Bronchoscopy Risk Factors, Medications, and Complications

1. Linda Paradowski MD Bronchoscopy

2. Complications • Related to pre-meds & local anesthesia: • Resp depressiom, arrest • Tachycardia • Hypotension • Syncope • Seizures • Hyperexcitable state • Laryngospsasm • Anaphylaxis • methemoglobinemia • Cardiac arrest • bradycardia • Procedure-related • Epistaxis • Fever • Hypoxemia • Hypercarbia • Dyspnea • Resp. arrest • Laryngospasm, bronchospasm • Hemodynamic instability • Myocardial ischemia • Arrhythmias • Pneumonia • Aspiration • Transmission of TB • Barotrauma • Pulm. Hemorrhage • death

3. Risky Business • Coagulopathy: • Platelets < 50K for TBBX • BAL can be performed with platelets < 20K • INR > 1.5 • BUN > 50 • Platelet aggregation inhibitors taken within 7 – 10 days • SVC syndrome • Pulmonary: • Arterial p02 < 70 with FI02 > 70% • PEEP > 10 • Active bronchospasm • BAL may drop p02 by 10-20 • Pulmonary hypertension with TBBX • Inability to cough • Large abscesses

4. Risky Business II • Cardiac: • Recent MI < 48 hours for emergent bronchoscopy • MI < 6 weeks for elective bronchoscopy • Unstable arrhythmia • Mean arterial pressure < 65 • CNS: • Evidence for increased ICP • Incipient herniation • Inability to handle secretions & protect airway

5. All about the meds • Lidocaine • Rapid onset of action • Up to 300 mg can be given safely in small aliquots • Reduce dosage with hepatic dysfunction • Can induce bronchospasm in animals • 2% above the cords, 1% below • Midazolam • Rapid onset of action, short duration, good amnesia • Apnea if injected rapidly • Effect with cirrhotics is even more pronounced

6. All about the meds cont. • Meperidine • Little effect on cough • Metabolites seizure inducing esp. with renal insufficiency • Will be off formulary soon • Fentanyl • Synthetic opioid with the fastest onset of action & shortest duration • Good cough control • 80 times more potent than morphine • At high doses can cause muscle rigidity especially if given as IV push • Liver & kidney disease can impair clearance

7. BAL cell count • Normal cell count differential in nonsmokers: • 80 – 90% macrophages • 5 – 15% lymphocytes • 1 – 3% neutrophils • < 1% eosinophils • < 1% mast cells • Complication rate: 3% • Mostly fever & chills, transient hypoxemia

8. BAL cell predominance • Eosinophils: > 10%significant • indicative of eosinophilic pneumonia • other immunologic phenomena like transplant rejection • Lymphocytic predominance & subsets: • Elevated CD4/CD8 ratio suggests sarcoid but can be found in collagen vascular disease, TB, malignancy • If ratio > 3.5 then specific for sarcoid • Low CD4/CD8 may be seen in hypersensitivity pneumonia • Mast cells may be seen: • asthma • radiation pneumonitis • BOOP • HP

9. BAL cells • Neutrophils: • Acute inflammation • Old literature: in UIP & with eos = worse prognosis • Rare for HIV related PCP • Hemosiderin – laden macrophages • Hemoglobin degradation product of hemoglobin • Requires two days to form • Cleared from the lungs after 2 – 4 weeks • Indicates chronicity & verifies not iatrogenic

10. BAL cell count & diseases

11. TBBX - indications • Sarcoidosis – stage II & III - > 85% yield • Pulmonary histiocytosis • PCP in non-AIDS patients • Diffuse infection caused by mycobacteria & mycoses • Lymphangitic carcinomatosis • PAP • Alveolar cell carcinoma • Diffuse pulmonary lymphoma • LAM • Silicosis

12. TBBX - complications • Increases mortality from bronchoscopy from 0.04% to .12% • Incidence of significant hemorrhage ( > 50ml) about 1% • 29% in immunocompromised • 45% in uremic patients • Incidence of pneumothorax is between 1-2% - lessened with flouroscopy • 7% in patients on mechanical ventilation • Higher if patient receiving PEEP

