Bronchoscopy Procedure Note (ICU)

Procedure: Flexible bronchoscopy with [BAL / bronchial wash / protected specimen brush / therapeutic airway toilet / mucus plug removal / other] (List all procedures performed)

Date/Time: [Date and time]

Location: [ICU bedside / procedure room]

Operators: [Primary bronchoscopist]; Assistants: [RT / RN / other]

Airway Route: [oral / nasal / via endotracheal tube (size: [size]) / via tracheostomy] (Note adapter use if applicable)

Indication(s): [Diagnostic sampling / Therapeutic suctioning / Both]

Pre-procedure Diagnosis: [Diagnosis or clinical problem prompting bronchoscopy]

Post-procedure Diagnosis: [Diagnosis aligned with findings; note pending results if applicable]

Procedure Summary: [One-line summary of route, purpose, sites sampled/treated, and immediate complications status]

Indication and Clinical Context

[Immediate clinical problem prompting bronchoscopy, e.g., acute hypoxemia, new infiltrates, persistent lobar collapse] [Specific goals: diagnostic sampling for pathogen identification / therapeutic secretion clearance] [Pertinent ICU context: hemodynamic status, degree of hypoxemia with SpO₂/FiO₂ or P/F ratio if available, anticoagulation status if relevant] (Include target diagnoses only if they directed sampling strategy, e.g., "rule out PCP → BAL for DFA/PCR." Do not introduce unstated diagnoses.)

Pre-Procedure Assessment

• Baseline vitals: SpO₂ [value]% on FiO₂ [value]%; HR [value]/min; BP/MAP [value]; vasoactive support [none / agent and dose]; temperature [value] (Include values closest to procedure start. If not available: [Baseline vitals not documented].)
• Respiratory support: [Intubated / Non-intubated]
  • (If intubated) Ventilator: mode [value], FiO₂ [value]%, PEEP [value] cmH₂O, RR [value]/min, [Vt or pressure settings]. (If not provided: [Ventilator settings not documented—please provide mode, FiO₂, PEEP, RR, and Vt/pressure settings].)
  • (If non-intubated) Device [HFNC / NIV / other] with settings [flow/pressure, FiO₂]. Contingency plan [escalation strategy if hypoxemia].
• Bleeding risk: Anticoagulant/antiplatelet use [none / agent and timing]; platelet count [value] and INR [value] if relevant to planned sampling. (If unknown: [Not documented].)
• Consent: [Informed consent obtained from patient / surrogate] or [Emergency exception: rationale] (Always document. If not dictated: [Consent status not documented].)
• Time-out: [Completed / Not completed] — patient identity, procedure, site, allergies, and bleeding risk verified. (If not dictated: [Time-out status not documented].)
• Equipment readiness: [Bronchoscope, suction, oxygen delivery, bronchoscopy adapter, resuscitation equipment confirmed] (If not stated: [Equipment check not documented].)

Sedation and Anesthesia

[No additional sedation required / Additional sedation administered as below] (If on continuous ICU sedation, note baseline rates and any procedural adjustments.)

• Sedation level: [Minimal / Moderate / Deep / General anesthesia]
• Medications: [Agent, dose, route, timing] (Include boluses and infusions; for ongoing ICU infusions, note baseline and changes.)
• Topical anesthesia: Lidocaine [concentration]% via [spray-as-you-go / nebulized]; estimated total dose [mg]
• Monitoring: [Continuous SpO₂; BP/HR q [frequency]; capnography [used / not used]]; monitored by [RN / RT / physician]

Procedure

[Airway entry and route: oral/nasal/ETT/tracheostomy; tube size and bronchoscopy adapter if applicable; any seal or ventilation issues] [Ventilator strategy: pre-oxygenation, FiO₂ changes, mode adjustments, alarm limit modifications] [Airway survey: structures examined, completeness, limitations] [Therapeutic actions: suctioning, mucus plug or clot removal, lavage] [Sampling: sequence, sites, techniques] [Events: desaturation episodes with threshold, duration, corrective action, and response] [Conclusion: hemostasis confirmed, airway reassessed] (Chronological narrative; keep to observed facts without etiologic conclusions.)

Specimens Obtained

[No specimens obtained] (If none, state explicitly. Do not infer tests not dictated.)

• [BAL / bronchial wash / brush-PSB / other]: Site [lobe/segment]
  • (For BAL) Volume instilled [mL] ([number] × [mL] aliquots); return [mL or not measured]; appearance [clear / cloudy / bloody / purulent]
  • (For brush/PSB) Passes [number]
  • Tests ordered: [Gram stain/culture / fungal culture / AFB / viral PCR / cytology / cell count-differential / other]
  • Labeling: Two patient identifiers and anatomic source confirmed
• [Additional specimen type]: Site [lobe/segment]. (Repeat structure as needed.)

Findings

• Trachea and main bronchi: [Appearance, patency, secretions]
• Lobar and segmental airways: [Right lung by lobe/segment]; [Left lung by lobe/segment]; [Areas not visualized]
• Secretions: [Character: purulent / mucoid / bloody / thin / thick]; [distribution]; mucus plugging [present / absent]
• Mucosa: [Normal / erythema / friability / edema] with distribution and severity
• Focal abnormalities: [None / masses / stenosis / extrinsic compression] with location, appearance, degree of obstruction
• Bleeding: [Absent / Present: site, severity, response to intervention]
• Exam limitations: [None / patient tolerance / hypoxemia / secretions / anatomy / other]

Complications and Tolerance

• Complications: [None / Hypoxemia / Hypotension / Arrhythmia / Bronchospasm / Bleeding / Other] (Always document even if none.)
• Interventions required: [None / FiO₂ increase / PEEP adjustment / vasopressor adjustment / bronchodilator / iced saline / epinephrine / procedure aborted]
• Estimated blood loss: [Minimal / quantified if significant]
• Tolerance: [Patient tolerated procedure well with stable hemodynamics and oxygenation] or [specify instability with objective parameters]

Post-Procedure Status and Plan

Current Status

• Airway: [Intubated / Tracheostomy / Non-intubated]; tube position [confirmed / adjusted]
• Respiratory: SpO₂ [value]% on FiO₂ [value]%, PEEP [value] cmH₂O; [returned to baseline / temporarily elevated with plan]
• Hemodynamics: MAP [value]; pressor changes [none / details]
• Sedation: [Returned to baseline / adjustments: details]

Plan

• Monitoring: Watch for [delayed hypoxemia / bleeding / bronchospasm]; escalation triggers and responsible team
• Imaging/labs: [Post-procedure CXR if indicated / ABG if indicated / none]
• Pending results: [Responsible clinician for follow-up]; anticipated turnaround [timeframe]; critical result escalation plan
• Communication: Findings communicated to [ICU team / consulting services]