Repeated Bronchoscopies - Risks, Severity and Management

Introduction

Bronchoscopy is one of the most commonly performed procedures to detect the airways. Although they occur occasionally and are usually self-limiting, it is one of the most frightening scenarios chest physicians face during flexible bronchoscopy. Significant bleeding may result from conventional or cryoprobe-assisted transbronchial biopsy (a novel technique of obtaining lung biopsy). The condition may be life-threatening in case of severe injury and blood loss. The main thoracic society has put forward some guidelines on flexible bronchoscopy that gives few recommendations for handling iatrogenic (illness or injury caused by medical examination, treatment, or hospital admissions) bleeding.

Standardization of the bronchoscopy units and an action plan are necessary to avoid life-threatening bleeding resulting from injuries to the airways. A suitable action plan can save the situation if bleeding is observed during the examination. The first line strategy involves,

• Wedge the bronchoscope into the site of injury to stop bleeding.

• Place the patient in an anti-Trendelenburg position (patients are placed at 15 -30 degree inclines, with the head higher than their legs) onto a side with the bleeding lung in a dependent position.

• Administering vasoconstrictors.

• Early use of a tamponade balloon (inflating the balloon will stop bleeding by compressing the surface of the injury).

A resuscitation team should be involved earlier in case of severe bleeding, blood volume loss, blood pressure changes, and desaturation.

What Are the Risk and Severity of Bleeding in Repeated Bronchoscopies?

The risk of bleeding during diagnostic bronchoscopies is minimal and occurs between 0.26 - 5 % of the cases. Increased risk of bleeding is seen with transbronchial biopsies (biopsy performed during bronchoscopy to obtain peripheral lung tissues). Massive bleeding and deaths are rare and are seen only in therapeutic bronchoscopies as opposed to diagnostic bronchoscopies. However, cases of near-fatal bleeding have been observed in endoscopy centers.

The severity of bleeding is measured by the quantity of blood and fluid aspirated and the type of intervention required to control bleeding. Severe and moderate bleeding are the ones that require wedging of the biopsied segment using the bronchoscope to the site of injury, and the cases that need additional medical interventions, like,

• Placing a temporary bronchus-blocker.

• Application of fibrin sealants.

• Critical care unit admission.

• Need for blood products.

What Are the Risk Factors for Bleeding During Bronchoscopic Examination?

Several factors influence the risk of bleeding during flexible bronchoscopy. It depends upon the procedure and the examined tissues' vascularisation. Using flexible bronchoscopy for inspection and bronchoalveolar lavage is less traumatic and associated with minimal and no bleeding, even in thrombocytopenic patients. In addition, oral bronchoscope insertion has less risk of inducing bleeding.

• Patient Factors: Lung cancer is a common indication for flexible bronchoscopy and is usually associated with an increased risk of bleeding during the procedure. In addition, lung transplant and immunocompromised patients are more likely to have a new injury or worsen a previously existing injury leading to bleeding. Therefore in such patients, the procedure might be terminated early due to bleeding.

• Hemostasis-Related Factors: The risk of iatrogenic bleeding is higher in patients with bleeding and clotting disorders. The British Thoracic Society suggests performing studies on platelet count, hemoglobin concentration, and coagulation before performing bronchoscopy procedures in the presence of coagulation-related risk factors in patients.Several drugs are available in the market that inhibit blood coagulation and platelet functions used for different purposes. Inevitably, these drugs are associated with an increased risk of iatrogenic bleeding.

• Patients on Anticoagulants: Patients taking anticoagulants are at increased risk of bleeding. Therefore, the therapeutic anticoagulant should be withheld briefly before the procedure to minimize bleeding risks. However, discontinuing the drugs might induce serious blood clotting events in the arteries or veins, so it is critical to discontinue the drug only for a very short duration.

• Risk Factors Related to Tissue Sample: The blood supply of the sampling tissue is a risk factor for bleeding. Biopsy of highly vascularised inflammatory tissues and tumors is associated with an increased rate of bleeding. Another risk factor is the presence of vascular abnormalities like bronchiectasis (widening of the airways leading to a buildup of excess mucous) or pulmonary artery pseudoaneurysms (dilation of a pulmonary artery segment).

What Are the Prophylactic Measures to Prevent Bleeding?

• The indication, potential risks, and benefits of flexible bronchoscopy and sampling procedures should be evaluated beforehand and performed only if necessary.

• While performing the procedure, emergency resuscitation (action of reviving from unconsciousness or death) equipment and staff should be readily available to counter unexpected life-threatening bleeding, if it occurs at all.

• Patients should be thoroughly evaluated for any risk factor and optimized before the procedure.

• Applying vasoconstrictors to the nares will make the scope passage easier in case of nasal bronchoscopy.

• The British Thoracic Society recommends the administration of vasoconstrictors in the airway if bleeding is likely. However, adverse cardiac events can occur at a very low dose of adrenaline, and the consequences of adrenaline in the airways are unforeseeable.

How to Manage a Case of Bleeding During Bronchoscopy?

Bleeding during bronchoscopy is an unlikely event and is usually self-limiting. However, very rare cases may show serious life-threatening bleeding. Therefore, studies suggest that every bronchoscopy unit must have a standard action plan before the procedure to encounter an unfortunate event and reduce the chances of morbidity.

1. Action Plan For Life-Threatening Bleeding:

In case of massive bleeding with hemodynamic instabilities, assistance from the resuscitation team should be taken. General anesthesia, rigid bronchoscopy, and hemostatic therapies are employed. It will clear blood from the bronchial tree. The bleeding lung lobe is isolated, and the remaining portion of the lung is ventilated. Advanced hemostatic therapies will help control bleeding. Advanced hemostatic procedures are

• Argon plasma coagulation.

• LASER coagulation.

• Blocking devices for peripheral bleeding.

2. Action-Plan for Non-life-Threatning Bleeding:

Interventions for controlling non-life-threatening bleeding depend upon the site of bleeding. Lesions from the central portion of the lungs and lesions from the periphery are treated in different maneuvers.

• Managing Central Lesions: Hemostatic balloons are used to encourage coagulation at the site of the lesion. Argon plasma coagulation is a thermal ablation technique. It uses argon to generate heat which in turn causes coagulation. Another method is LASER (Nd: YAP or diode laser), which allows deeper coagulation.

• Managing Peripheral Lesions: The first step should be placing the patient in an anti-Trendelenburg position tilted to the affected side to prevent involvement of the other lungs and supply adequate oxygen. Wedging the bronchoscope to the site of bleeding will help clot formation. Administering ice-cold saline, vasoconstrictors, and procoagulants will reduce the bleeding.

Conclusion

Bleeding during bronchoscopy is an unlikely event. However, if it occurs it leads to a serious and frightening situation. A thorough history and physical examination are necessary to determine the risk of bleeding. If the patients are chosen wisely for performing bronchoscopy, serious bleeding complications can be avoided.