Best of ATS Video Lecture Series: Bronchoscopy. Part of a larger collection of videos curated by ATS. These videos introduce strategies for preparation, examination, and bronchoalveolar lavage.

Weiss SM, Hert RC, Gianola FJ et al. Complications of fiberoptic bronchoscopy in thrombocytopenic patients. Chest 1993;104:1025-8. Established safety of transnasal bronchs for bronchoalveolar lavage in thrombocytopenic patients.
PMID: 8404159
Free Full Text

Herth FJF, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest 2002;122:1461-4 Prospective study compared 285 patients taking ASA within 24 hrs of TBB to 932 non-ASA users and found no difference in the risk of minor, moderate, or major bleeding.
PMID: 12377879
Free Full Text

***See also Lung Cancer Staging

Interventional Bronchoscopy:

The following 3 articles serve as an introduction for budding interventionalists and as a resource for non-interventionalists considering a referral.
Criner GJ, Eberhardt R, Fernandez-Bussy S, et al. Interventional bronchoscopy. Am J Respir Crit Care Med. 2020; 202:29-50.  Provides an excellent broad overview of advanced bronchoscopy, including bronchial thermoplasty, cryobiopsy, lung volume reduction and others.
PMID: 32023078

Katsis JM, Rickman OB, Maldonado F, et al. Bronchoscopic biopsy of peripheral pulmonary lesions in 2020: a review of existing technologies. J Thorac Dis. 2020;12:3253-3262. A succinct overview of the available advanced bronchoscopic techniques (not including robotic bronchoscopy) to sample peripheral pulmonary lesions.
PMID: 32642248
Free Full Text

Agrawal A, Hogarth DK, Murgu S. Robotic bronchoscopy for pulmonary lesions: a review of existing technologies and clinical data. J Thorac Dis. 2020;12:3279-3286. A review of 2 of the available robotic bronchoscopic modalities for sampling peripheral lesions.
PMID: 32642251
Free Full Text

Endotracheal intubation:

Mosier JM, Sakles JC, Law JA, et al. Tracheal intubation in the critically ill. where we came from and where we should go. Am J Respir Crit Care Med. 2020; 201:775-788. This review summarizes the relevant evidence and guideline recommendations, but the practical pearls are especially valuable.
PMID: 31895986

Casey JD, Janz DR, Russell DW et al. Bag-mask ventilation during tracheal intubation of critically ill adults. N Engl J Med. 2019; 380: 811-821. This pragmatic, multicenter randomized clinical assigned 401 patients undergoing intubation to receive ventilation with a bag-mask device or no-ventilation between induction and laryngoscopy. Bag-mask ventilation increased the median lowest oxygen saturation (from 93% to 96%) and reduced rates of severe hypoxemia (from 22.8% to 10.9%, RR 0.48 CI 0.3-0.77) without an increase in aspiration. Most patients in the no-ventilation group received supplemental oxygen via non-rebreather or nasal cannula.
PMID: 30779528

Prekker ME, Driver BE, Trent SA et al. Video versus direct laryngoscopy for tracheal intubation of critically ill adults.  N Engl J Med2023; 389:418-29. This pragmatic, multicenter, randomized trial in 17 emergency departments and ICUs randomly assigned 1417 critically ill adults undergoing intubation to the video-laryngoscope group or the direct-laryngoscope group. Use of the video-laryngoscope resulted in a higher incidence of successful intubation on the first attempt (85.1% vs 70.8% in the direct-laryngoscope group). There were no differences in rates of complications.
PMID: 37326325

Percutaneous tracheostomies:

Ghattas C, Alsunaid S, Pickering EM, et al. State of the art: percutaneous tracheostomy in the intensive care unit. J Thorac Dis. 2021;13:5261-76. Provides a comprehensive overview including pre-procedural preparation, procedural technique, and post-tracheostomy management.
PMID: 34527365
Free Full Text

Central Lines:

