Iatrogenic bleeding during flexible bronchoscopy: risk factors, prophylactic measures and management

Anesthesia for Bronchoscopy-An Update

The field of interventional pulmonology has grown immensely and is increasingly recognized as a subspecialty. The new procedures introduced in the last decade pose unique challenges, and anesthesiologists need to readapt to their specific demands. In this review, we extensively discuss the pathophysiology, technical aspects, preprocedural preparation, anesthetic management, and postprocedural challenges of many new procedures such as navigational bronchoscopy, endobronchial valve deployment, and bronchial thermoplasty. Majority of these procedures are performed under general anesthesia with an endotracheal tube. Total intravenous anesthesia with rocuronium as a muscle relaxant seems to be the standard US practice. The easy availability and proven safety and efficacy of sugammadex as a reversal agent of rocuronium has decreased the need for high-dose remifentanil as an agent to avoid muscle relaxants. Additional research is available with regard to the utility of nebulized lidocaine and is discussed. Finally, two newer drugs administered for conscious sedation (typically without the need of an anesthesiologist) are likely to gain popularity in the future. Remimazolam is a new short-acting benzodiazepine with a relatively faster offset of clinical effects. Dexmedetomidine, a selective adrenergic agonist, is increasingly employed in bronchoscopy as a sedative during bronchoscopic procedures.

Clinical Approach to Massive Hemoptysis: Perioperative Focus on Causes and Management

Massive hemoptysis is a time critical airway emergency in the perioperative setting, with an associated mortality exceeding 50%. Causes of hemoptysis in the perioperative setting include procedural complication, coagulopathy, malignancy, chronic lung disease, infection, left-sided cardiac disease, pulmonary vascular disease and autoimmune disease. A rapid and coordinated multidisciplinary response is required to secure the airway, isolate the lung, ensure adequate oxygenation and ventilation, identify the underlying cause and initiate specific systemic, bronchoscopic, endovascular, or surgical treatment. This review examines the etiology, pathophysiology, as well as approach to management and interventions in perioperative massive hemoptysis.

Stereotactic Body Radiotherapy for Centrally Located Inoperable Early-Stage NSCLC: EORTC 22113-08113 LungTech Phase II Trial Results

INTRODUCTION

The international phase II single-arm LungTech trial 22113-08113 of the European Organization for Research and Treatment of Cancer assessed the safety and efficacy of stereotactic body radiotherapy (SBRT) in patients with centrally located early-stage NSCLC.

METHODS

Patients with inoperable non-metastatic central NSCLC (T1-T3 N0 M0, ≤7cm) were included. After prospective central imaging review and radiation therapy quality assurance for any eligible patient, SBRT (8 × 7.5 Gy) was delivered. The primary endpoint was freedom from local progression probability three years after the start of SBRT.

RESULTS

The trial was closed early due to poor accrual related to repeated safety-related pauses in recruitment. Between August 2015 and December 2017, 39 patients from six European countries were included and 31 were treated per protocol and analyzed. Patients were mainly male (58%) with a median age of 75 years. Baseline comorbidities were mainly respiratory (68%) and cardiac (48%). Median tumor size was 2.6 cm (range 1.2-5.5) and most cancers were T1 (51.6%) or T2a (38.7%) N0 M0 and of squamous cell origin (48.4%). Six patients (19.4%) had an ultracentral tumor location. The median follow-up was 3.6 years. The rates of 3-year freedom from local progression and overall survival were 81.5% (90% confidence interval [CI]: 62.7%-91.4%) and 61.1% (90% CI: 44.1%-74.4%), respectively. Cumulative incidence rates of local, regional, and distant progression at three years were 6.7% (90% CI: 1.6%-17.1%), 3.3% (90% CI: 0.4%-12.4%), and 29.8% (90% CI: 16.8%-44.1%), respectively. SBRT-related acute adverse events and late adverse events ≥ G3 were reported in 6.5% (n = 2, including one G5 pneumonitis in a patient with prior interstitial lung disease) and 19.4% (n = 6, including one lethal hemoptysis after a lung biopsy in a patient receiving anticoagulants), respectively.

