We’re super excited to have a joint episode this week with Dr. Cyrus Askin and Dr. Nick Mark from Critical Care Time! We discuss all the ways that bronchoscopy can be your best friend in the ICU and how to be prepared for the unexpected scary situations that arise in the ICU. This ranges from airway bleeds, difficult intubations, lobar collapse, and trach emergencies. Don’t miss this great discussion! Key Learning Points Utility of bronchoscopy in people with critical illness * Bronchoscopy can be both diagnostic and therapeutic; both are potentially lifesaving.  * General situations where bronchoscopy is useful in the ICU: * Placing (or confirming placement of) an endotracheal tube or tracheostomy tube * Removing a foreign body or mucous plugs from the lungs * Localizing the source of pulmonary hemorrhage or performing interventions to stop/contain the bleed * Diagnosing certain rare conditions, particularly those where the diagnosis can substantially change management (e.g. DAH, AEP, rare infections, etc). * Proficiency with bronchoscopy is important to realize the benefits. Simply “having the equipment” is insufficient, regular practice/simulation is essential * Anesthesiologists, emergency physicians, and other specialists may have limited experience with bronchoscopy in training. Even experienced pulmonologists, who may be good at diagnostic bronchoscopy often have limited experience deploying bronchial blockers, using retrieval baskets, etc. * Remember: “People don’t rise to the occasion, they sink to the level of their training.” * If you haven’t regularly practiced with a bronchoscope, you are not going to be able to use it effectively under stress when performing high acuity low occurrence (HALO) procedures such as in emergent airways, deploying bronchial blockers, retrieving foreign bodies, etc. Practice practice practice: High fidelity bronchoscopy simulators are available. Low cost bronchoscopy simulators (e.g. 3D printed DIY) are available. Difficult Airways * Two broad situations where a bronchoscope is generally used: * Awake intubation in the anticipated difficult airway (e.g. someone with abnormal anatomy, airway tumor, etc) * Rescue method in the unanticipated difficult airway (e.g. very anterior cords, difficulty with Bougie, etc) * Nasal vs Oral approach: * Oral approach is usually used in an unanticipated difficult airway * Nasal approach: More common if performing an awake intubation. Nasal is often better tolerated however epistaxis can make a difficult airway almost impossible. * Sedation strategy: * Full topicalization: lidocaine vs cocaine (equally effective and lidocaine is normally preferred, however the vasoconstriction action of cocaine may be helpful in preventing epistaxis). * Which types of topicalization work best? * Spray as you go w/ or w/o and atomizer  * Nebulization (maybe better? maybe) * Gurgling (Nick: from personal experience lidocaine is super gross) * Remember total dose of lidocaine: 8 mg/kg * Ketamine * Ideal because it’s dissociative and analgesic, maintains respiratory drive and (maybe) airway reflexes