Parienti JJ, Mongardon N, Mégarbane B, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015; 373:1220-9. This study randomized 3027 patients to internal jugular, subclavian, or femoral venous sites in a 1:1:1, or 1:1 fashion depending on the number of sites available. Subclavian lines had a lower rate of infectious complications and a higher rate of mechanical complications than either femoral or internal jugular sites. Concerns include the inconsistent use of ultrasound for subclavian lines, and the potential bias of determining if 2 vs. 3 sites were “suitable”. Interestingly, femoral and internal jugular lines had similar rates of infectious complications.
PMID: 26398070
Free Full Text

Van Baarle FLF, van de Weerdt EK, van der Velden WJFM et al. Platelet transfusion before CVC placement in patients with thrombocytopenia. N Engl J Med. 2023; 388:1956-65. This multicenter RCT assigned 338 patients in ICUs or hematology wards with severe thrombocytopenia (10,000 to 50,000) to receive one unit of prophylactic platelets or no platelet transfusion before central line placement. Platelet transfusion resulted in lower rates of catheter-related bleeding of grade 2 to 4 (bleeding requiring at least prolonged manual compression>20 minutes, reduced from 11.9% to 4.8%) and grade 3 or 4 (bleeding resulting in operative intervention or red-cell transfusion, reduced from 4.9% to 2.1%) at 24 hours.
PMID: 37224197


Swiderek J, Morcos S, Donthireddy V, et al. Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest 2010; 137:68-73. Prospective single center study of 103 patients with known or suspected malignant effusion found aliquots of 60 mL or >150 mL had significantly higher sensitivity and negative predictive value than aliquots of 10 mL, suggesting larger volumes are of diagnostic benefit. This is in contrast to earlier retrospective and smaller prospective studies suggesting diagnosis was independent of volume (See Chest 2002;122:1913-7, Chest 2009; 135:999-1001)
PMID: 19741064
Free Full Text

Lentz RJ, Lerner AD, Pannu JK, et al. Routine monitoring with pleural manometry during therapeutic large-volume thoracentesis to prevent pleural-pressure-related complications: a multicentre, single-blind randomised controlled trial. Lancet Respir Med. 2019; 7:447-455. This study randomized 124 patients with free-flowing effusions with estimated volume > 500 ml (63% with malignant effusion) to thoracentesis drainage based on symptoms alone vs. symptoms plus pleural manometry. There was no significant difference in chest discomfort, volume of fluid drained, proportion of patients with complete lung expansion, or clinically significant complications. Of note, the mean volume of fluid drained was 1,100 ml (SD 500 ml) and patients with known re-expandable lung, such as those with a large hepatic hydrothorax, were excluded.
PMID: 30772283

Lentz RJ, Shojaee S, Grosu HB, et al. The impact of gravity vs suction-driven therapeutic thoracentesis on pressure-related complications: The GRAVITAS multicenter randomized controlled trial. Chest. 2020; 157:702-711. This study found no difference in chest discomfort or dyspnea during, or in the 48 hours following, thoracentesis.
PMID: 31711990

Williams JG, Lerner AD. Managing complications of pleural procedures. J Thorac Dis. 2021; 13:5242-50.  This article reviews the relevant anatomy followed by diagnosis and management of complications including pneumothorax, bleeding, re-expansion pulmonary edema, pain, and infection.
Free Full Text

***For additional information, see Pleural disease section

General Procedural Safety:

Wolfe K, Kress J. Risk of procedural hemorrhage. Chest 2016;150:237-46. Review article addressing the risk factors for hemorrhage associated with procedures commonly performed in the ICU, including central line placement, thoracentesis, paracentesis, lumbar puncture, and others.
PMID: 26836937

Procedure Videos:

The New England Journal of Medicine has developed and published a series of Videos in Clinical Medicine, intended to facilitate teaching and learning of common procedural techniques. Videos and accompanying text provide an excellent review of indications, pertinent techniques, and potential complications. Links to those procedures most applicable to critical care medicine are provided below. Access requires subscription.