CONCLUSIONS

The LungTech trial suggests that SBRT with 8 × 7.5Gy for central lung tumors in inoperable patients is associated with acceptable local control rates. However, late severe adverse events may occur after completion of treatment. This SBRT regimen is a viable treatment option after a thorough risk-benefit discussion with patients. To minimize potentially fatal toxicity, careful management of dose constraints, and post-SBRT interventions is crucial.

Endobronchial Phenylephrine in Airway Bleeding During Bronchoscopy Does not Cause Hypertension: A Retrospective Observational Study

BACKGROUND

Bleeding is a known complication during bronchoscopy, with increased incidence in patients undergoing a more invasive procedure. Phenylephrine is a potent vasoconstrictor that can control airway bleeding when applied topically and has been used as an alternative to epinephrine. The clinical effects of endobronchial phenylephrine on systemic vasoconstriction have not been clearly evaluated. Here, we compared the effects of endobronchial phenylephrine versus cold saline on systemic blood pressure.

METHODS

In all, 160 patients who underwent bronchoscopy and received either endobronchial phenylephrine or cold saline from July 1, 2017 to June 30, 2022 were included in this retrospective observational study. Intra-procedural blood pressure absolute and percent changes were measured and compared between the 2 groups.

RESULTS

There were no observed statistical differences in blood pressure changes between groups. The median absolute change between the median and the maximum intra-procedural systolic blood pressure in the cold saline group was 29 mm Hg (IQR 19 to 41) compared with 31.8 mm Hg (IQR 18 to 45.5) in the phenylephrine group. The corresponding median percent changes in SBP were 33.6 % (IQR 18.8 to 39.4) and 28% (IQR 16.8 to 43.5) for the cold saline and phenylephrine groups, respectively. Similarly, there were no statistically significant differences in diastolic and mean arterial blood pressure changes between both groups.

CONCLUSIONS

We found no significant differences in median intra-procedural systemic blood pressure changes comparing patients who received endobronchial cold saline to those receiving phenylephrine. Overall, this argues for the vascular and systemic safety of phenylephrine for airway bleeding as a reasonable alternative to epinephrine.

Flexible bronchoscopy in pediatric lung transplantation

Pediatric lung transplantation represents a treatment option for children with advanced lung disease or pulmonary vascular disorders who are deemed an appropriate candidate. Pediatric flexible bronchoscopy is an important and evolving field that is highly relevant in the pediatric lung transplant population. It is thus important to advance our knowledge to better understand how care for children after lung transplant can be maximally optimized using pediatric bronchoscopy. Our goals are to continually improve procedural skills when performing bronchoscopy and to decrease the complication rate while acquiring adequate samples for diagnostic evaluation. Attainment of these goals is critical since allograft assessment by bronchoscopic biopsy is required for histological diagnosis of acute cellular rejection and is an important contributor to establishing chronic lung allograft dysfunction, a common complication after lung transplant. Flexible bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsy plays a key role in lung transplant graft assessment. In this article, we discuss the application of bronchoscopy in pediatric lung transplant evaluation including historical approaches, our experience, and future directions not only in bronchoscopy but also in the evolving pediatric lung transplantation field. Pediatric flexible bronchoscopy has become a vital modality for diagnosing lung transplant complications in children as well as assessing therapeutic responses. Herein, we review the value of flexible bronchoscopy in the management of children after lung transplant and discuss the application of novel techniques to improve care for this complex pediatric patient population and we provide a brief update about new diagnostic techniques applied in the growing lung transplantation field.

Bronchoscopic Electrocautery Versus Adrenaline and Cold Saline Instillation for Prophylactic Haemostasis Prior to Biopsy of Endobronchial Lesions (BEVACS): A Randomized Controlled Trial

BACKGROUND

Flexible bronchoscopy-guided endobronchial biopsy (EBB) is routinely performed as an outpatient daycare procedure. Bleeding after EBB is a common complication, that at times disrupts the procedure and can rarely lead to a catastrophe. We aimed to compare the efficacy of prebiopsy prophylactic bronchoscopic electrocautery with adrenaline and cold saline instillation in achieving hemostasis in patients with endobronchial lesions with a higher risk of bleeding during EBB.

