An analysis of potential risk factors for early complications from fiberoptic bronchoscopy in lung transplant recipients

Prophylactic epinephrine attenuates severe bleeding in lung transplantation patients undergoing transbronchial lung biopsy: Results of the PROPHET randomized trial

BACKGROUND

Severe hemorrhage is an uncommon yet potentially life-threatening complication of transbronchial lung biopsy. Lung transplantation recipients undergo multiple bronchoscopies with biopsy and are considered to be at an increased risk for bleeding from transbronchial biopsy, independent of traditional risk factors. We aimed to evaluate the efficacy and safety of endobronchial administration of prophylactic topical epinephrine in attenuating transbronchial biopsy-related hemorrhage in lung transplant recipients.

METHODS

The Prophylactic Epinephrine for the Prevention of Transbronchial Lung Biopsy-related Bleeding in Lung Transplant Recipients study was a 2-center, randomized, double blind, placebo-controlled clinical trial. Participants undergoing transbronchial lung biopsy were randomized to receive 1:10,000-diluted topical epinephrine vs saline placebo administered prophylactically into the target segmental airway. Bleeding was graded based on a clinical severity scale. The primary efficacy outcome was incidence of severe or very severe hemorrhage. The primary safety outcome was a composite of 3-hours all-cause mortality and an acute cardiovascular event.

RESULTS

A total of 66 lung transplantation recipients underwent 100 bronchoscopies during the study period. The primary outcome of severe or very severe hemorrhage occurred in 4 cases (8%) in the prophylactic epinephrine group and in 13 cases (24%) in the control group (p = 0.04). The composite primary safety outcome did not occur in any of the study groups.

CONCLUSIONS

In lung transplantation recipients undergoing transbronchial lung biopsy, prophylactic administration of 1:10,000-diluted topical epinephrine into the target segmental airway before biopsy attenuates the incidence of significant endobronchial hemorrhage without conveying a significant cardiovascular risk. (ClinicalTrials.gov identifier: NCT03126968).

Lung transplantation for lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease, associated with respiratory symptoms of dyspnea and spontaneous pneumothorax, along with various extra-thoracic manifestations. Often a progressive disease, albeit slowly, patients can develop chronic and severe respiratory failure and require supplemental oxygen. Lung transplantation (LTX) can offer improved duration and quality of life for patients with end-stage lung disease due to LAM. There are several unique considerations for LTX in LAM patients, and disease-specific complications of LAM prior to LTX can affect management decisions. Furthermore, there are several possible post-transplant issues specific to LAM. In this review, we discuss evaluation and management, disease-specific complications (both pre- and post-transplant), and outcomes for LAM patients undergoing lung transplantation.

Routine Chest Radiography for the Evaluation of Pneumothorax Following Bronchoscopy

RATIONALE AND OBJECTIVES

To determine the utility of routine postbronchoscopy chest radiography to detect pneumothorax.

MATERIALS AND METHODS

This retrospective quality improvement cohort study was approved by the Institutional Review Board. All outpatients (n = 1443) who underwent protocol-driven postbronchoscopy chest radiography in one health system from January 2010 to July 2017 were identified by electronic medical record query. The prevalence of pneumothorax (with 95% confidence intervals [CI]) and clinical outcome were determined following coded review of chest radiography reports and review of the electronic medical record. The effect of smoking and lung disease on risk of pneumothorax was determined with Chi Square tests.

RESULTS

Of 1443 subjects undergoing interventional bronchoscopy, 6% (93/1443) were current smokers, 35% (505/1442) were former smokers, and 35% (540/1443) had known lung disease. Pneumothorax prevalence was 3.4% (49/1443; 95% CI: 2.6%-4.5%) following any intervention and 4.1% (42/1032; 95% CI: 3.9%-5.5%) following transbronchial intervention. In those without known pre-existing pneumothorax or a confirmed false positive diagnosis, the real overall pneumothorax rate was 2.9% (42/1443; 95% CI: 2.1%-3.9%). The risk of pneumothorax did not differ based on smoking history (p = 0.99) or history of lung disease (p = 0.19). Of 49 subjects with pneumothorax, 13 were symptomatic, and 10 had a change in management including chest tube placement (N = 2), inpatient admission (N = 3), and/or observation (N = 7). No pneumothorax-related intervention was performed in asymptomatic patients.

CONCLUSION

Pneumothorax following interventional outpatient bronchoscopy is uncommon, usually asymptomatic, and often clinically insignificant. Asymptomatic postbronchoscopy patients are very low risk and may not need routine imaging.

Bronchoscopic procedures and lung biopsies in pediatric lung transplant recipients

Bronchoscopy remains a pivotal diagnostic and therapeutic intervention in pediatric patients undergoing lung transplantation (LTx). Whether performed as part of a surveillance protocol or if clinically indicated, fibre-optic bronchoscopy allows direct visualization of the transplanted allograft, and in particular, an assessment of the patency of the bronchial anastomosis (or tracheal anastomosis following heart-lung transplantation). Additionally, bronchoscopy facilitates differentiation of infective processes from rejection episodes through collection and subsequent assessment of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) samples. Indeed, the diagnostic criteria for the grading of acute cellular rejection is dependent upon the histopathological assessment of biopsy samples collected at the time of bronchoscopy. Typically, performed in an out-patient setting, bronchoscopy is generally a safe procedure, although complications related to hemorrhage and pneumothorax are occasionally seen. Airway complications, including stenosis, malacia, and dehiscence are diagnosed at bronchoscopy, and subsequent management including balloon dilatation, laser therapy and stent insertion can also be performed bronchoscopically. Finally, bronchoscopy has been and continues to be an important research tool allowing a better understanding of the immuno-biology of the lung allograft through the collection and analysis of collected BAL and TBBx samples. Whilst new investigational tools continue to evolve, the simple visualization and collection of samples within the lung allograft by bronchoscopy remains the gold standard in the evaluation of the lung allograft. This review describes the use and experience of bronchoscopy following lung transplantation in the pediatric setting.

Pneumothorax after transbronchial needle biopsy

Currently there several diagnostic techniques that re used by radiologists and pulmonary physicians for lung cancer diagnostics. In several cases pneumothorax (PNTX) is induced and immediate action is needed. Both radiologists and pulmonary physicians can insert a chest tube for symptom relief. However; only pulmonary physicians and thoracic surgeons can provide a permanent solution for the patient. The final solution would be for a patient to undergo surgery for a final solution. In our current work we will provide all those diagnostic cases where PNTX is induced and treatment from the point of view of expert radiologists and pulmonary physicians.

Diagnostic bronchoscopy in solid-organ and hematopoietic stem cell transplantation

Fiberoptic bronchoscopy is a valuable diagnostic tool in solid-organ and hematopoietic stem cell transplant recipients presenting with a range of pulmonary complications. This article provides a comprehensive overview of the utility and potential adverse effects of diagnostic bronchoscopy for transplant recipients. Recommendations are offered on the selection of patients, the timing of bronchoscopy, and the samples to be obtained across the spectrum of suspected pulmonary complications of transplantation. Based on review of the literature, the authors recommend early diagnostic bronchoscopy over empiric treatment in transplant recipients with evidence of certain acute, subacute, or chronic pulmonary processes. This approach may be most critical when an underlying infectious etiology is suspected. In the absence of prompt diagnostic information on which to base effective treatment, the risks associated with empiric antimicrobial therapy, including medication side effects and the development of antibiotic resistance, compound the potential harm of delaying targeted management.