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Chapter 33 Airway Management Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Learning Objectives ● Describe how to safely perform endotracheal and nasotracheal suctioning. ● Describe how to properly obtain sputum samples. ● Assess the need for and select an artificial airway. ● Identify the complications and hazards associated with insertion of artificial airways. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 2 Learning Objectives (cont.) ● Describe how to perform orotracheal and nasotracheal intubation of an adult. ● Assess and confirm proper endotracheal tube placement. ● Describe the rationale and the methods for performing a tracheotomy. ● Identify the types of damage artificial airways can cause. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 3 Learning Objectives (cont.) ● Describe how to properly maintain and troubleshoot artificial airways. ● Describe techniques for measuring and adjusting tracheal tube cuff pressures. ● Identify when and how to extubate or decannulate a patient. ● Describe how to use alternative airway devices. ● Describe how to assist a physician in setting up and performing bronchoscopy. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 4 Suctioning Application of negative pressure to airways through collecting tube Suctioning of trachea & bronchi is usually done through endotracheal tube or tracheostomy tube Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 5 Suctioning (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 6 Suctioning (cont.) Selecting Suction Catheter Size External diameter (ED)of suction catheter should be no more than ½ internal diameter (ID) of artificial airway Formulas to estimate proper catheter size: • ID x 3/2 (then use next larger Fr size) • ID x 2 (then use next smallest Fr size) Example: Size 8.0 ETT x 3 = 24 / 2 = 12 Next larger =14 Fr Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 7 Suctioning (cont.) Vacuum Pressure Adults -100 to -120 mm Hg Children -80 to -100 mm Hg Infants -60 to -80 mm Hg Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 8 Endotracheal Suctioning Two techniques for endotracheal suctioning: Open, sterile technique requires disconnecting patient from ventilator Closed technique uses sterile, closed, in line suction catheter which is attached to ventilator circuit • suction catheter can be advanced into patient’s endotracheal airway without patient-ventilator disconnection Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 9 Endotracheal Suctioning (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 10 Endotracheal Suctioning Step 1: Assess patient for indications Patient should never be suctioned according to preset schedule Abnormal breath sounds (e.g., coarse crackles) suggest that suctioning is needed Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 11 Endotracheal Suctioning (cont.) Step 2: Assemble & check equipment Step 3: Hyperoxygenate patient Step 4: Insert catheter Step 5: Apply suction/clear catheter Use 100% oxygen. Total suction time should be <15 seconds Step 6: Reoxygenate patient Step 7: Monitor patient & assess outcomes Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 12 Endotracheal Suctioning (cont.) Minimizing complications & adverse responses Preoxygenation helps minimize incidence of hypoxemia Avoid atelectasis by limiting amount of negative pressure used, keeping duration of suctioning as short as possible, using appropriate size suction catheter, & avoiding disconnection from ventilator Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 13 Endotracheal Suctioning (cont.) Minimizing complications & adverse responses (cont.) Use sterile technique during suctioning & manually ventilating patient to minimize bacterial colonization Do not routinely instill sterile normal saline into artificial airway prior to suctioning unless necessary to help mobilize thick secretions Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 14 Nasotracheal Suctioning Indicated for patients who retain secretions but do not have artificial airway in place Placing catheter in larynx & trachea is facilitated by having patient assume “sniffing position” Procedure may cause patient to gag or regurgitate; avoid suctioning immediately after meals Prepare to reposition patient & suction oropharynx if this occurs Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 15 Nasotracheal Suctioning (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 16 Procedures that minimize the complications of suctioning include all of the following, except: A. preoxygenation B. limiting negative pressure C. using septic technique D. limiting suction time Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 17 Sputum Sampling Collected to identify organisms affecting airway Patients with strong enough cough can provide ample sputum specimen by expectorating in sterile cup Sterile technique must be maintained when touching connection points on sterile/Luken’s trap Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 18 Sputum Sampling (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 19 Establishing an Artificial Airway Routes Pharyngeal airways extend only into pharynx Artificial airways placed through mouth & nose into trachea are called endotracheal tubes Intubation: process of placing artificial airway into trachea • Orotracheal intubation is when tube is passed through mouth on its way into trachea • Nasotracheal intubation is when endotracheal tube is passed through nose first Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 20 Pharyngeal Airways Nasal pharyngeal airway is most often placed to facilitate frequent nasotracheal suctioning Minimizes damage to nasal mucosa caused by suction catheter Oral pharyngeal airway should be restricted to unconscious patient to avoid gagging & regurgitation Maintains patient airway by preventing tongue from obstructing oropharynx Can be used as bite block for patients with oral tubes Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 21 Pharyngeal Airways Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 22 Tracheal Airways Two basic types Endotracheal tubes are inserted through either mouth or nose, through larynx, & into trachea Tracheostomy tubes are inserted through surgically created opening in neck directly