METHODS

In this open-label, randomized controlled trial, 60 patients with endobronchial lesions were randomized to either the prophylactic electrocautery arm or the adrenaline and cold saline arm. Postbiopsy endobronchial bleed was quantified in millimeters using the Visual Analog Scale (VAS) and graded as per the British Thoracic Society grading system. Electrocautery-induced tissue damage was graded by the pathologist as "no damage," "mild," "moderate," and "severe."

RESULTS

The median VAS score of bleeding was 6.14 mm (interquartile range: 8 mm) in the electrocautery arm and 10.17 mm (interquartile range: 7 mm) in the adrenaline and cold saline arm. Though the difference in the VAS score of bleeding between the two groups was statistically significant, there was no significant difference in the proportion of grade 2 or higher bleeding.

CONCLUSION

No difference in postbiopsy bleed was observed between the application of electrocautery or instillation of cold saline plus adrenaline before biopsy of those endobronchial lesions which were likely to bleed more after biopsy. Although controlled prophylactic electrocautery using 15 watts did not impair the quality of EBB specimens, a higher wattage may change this observation, as well as the bleeding quantity.

Lung isolation-a personalized and clinically adapted approach to control bronchoscopy-associated acute massive airway hemorrhage

BACKGROUND

The current concept of bronchoscopy-associated massive airway hemorrhage is not accurate enough, and the amount of bleeding as the only evaluation criterion cannot comprehensively evaluate magnitude of the effects and the severity.

OBJECTIVE

To propose the concept of bronchoscopy-associated acute massive airway hemorrhage, analyze its impact on patients and highlight the treatment approach of acute massive airway hemorrhage without ECMO support.

DESIGNS

A retrospective cohort study.

SETTING

Include all patients who received bronchoscopy intervention therapy at Interventional Pulmonology Center of Emergency General Hospital from 2004 to December 2021.

PATIENTS

223 patients met the inclusion criteria.

INTERVENTION

Patients were divided into two groups: acute massive airway hemorrhage group (n = 29) and non-acute massive airway hemorrhage group (n = 194).

MAIN OUTCOME MEASURES

Perioperative adverse events between two groups were the main outcome. Secondary outcome was the impact of lung isolation on patient in group Acute.

RESULTS

The incidence of acute massive airway hemorrhage was 0.11%, and the incidence of non-acute massive airway hemorrhage was 0.76% in this study. There were significant differences in the incidence of intraoperative hypoxemia, lowest SpO2, hemorrhagic shock, cardiopulmonary resuscitation, intraoperative mortality, and transfer to ICU between acute group and non-acute group (P<0.05, respectively). Lung isolation was used in 12 patients with acute massive airway hemorrhage, and only 2 patients died during the operation.

CONCLUSION

Bronchoscopy-associated acute massive airway hemorrhage had more serious impact on patients due to rapid bleeding, blurred vision of bronchoscopy, inability to stop bleeding quickly, blood filling alveoli, and serious impact on oxygenation of the lung lobes. Polyvinyl chloride single-lumen endotracheal intubation for lung isolation, with its characteristics of low difficulty, wide applicability and available in most hospitals, may reduce the intraoperative mortality of patients with bronchoscopy-associated acute massive airway hemorrhage.

TRIAL REGISTRATION

Chinese Clinical Trial Registry on 13/03/2022.

REGISTRATION NUMBER

ChiCTR2200057470.

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).

The Use of a Fabricated Endotracheal Tube During an Acute Massive Pulmonary Hemorrhage: A Case Report

A massive pulmonary hemorrhage is an emergency that can lead to airway compromise and cardiovascular collapse. The goals of airway management are to isolate and protect the nonbleeding lung while providing a route for interventions to diagnose and control the bleeding site. We present a case of an adult male with a lung mass who underwent a bronchoscopy and cryobiopsy that was complicated by a massive pulmonary hemorrhage. We report the successful use of an elongated fabricated end-to-end endotracheal tube to manage his airway during this time-critical situation.