13. Retained secretions & atelectasis • Significant improvement in 41 – 81% • Superiority of FOB over CPT not clearly established with lobar atelectasis especially with air bronchograms • Can be life saving in whole lung atelectasis especially if patient is hypoxemic • Radiographic response is delayed 6 – 24 hours & follows improved gas exchange

14. Mucous plugs

15. Hemoptysis • Highest chance for visualizing sources is within 12 – 18 hours of event • Major causes: • Bronchogenic carcinoma – 29% • Bronchitis – 23% • No specific cause – 22% • Direct therapeutic interventions: saline, epinephrine, thrombin, fibrinogen-thrombin combination, balloon tamponade • Yield for bronchoscopy in diagnosing an occult malignancy in a patient with hemoptysis & a normal X-ray is about 10% if the patient is older than 40 & has smoked > than 40 pack years

16. Chronic cough • Low yield for bronchoscopy if chest X-ray is normal • Most common causes: asthma, GERD, postnasal drip • 90 % response rate to specific therapy • 20% have more than one cause • Some advocate a 4 week trial of GERD therapy for any unexplained cough

17. Pleural effusions • Irish study: • retrospective review of 3K FOBs • 50 performed for lone pleural effusion. • 7 pts. had bronchogenic cancer • only one was visualized endobronchially • Rochester study: • 115 pts. With suspected bronchogenic carcinoma with pleural effusion underwent FOB • FOB was useful only • with hemoptysis • obvious mass with infiltrated &/or atelectasis • if the effusion was massive • in cytology positive effusion without obvious primary

18. Ventilator associated pneumonia • Mortality can be up to 60% & broad spectrum antibiotics can encourage resistance • PSB & BAL give similar results • False negatives & false positives are around 30% • Results may not be valid if patient on antibiotics for 72 hours • Invasive diagnostics have had no influence on mortality, ICU stay or time on ventilator with VAP • Mortality is influenced by inadequate anti-microbial treatment • Bronchoscopy most useful for drug-resistant & opportunistic pathogens, noninfectious conditions like EP, DAH,HP & possibly for failure to respond to initial antimicrobials

19. Tracheo-esophageal fistula

20. Tracheo-pleural fistula

21. Post intubation stenosis

22. Bronchopleural fistula

23. Bronchomalacia

24. Airway inflammation

25. Scleroderma & BAL • Hopkins study in Annals of Int. Med 2000 • 69 scleroderma pts. followed a minimum of 6 mos. • Alveolitis diagnosed by BAL if PMNs > 3% or eos > 2.2% • Those diagnosed with alveolitis had improved survival & PFTs if treated with cyclophosphamide • Ann Rheum Dis 1999 • 73 pts. with diffuse scleroderma • Pts with BAL PMNs > 3% but not those with lymphocytes > 15% had deterioration in lung function especially DLCO • Authors concluded that the group with neutrophils should be aggressively treated

26. Scleroderma & BAL • AM Journal of R&CCM 2002 • Classified the histologic appearance of lung biopsies in 80 pts & compared prognostic value with clinical indices • Most pts. had fibrotic NSIP but 5 year survival was 80% • BAL did not identify future progression • Changes in DLCO were linked to survival but probably reflected pulm. vascular disease

27. Scleroderma & ILD • Most patients with SS & ILD have fibrotic NSIP but a minority develop UIP with poorer survival • Both are associated with a neutrophilic or eosinophilic BAL • Cytoxan appears to be beneficial in terms of stabilization of PFTs for some patients • It is unclear if BAL can identify a subset of patients who will have a good response to cyclophosphamide • It is also unclear if BAL is more sensitive or specific than HRCT in identifying ILD

28. Endobronchial Neoplasms

29. Hamartoma • Most common benign tumor of lungs • Contains a mixture of cartilage, smooth muscle, fat, epithelial & mesenchymal cells • Slow growing • Malignant transformation is rare

30. Pulmonary carcinoid • Neuro-endocrine tumor that presents most frequently with bronchial obstruction • obstructive pneumonitis • pleuritic pain • atelectasis • dyspnea • Carcinoid syndrome extremely rare & indicates metastatic disease • Diagnose via endobronchial biopsy • has 1% risk of significant bleeding • diagnostic yield is 80% because the tumor may be covered by normal bronchial mucosa

31. Carcinoid & Mucoepidermoid tumors

32. More neoplasms

33. Brachytherapy

34. Stents

35. The end