into trachea Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 23 Tracheal Airways Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 24 Establishing an Artificial Airway Procedures Orotracheal Intubation Nasotracheal Intubation Tracheotomy Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 25 Orotracheal Intubation Step 1: Assemble & check equipment Step 2: Position patient Step 3: Preoxygenate & ventilate patient Step 4: Insert laryngoscope Step 5: Visualize glottis Step 6: Displace epiglottis Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 26 Orotracheal Intubation (cont.) Step 7: Insert tube Step 8: Assess tube position Tip of tube should be about 3-6 cm above carina Step 9: Stabilize tube/confirm placement Listen for equal & bilateral breath sounds as patient is being ventilated Observe chest wall for adequate & equal chest expansion If ET tube in airway, chest CO2 levels begin to rise; seen on capnogram Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 27 Orotracheal Intubation (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 28 Orotracheal Intubation (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 29 Orotracheal Intubation (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 30 Nasotracheal Intubation More difficult than orotracheal intubation Performed either blindly or with visualization Direct visualization requires either standard or fiberoptic laryngoscope Steps for nasotracheal intubation are similar to those of orotracheal intubation Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 31 Nasotracheal Intubation (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 32 Tracheotomy Procedure of establishing access to trachea via neck incision Either traditional surgical tracheotomy or percutaneous dilatational tracheotomy can be performed Opening in neck is called “tracheostomy” Procedure is best performed by physician or surgeon in surgical setting after patient’s airway is stabilized Selection of tracheostomy tubes depend on patient’s age, height, weight, & airway anatomy Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 33 Tracheotomy Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 34 The primary indications for an artificial tracheal airway include all of the following, except: A. facilitate secretion removal B. relieve airway obstruction C. protect against aspiration D. provide negative pressure ventilation Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 35 Airway Trauma Associated With Tracheal Tubes Laryngeal lesions Most common injuries to larynx are: • Glottic edema • Vocal cord inflammation • Laryngeal/vocal cord ulcerations • Vocal cord polyps or granulomas Less common but more serious injuries include vocal cord paralysis & stenosis Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 36 Airway Trauma Associated With Tracheal Tubes (cont.) Tracheal lesions Granulomas Tracheomalacia Tracheal stenosis Tracheoesophageal & tracheoinominate artery fistula Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 37 Airway Trauma Associated With Tracheal Tubes (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 38 Airway Trauma Associated With Tracheal Tubes (cont.) Treatment Depends on severity, especially length & circumference of damage Laser therapy may be useful for small lesions Resection & end-to-end anastomosis may be indicated when damage involves less than three tracheal rings Staged repair & stents may be required for more involved damages Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 39 Airway Trauma Associated With Tracheal Tubes (cont.) Prevention Tube movement is primary cause of injury Sedation can help avoid self-extubation Nasotracheal tubes are easier to stabilize Swivel adapter can reduce tube traction Selection of correct airway size is important Maintain pressures of 25-35 cm H2O to reduce tracheal wall injury Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 40 Airway Trauma Associated With Tracheal Tubes (cont.) Alternative cuff designs Lanz tub incorporates external pressure regulating valve & control reservoir • Designed to limit cuff pressure between 16 & 18 mm Hg Foam cuff designed to seal trachea with atmospheric pressure in cuff • Not commonly used except in patients who have already developed tracheal injury Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 41 Airway Trauma Associated With Tracheal Tubes (cont.) Alternative cuff designs (cont.) Tight-to-shaft cuff is low-volume, high pressure cuff design that maximizes airflow around tube when deflated • Can only be inflated with sterile water; not air since it is made of porous silicone material Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 42 Airway Maintenance Role of RTs Secure tube & maintain placement Provide for patient communication Ensure adequate humidification Minimize possibility of infection Aide in secretion clearance Provide appropriate cuff care Troubleshoot airway-related problems Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 43 Airway Maintenance (cont.) Tracheostomy care Step 1: Assemble & check equipment Step 2: Explain procedure to patient Step 3: Suction patient Step 4: Remove & clean inner cannula Step 5: Clean & examine stoma site Step 6: Change ties/holder Step 7: Replace clean inner cannula (if present) Step 8: Reassess patient • Check for adequate breath sounds, check vital signs & oxygenation, as well as confirm no adverse effects Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 44 Serious complications of emergency airway management include all of the following, except: A. acute hypoxemia B. hypocapnia C. bradycardia D. cardiac arrest Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 45 Troubleshooting Airway Emergencies Tube obstruction Kinking or biting tube • Obstruction is reversed by moving patient’s head & neck or repositioning tube Herniation of cuff over tip • Deflate cuff • If deflating cuff fails to overcome obstruction, try to pass suction catheter through tube Obstruction of tube orifice against tracheal wall Mucus plugging • Suction tube if instillation of sterile normal saline is not necessary Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 46 Troubleshooting Airway Emergencies (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 47 Troubleshooting Airway Emergencies (cont.) Cuff leaks Primarily