The Surgical Management of Lung Neuroendocrine Neoplasms

This review summarizes key recent developments relevant to the surgical management of lung neuroendocrine neoplasms (L-NENs), including typical and atypical carcinoids, large cell neuroendocrine carcinoma, and small cell lung carcinoma. This review includes recent insights into the classification, clinical presentation, diagnostic workup, treatment options, and follow-up. Highlighted topics include general principles of surgery in localized or locally advanced or metastatic L-NENs, lung-sparing surgery for small, peripheral typical carcinoids, adjuvant and systemic therapies for typical and atypical carcinoids, and surgery and adjuvant therapies for large cell neuroendocrine carcinoma and small cell lung carcinoma.

Risk of bleeding associated with transbronchial biopsy using flexible bronchoscopy in patients with echocardiographic or chest CT evidence of pulmonary hypertension

Background

Endobronchial ultrasound (EBUS)-guided transbronchial biopsy (TBB) facilitates the diagnosis of various respiratory diseases. The safety of performing EBUS-guided TBB in patients with a finding of pulmonary hypertension (PH) is controversial. Little is known about the relationship between the risk of bleeding associated with EBUS-guided TBB in the presence of PH suspected on echocardiography or chest CT.

Methods

To assess the risk of bleeding associated with EBUS-guided TBB in patients with presumed PH per echocardiography or chest CT, we retrospectively reviewed the medical records of 314 consecutive patients who underwent EBUS-guided TBB using a guide sheath (GS), as well as echocardiography and chest CT. Bleeding complication was defined as over one minute of suctioning; repeated wedging of the bronchoscope; instillation of cold saline, diluted vasoactive substances, or thrombin due to persistent bleeding. Findings of suspected PH were defined as peak tricuspid regurgitation velocity (TRV) > 2.8 m/s on echocardiography or pulmonary artery to aorta ratio (PA:A ratio) > 0.9 on chest CT.

Results

In total, 35 (11.1%) patients developed bleeding, and all cases were managed safely. Furthermore, 17 (5.4%) and 59 (18.8%) patients were suspected to have PH based on echocardiography and chest CT, respectively. Among the patients suspected to have PH on echocardiography, five (5/17 = 29.4%) patients developed bleeding. Among the patients suspected to have PH on chest CT, 11 (11/59 = 18.6%) patients developed bleeding. Univariate analysis revealed that long diameter (≥ 30 mm) of the lesion, lesion location (the biopsy site was inner than the segmental bronchus), bronchoscopic diagnosis of malignancy, and additional biopsy were potential predictive factors for bleeding. The finding of suspected PH on echocardiography correlated significantly with bleeding (p = 0.03). On multivariate analysis, long diameter (≥ 30 mm) of the lesion (p = .021) and findings of suspected PH on echocardiography (p = .049) were significantly associated with bleeding.

Conclusion

All cases of bleeding in the present study were managed safely. The risk of bleeding is moderately elevated when PH is suspected by echocardiography in patients undergoing EBUS-guided TBB using a GS.

Novel use of metallic stent to control post-debulking bleeding in a patient with central airway obstruction

Bronchoscopy-related bleeding is often encountered and is usually self-limiting or controllable by conservative measures. However, major bleeds can be life threatening for the patient as well as challenging for the physician to manage. There are several methods to achieve adequate haemostasis should a significant airway bleed occur. In this context, we describe a patient who had a post-bronchoscopic debulking bleed which persisted despite use of all available measures, and we deployed a self-expanding metallic stent in an attempt to control it. To the best of our knowledge, this is the first instance of a metallic airway stent being used to control bronchoscopy associated bleeding, though reports of its usage in management of intractable haemoptysis exist in the literature.

Tranexamic Acid vs Adrenaline for Controlling Iatrogenic Bleeding During Flexible Bronchoscopy: A Double-Blind Randomized Controlled Trial

BACKGROUND

The most commonly used topical hemostatic agents during flexible bronchoscopy (FB) are cold saline and adrenaline. Data on use of other agents such as tranexamic acid (TXA) for this purpose are limited.

