarm limit so the breath isn’t truncated, and watch for barotrauma.
Pressure control
caps pressure (protects against barotrauma) but tidal volume falls around the scope. You will need to accept and anticipate hypoventilation and hypercapnia, and not be surprised by the volume drop.
Raise the high-pressure alarm limit (volume control) so the ventilator keeps delivering; widen low–tidal-volume/low–minute-volume alarms.
Consider a lower respiratory rate/longer expiratory time to give trapped gas time to escape and limit auto-PEEP.
Expect a leak around the scope – you may need to increase set tidal volume to compensate.
During bronchoscopy
Minimise suction time
each suction decreases PEEP and lung volume
prolonged suction can cause mucosal trauma
Intermittent, brief suctioning is preferred over continuous suctioning.
Assess the flow–time curve for gas trapping (expiratory flow not returning to zero) and the pressure waveform.
Re-recruit and restore PEEP/FiO₂ deliberately after withdrawal