problem for patients receiving mechanical ventilation Will cause reduced delivery of tidal volume If pilot tube or valve is leaking, tube needs to be changed as soon as possible • Pilot valve repair kit offers safe & effective alternative by permitting insertion of replacement valve into pilot tubing Ruptured cuff requires extubation & re-intubation or using endotracheal tube exchanger • Endotracheal tube exchanger is semi-rigid guide, over which damaged tube can be removed & new tube inserted Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 48 Troubleshooting Airway Emergencies (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 49 Troubleshooting Airway Emergencies (cont.) Accidental extubation Partial displacement of airway out of trachea can be detected by: • Decreased breath sounds • Decreased airflow through tube • Decreased ability to pass catheter past end of tube With positive pressure ventilation, airflow through mouth & nose or into stomach may be heard • Completely remove tube & provide ventilatory support by manual resuscitator & mask as needed until patient can be reintubated or tracheostomy tube reinserted Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 50 Extubation/Decannulation Extubation: Process of removing oral or nasal endotracheal airway Decannulation: Process of removing tracheostomy tube Assess patient readiness for extubation or decannulation Original problem is no longer present Quantity & thickness of secretions Upper airway patency Presence of intact gag reflex Ability to clear airway secretions Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 51 Steps of Extubation Step 1: Assemble needed equipment Step 2: Suction endotracheal tube & pharynx above cuff Step 3: Oxygenate patient Step 4: Deflate cuff Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 52 Steps of Extubation (cont.) Step 5: Remove tube Step 6: Apply appropriate oxygen & humidity therapy Oxygen with cool mist Step 7: Assess/reassess patient Check for good air movement by auscultation Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 53 During extubation, the ET tube should be withdrawn at what point of the breathing cycle? A. beginning of inspiration B. peak inspiration C. beginning of exhalation D. during exhalation Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 54 Decannulation Removal of tracheostomy tube Weaning process: Fenestrated tubes • Double cannulated tube that has opening in posterior wall of outer cannula above cuff Progressively smaller tubes Tracheostomy buttons Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 55 Decannulation (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 56 Alternative Airway Devices Laryngeal mask airway (LMA) Consists of short tube & small mask that is inserted deep into oropharynx Open surface of mask faces laryngeal opening Ventilation is directed to lungs. LMAs range in sizes from size 5 for adults to 1 for infants Disadvantages: • Cannot be used in conscious or semi-comatose patients due to stimulation of gag reflex • If ventilation pressure greater than 20 cm H2O is needed, gastric distention may occur Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 57 Alternative Airway Devices (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 58 Alternative Airway Devices (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 59 Alternative Airway Devices (cont.) Double-lumen airway Also called Combitube Inserted blindly through oropharynx & into trachea or esophagus Has two external openings, two 15-mm adapters, two lumens, & two cuffs One cuff seals oropharyx & second seals trachea or esophagus Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 60 Alternative Airway Devices (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 61 Bronchoscopy Insertion of visualization instrument endoscope into bronchi Purpose: Inspect airways Collect samples Remove foreign objects Place devices into airway Two different bronchoscopic techniques: Rigid tube bronchoscopy Flexible bronchoscopy Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 62 Bronchoscopy (cont.) Rigid tube bronchoscopy Open metal tube with distal light source & port for attaching oxygen or ventilating equipment Used most often by otorhinolaryngologists & thoracic surgeons Disadvantages: • Very uncomfortable for conscious patients • Usually requires assistance of anesthesiologist & use of operating room • Cannot assess smaller airways Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 63 Bronchoscopy (cont.) Flexible fiberoptic bronchoscopy Gained popularity because it allows access to small airways Typical scope has three channels • Light transmission channel • Visualization channel • Multipurpose open channel Used to give oxygen, take tissue samples, & suction Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 64 Bronchoscopy (cont.) Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 65 Bronchoscopy (cont.) Premedication Sedatives reduce anxiety Anticholinergic agent dry patient’s airway Narcotic analgesics may also be given to reduce pain Equipment preparation RTs are often responsible for preparing equipment, & thoroughly checking for function, tight connections, & integrity Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 66 Bronchoscopy (cont.) Airway preparation Goal is to prevent bleeding, coughing, gagging, & pain Topical vasoconstrictors such as pseudoephedrine or dilute epinephrine may be used to prevent bleeding Airway anesthesia is achieved by topical anesthetics or nerve block Monitoring RTs have active role in monitoring SpO2, ECG, vital signs Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 67 Bronchoscopy (cont.) Complications Hypoxemia • Minimized by providing oxygen before & after procedure Hemodynamic changes • Heart rate, blood pressure, & cardiac output vary depending on technique & medications used Bronchospasm • Premedicate with albuterol & ipratropium bromide • Meperidine & fentanyl are better for asthma patients RT should be present during procedure to adjust ventilator & monitor oxygen saturation & exhaled volumes Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 68 Complications of bronchoscopy include all of the following, except: A. hypoxemia B. arrhythmias C. bronchospasm D. hypertension Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 69