RESEARCH QUESTION

Is TXA effective and safe in controlling iatrogenic bleeding during FB compared with adrenaline?

STUDY DESIGN AND METHODS

We conducted a cluster-randomized, double-blind, single-center trial in a tertiary teaching hospital. Patients were randomized in weekly clusters to receive up to three applications of TXA (100 mg, 2 mL) or adrenaline (0.2 mg, 2 mL, 1:10000) after hemostasis failure after three applications of cold saline (4 ° C, 5 mL). Crossover was allowed (for up to three further applications) before proceeding with other interventions. Bleeding severity was graded by the bronchoscopist using a visual analog scale (VAS; 1 = very mild, 10 = severe).

RESULTS

A total of 2,033 FBs were performed and 130 patients were randomized successfully to adrenaline (n = 65) or TXA (n = 65), whereas 12 patients had to be excluded for protocol violations (two patients from the adrenaline arm and 10 patients from TXA arm). Bleeding was stopped in 83.1% of patients (54/65) in both groups (P = 1). The severity of bleeding and number of applications needed for bleeding control were similar in both groups (adrenaline: mean VAS score, 4.9 ± 1.3 [n = 1.8 ± 0.8]; TXA: mean VAS score, 5.3 ± 1.4 [n = 1.8 ± 0.8]). Both adrenaline and TXA were more successful in controlling moderate bleeding (86.7% and 88.7%, respectively) than severe bleeding (40% and 58.3%, respectively; P = .008 and P = .012, respectively) and required more applications for severe bleeding (3.0 ± 0 and 2.4 ± 0.5, respectively) than moderate bleeding (1.7 ± 0.8 and 1.7 ± 0.8, respectively) control (P = .006 and P = .002, respectively). We observed no drug-related adverse events in either group.

INTERPRETATION

We found no significant difference between adrenaline and TXA for controlling noncatastrophic iatrogenic endobronchial bleeding after cold saline failure, adding to the body of evidence that TXA can be used safely and effectively during FB.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT04771923; URL: www.

CLINICALTRIALS

gov.

Catastrophic pulmonary haemorrhage after endobronchial biopsy of necrotic lung mass

Flexible bronchoscopy (FB) is instrumental in the diagnosis and treatment of respiratory illness, with low rates of bleeding post-procedure but unpredictable degrees of severity. Although exceedingly rare, massive pulmonary haemorrhage after FB is often catastrophic. We present a case of massive pulmonary haemorrhage after endobronchial biopsy of a 67-year-old patient with a prior diagnosis of right upper lobe (RUL) necrotic lung mass. Imaging revealed possible lymphangitic carcinomatosis and tumour invasion into the lymphatics and vasculature. Significant RUL tumour burden was visualized during the procedure, however, routine endobronchial biopsy resulted in massive pulmonary haemorrhage leading to pulseless electrical activity. Prevention of massive pulmonary haemorrhage may be possible with identification of known risk factors. Catastrophic outcomes from massive pulmonary haemorrhage remain high despite current therapies. Further studies identifying modifiable risk factors, treatment protocols, and the formulation of a multi-disciplinary action plan could prove lifesaving.

Nonintubated bronchoscopic interventions with high-flow nasal oxygen: A retrospective observational study

To determine the feasibility on maintaining oxygenation of high-flow nasal oxygenation (HFNO) with bispectral index-guided intravenous anesthesia for nonintubated interventional bronchoscopy (NIIB). If desaturation happens, the factors influencing intraprocedural desaturation were also analyzed.This is a single-center retrospective study on patients receiving NIIB with HFNO and intravenous anesthesia guided by bispectral index levels to the depth of general anesthesia, which were between 40 and 60. Intraprocedural desaturation (SPO2 < 90%) and complications (bleeding, delayed discharge, unexpected admission) were collected. Factors affecting desaturation and complications were analyzed including patients' factors (age, American Society of Anesthesiologists classification, body mass index [BMI]), procedural factors (procedural time, with or without use of cryoprobe), and setting (outpatient or hospitalized).Records of 223 patients receiving NIIB were collected. The NIIB procedures time was 56.1 ± 26.8 minute. Sixty patients (26.9%) presented desaturation events. Higher BMI, but not procedure time or setting, was significantly associated with desaturation. The desaturation were resolved after relieving upper airway obstruction but 1 patient required bag-valve-mask ventilation to restore oxygenation. Accidental massive bleeding and intraprocedural desaturation during tracheal and bronchial recannulation with cryoprobes happened in 2 patients and 1 of them was admitted to intensive care unit.HFNO is feasible to maintain oxygenation during NIIB only if there is effective upper airway management especially for patients with higher BMI. Longer procedural time and different setting did not affect the desaturation rate. Complications and unexpected admission were associated with the use of cryoprobes.

