Flexible or fiberoptic bronchoscopy has become an essential tool for the adequate management (diagnostic and therapeutic) of patients admitted to the Department of Intensive Care Medicine (DICM).8 In the hands of adequately trained professionals, and adopting the necessary precautions, the safety and usefulness of FB has caused it to become increasingly used even in unstable critical patients subjected to mechanical ventilation (MV) and with high oxygen demands.9 Based on the recommendations of the British Thoracic Society, the DICM should be adequately equipped to perform FB for diagnostic and therapeutic procedures on both a programmed basis and in emergency situations.

One of the most common and useful applications of FB in mechanically ventilated patients is the diagnosis and treatment of lobar collapse refractory to the usual management measures such as for example postural changes and respiratory physiotherapy. The success rate in such situations is reportedly 79–89%.10–13 FB is probably less effective in patients with subsegmental atelectasis or air bronchogram on the chest X-rays.14,15

The appearance of retained bronchial secretions can obstruct the main airway and increase the risk of infection. Guided suctioning, together with saline solution lavage, can be very effective in dealing with this complication. Likewise, certain foreign bodies, such as impacted food following bronchoaspiration, or tooth fragments, can be easily removed with the accessories adapted to the flexible bronchoscope.

Minimum endotracheal bleeding is common during routine tracheal suctioning in the ventilated patient, and can be a consequence of tracheal epithelial erosion. If bleeding proves persistent or excessive, FB can be used to identify the origin and extent of the hemorrhage and contribute to define a management strategy. In situations of massive bleeding, visualization with the flexible bronchoscope can prove very difficult, however, and other techniques are then preferred, such as rigid bronchoscopy and/or the interventional vascular radiology, which require the intervention of other specialists such as thoracic surgeons, pneumologists and/or radiologists.

Nosocomial pneumonia is the most frequent in-hospital infection in Intensive Care. Flexible bronchoscopy is very useful in ventilated patients for guided microbiological sampling of the airway with diagnostic intent. An early diagnosis, particularly in immune depressed and neutropenic patients, is important in relation to treatment response following identification of the causal pathogen. FB allows us to establish an etiological diagnosis through the obtainment of non-contaminated secretions directly from the most distal airway of the affected area. Processing of the samples in quantitative cultures in turn allows differentiation between colonization and infection. The main diagnostic techniques are bronchoalveolar lavage (BAL) and protected specimen brush sampling. In performing BAL, we generally instill physiological saline solution at room temperature (typically 150–200ml in boluses of 20–50ml). The volume varies among the different publications and depends on the particular clinical conditions of the patient. In general, over 40% of the instilled volume is recovered. Bronchial protected catheter brush sampling is another option, and in some cases can offer greater specificity than BAL, since the risk of contamination is minimized–though the sample is collected from a more localized area. In contraposition, BAL is comparatively more sensitive, since it encompasses a much larger area of lung parenchyma–though there is a risk of contamination of the operating canal. A way to avoid or reduce such contamination is to insert the flexible bronchoscope without suctioning.16 The use of guided techniques compared with direct sampling remains subject of controversy, and it is important to underscore that the obtainment of microbiological samples by BAL or protected specimen brush sampling appears to be relatively safe and rapid, and in most cases causes no complications.17–19 Furthermore, the direct visualization of the secretions can help in the diagnosis and differentiation of ventilator associated pneumonia and/or tracheobronchitis.20

In some cases, a transbronchial biopsy may be needed to establish a histological diagnosis of lung parenchymal disorders of uncertain etiology.21 In the ventilated patient there is a significant risk of pneumothorax (10%) and bleeding (approximately 5%), and a definitive histological diagnosis can only be established in about one-third of the cases.

In the diagnosis of lesions caused by smoke inhalation–a relatively common condition seen in the DICM–emergency FB detects mucosal hyperemia and edema, inflammation of the subglottic region, and the presence of carbon particles in the airway, indicative of severe injury and anticipating the need for intubation.

Flexible bronchoscopy is very useful in situations characterized by difficult intubation in which the presence of anatomical variants, obstruction of the upper airway, limited mobility of the head and neck, protection in cervical fractures and severe bleeding tendency make it unadvisable to perform conventional intubation with the laryngoscope.22 Nevertheless, FB is only necessary in a small proportion of patients (0.07–3.4%) admitted to the DICM.9,23

The oral route is the preferred option for tracheal intubation, since it allows us to place a larger diameter endotracheal tube.7,22 The outer diameter of most flexible bronchoscopes varies between 1.8mm (ultrafine) and 6.4mm–the majority of adult bronchoscopes having an outer diameter of about 6.0mm. Most of the existing bronchoscopes pass through a 7.5-mm endotracheal tube, which is the preferred option in the intubation in adult patients.24 Pediatric bronchoscopes can also be used for nasotracheal intubation, since they are more flexible–though this lack of stiffness implies that the instrument is often directed into the esophagus by mistake.

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias, SEMICYUC), through its Acute Respiratory Failure (GT-IRA) and Infectious Diseases (GT-EI) Work Groups, aims to promote knowledge and quality standards in the performance of flexible bronchoscopy among all specialists in Intensive Care Medicine. After case consultation, and following the experience of other international Societies in these processes, the SEMICYUC has developed an accreditation system for all those who perform FB. By establishing standard and inviting specialists in Intensive Care Medicine and related disciplines to obtain this accreditation, the Society aims to promote learning and to elevate the quality standards of clinical practice in critically ill patients.

We are aware of the differences in training and performance of FB among different centers, and do not aim to establish rigid learning and practice criteria; rather, with a hope to implement the essential minimum requirements for training and performance of FB in critical patients, and to propose these capacities to the different medical Societies.

Such accreditation is voluntary and seeks to promote a standard defining norms referred to training in FB and to the quality of the DICM in promoting such skills. Through an expert committee, the SEMICYUC aims to accredit professional training in FB and the Units that request inclusion in the accreditation process. The latter aims to stimulate good learning practice and training quality. Both specialists in Intensive Care Medicine and other specialists, as well as patients, stand to benefit from the level of commitment and control afforded by such accreditation, and from the learning and training implied by this process. The accreditation will be recognized by the SEMICYUC and other specialties.