Acute upper gastrointestinal bleeding: A stitch on time saves nine

Upper gastrointestinal bleeding is common and often needs timely intervention for optimal outcomes. Esophageal bleeding may occur due to local advancement of malignancy or bleeding from an arterio-oesophageal fistula. We discuss the management options available for such cases.

Pulmonary Kaposi Sarcoma without Respiratory Symptoms and Skin Lesions in an HIV-Naïve Patient: A Case Report and Literature Review

Kaposi sarcoma (KS) is a multifocal lympho-angioproliferative, mesenchymal low-grade tumor associated with a γ2-herpesvirus, named Kaposi sarcoma-associated virus or human herpesvirus (KSHV/HHV8). The lung is considered a usual anatomical location of KS, despite being infrequent, often in association with extensive mucocutaneous lesions and very uncommonly as an isolated event. We report a case of a pulmonary KS (pKS) in a human immunodeficiency virus (HIV) naïve patient, which was atypical due to a lack of cutaneous involvement and an absence of respiratory symptoms. The pKS was initially identified as a tumoral suspected nodular lesion and only after immunohistochemical analysis was it characterized as KS. Furthermore, the diagnosis of pKS led to the discovery of the HIV-seropositive status of the patient, previously unknown. Our report underlines the importance of considering pKS even without skin lesions and as a first manifestation of HIV infection. We also reviewed literature on the current knowledge about pKS in people living with HIV (PLWH) to underline how one of the most common HIV/acquired immunodeficiency syndrome (AIDS) associated tumors can have a challenging localization and be difficult to recognize.

Role of bronchoscopy in critically ill patients managed in intermediate care units - indications and complications: A narrative review

Flexible bronchoscopy (FB) has become a standard of care for the triad of inspection, sampling, and treatment in critical care patients. It is an invaluable tool for diagnostic and therapeutic purposes in critically ill patients in intensive care unit (ICU). Less is known about its role outside the ICU, particularly in the intermediate care unit (IMCU), a specialized environment, where an intermediate grade of intensive care and monitoring between standard care unit and ICU is provided. In the IMCU, the leading indications for a diagnostic work-up are: To visualize airway system/obstructions, perform investigations to detect respiratory infections, and identify potential sources of hemoptysis. The main procedures for therapeutic purposes are secretion aspiration, mucus plug removal to solve atelectasis (total or lobar), and blood aspiration during hemoptysis. The decision to perform FB might depend on the balance between potential benefits and risks due to frailty of critically ill patients. Serious adverse events related to FB are relatively uncommon, but they may be due to lack of expertise or appropriate precautions. Finally, nowadays, during dramatic recent coronavirus disease 2019 (COVID-19) pandemic, the exact role of FB in COVID-19 patients admitted to IMCU has yet to be clearly defined. Hence, we provide a concise review on the role of FB in an IMCU setting, focusing on its indications, technical aspects and complications.

Removal of hematoma due to massive hemoptysis after transbronchial biopsy: a case report

Background

Massive hemoptysis is a life-threatening complication after transbronchial biopsy (TBB). Reports on massive hemoptysis occurring several days after TBB are scarce.

Case presentation

A 62-year-old man presented with massive hemoptysis and was admitted to hospital as an emergency on the eighth day after TBB. On the 12th day after TBB, computed tomography showed complete atelectasis of the right middle and lower lobes. The patient underwent emergent right upper lobectomy. The right upper lobe bronchus was separated with a scalpel, the hematoma was pulled out with forceps, and the bronchus subsequently sutured shut. The patient was discharged from the hospital uneventfully.

Conclusions

We experienced a case of massive hemoptysis on the eighth day after TBB, which required emergency surgery due to persistent bleeding into the airway and airway obstruction during follow-up. Postoperative pneumonia and atelectasis could be prevented by manual removal of the residual hematoma.

Cone Beam CT Guidance Improves Transbronchial Lung Cryobiopsy Safety

INTRODUCTION

Determining the cause of diffuse parenchymal lung disease (DPLD) is challenging. While surgical lung biopsy has been the standard approach, transbronchial lung cryobiopsy (TBLC) represents a minimally invasive alternative with an acceptable safety profile and reasonable accuracy. In this study, we prospectively assessed whether the use of cone beam CT (CBCT) coupled with a novel bronchoscope holder and prophylactic administration of vasoconstricting medications decreases potential complications and improves diagnostic accuracy when performing TBLC.

METHODS

33 patients presenting for evaluation of newly diagnosed DPLD were enrolled. Demographic data, pulmonary function values, chest imaging pattern, procedural information, and diagnosis were recorded.

RESULTS

Mean patient age was 67, with the majority Caucasian (n = 26, 79%) and male (n = 20, 61%). Mean pulmonary function values revealed restrictive lung disease (76 ± 14% predicted) and diffusing capacity impairment (52 ± 16%). A non-usual interstitial pneumonia imaging pattern was commonly seen (n = 20, 61%). CBCT guided TBLC was performed in one lobe (n = 29, 88%) or two lobes (n = 4, 12%) with mean probe-to-pleura distance of 4.2 ± 1.3 mm. No peri or post procedural complications occurred. 32 patients (97%) received a histological diagnosis with a final multidisciplinary conference diagnosis possible for 32 (97%).

CONCLUSION

CBCT guided TBLC coupled with a novel articulating scope holder and prophylactic phenylephrine administration has the potential to increase safety and diagnostic yield for patients with newly identified DPLD. Future studies comparing different aspects of this approach in isolation and with other modalities have the potential to refine this procedure to improve patient care.

The emergency department evaluation and management of massive hemoptysis

INTRODUCTION

Massive hemoptysis is a life-threatening emergency that requires rapid evaluation and management. Recognition of this deadly condition, knowledge of the initial resuscitation and diagnostic evaluation, and communication with consultants capable of definitive management are key to successful treatment.

OBJECTIVE

The objective of this narrative review is to provide an evidence-based review on the management of massive hemoptysis for the emergency clinician.

DISCUSSION

Rapid diagnosis and management of life-threatening hemoptysis is key to patient survival. The majority of cases arise from the bronchial arterial system, which is under systemic blood pressure. Initial management includes patient and airway stabilization, reversal of coagulopathy, and identification of the source of bleeding using computed tomography angiogram. Bronchial artery embolization with interventional radiology has become the mainstay of treatment; however, unstable patients may require advanced bronchoscopic procedures to treat or temporize while additional information and treatment can be directed at the underlying pathology.

CONCLUSION

Massive hemoptysis is a life-threatening condition that emergency clinicians must be prepared to manage. Emergency clinicians should focus their management on immediate resuscitation, airway preservation often including intubation and isolation of the non-bleeding lung, and coordination of definitive management with available consultants including interventional radiology, interventional pulmonology, and thoracic surgery.

Diagnostic Yield and Bleeding Complications Associated With Bronchoscopic Biopsy of Endobronchial Carcinoid Tumors

BACKGROUND

Bronchial carcinoid often appears hypervascular on bronchoscopic visualization and may be associated with hemoptysis. The diagnostic yield and bleeding complications associated with bronchoscopic biopsy of bronchial carcinoid tumors remain unclear.

MATERIALS AND METHODS

Patients with bronchial carcinoid tumors that were bronchoscopically visualized and biopsied at our tertiary referral medical center, over an 8-year period from 2010 to 2017, were retrospectively identified and reviewed to assess diagnostic yield and bleeding complications. Correlations with patient characteristics and carcinoid tumor features were analyzed.

RESULTS

Forty-nine patients were included (57% female). Tumors were predominantly (71%) located in proximal airways (mainstem and lobar bronchi). Bronchoscopic biopsy was diagnostic in 45 patients (92%). Thirteen patients (27%) experienced moderate (n=12, 25%) or severe (n=1, 2%) bleeding. Among these, 6 tumors (46%) had a vascular appearance and 4 patients (31%) had experienced recent hemoptysis. However, neither vascularity nor hemoptysis was associated with bleeding at biopsy (P=0.68 and 0.73, respectively). Carcinoid tumors were classified as typical in 79% and atypical in 21% with no difference in diagnostic yield or bleeding risk (P=0.28 and 0.92, respectively). Tumor size was also not associated with increased diagnostic yield or bleeding risk (P=0.54 and 0.39, respectively).

CONCLUSION

Bronchoscopic biopsy of endobronchial carcinoid is associated with a high diagnostic yield and severe bleeding is rarely encountered. Diagnostic yield and bleeding seemed independent of vascular tumor appearance or history of recent hemoptysis.

The value of virtual bronchoscopic navigation and radial endobronchial ultrasound-guided transbronchial lung cryobiopsies for pulmonary lymphangitic carcinomatosis

Background

Pulmonary lymphangitic carcinomatosis (PLC) is characterized by malignant infiltration into lung lymphatic channels from a primary site and is often observed in advanced malignant tumors. This study aimed to evaluate the diagnostic yield of transbronchial lung cryobiopsy in PLC guided by radial endobronchial ultrasound and virtual bronchoscopic navigation (VBN).

Methods

This prospective study enrolled 40 patients with clinical and radiologic features indicating PLC. The radial endobronchial ultrasound probe was initially advanced to the region of interest of the desired lobe near the pleura with guidance by VBN. Transbronchial lung biopsy and transbronchial lung cryobiopsy were both performed in the same ROI of all patients with the obtained samples being sent to the pathology laboratory for diagnostic analysis. Procedural complications were recorded.

Results

The average number of transbronchial lung biopsy and transbronchial lung cryobiopsy specimens were 4 (3 to 6) and 2 (1 to 3), respectively (t=10.43, P<0.01), with the corresponding mean diameters per biopsy being 3.7 and 8.7 mm (t=12.37, P<0.01). The diagnostic yields of transbronchial lung biopsy and transbronchial lung cryobiopsy were 70% (28/40) and 92.5% (37/40), respectively. The final positive predictive values of transbronchial lung cryobiopsy and transbronchial lung biopsy for PLC were 94.4% (34/36) and 77.8% (28/36), respectively (χ²=23.94, P<0.01). Further, 52.2% (12/23) and 81.5% (22/27) of the patients in the transbronchial lung biopsy and transbronchial lung cryobiopsy groups, respectively, were diagnosed with non-small lung cancer after further molecular analysis (χ²=19.56, P<0.01). Only 2 (5%) cases presented postoperative pneumothorax. Moreover, 0 (0%), 3 (7.5%), and 17 (42.5%) patients presented severe, moderate, and mild bleeding, respectively. There were no other adverse events or deaths.

Conclusions

Transbronchial lung cryobiopsy with the guidance of radial endobronchial ultrasound and VBN without fluoroscopy has a good diagnostic yield for PLC; moreover, it allows one to obtain adequate and intact tissue samples for further molecular analysis.

Case Studies Discussing the Pathology, Immunogenicity, and Proposed Mechanism of Toxicity of an Inhaled Anti-TGFβ Humanized Fab Antibody in Non-Human Primates and Mice

Treatment of nonhuman primates and mice with a humanized antigen-binding fragment (Fab) antibody (UCBFab) inhibiting transforming growth factor β via daily inhalation for up to 13 weeks resulted in low systemic exposure but high local exposure in the lung. Target engagement was demonstrated by reduced levels of signal transducers, phosphoSMAD and plasminogen activator inhibitor-1 in the bronchoalveolar lavage fluid (BALF). Treatment was associated with a high frequency and titer of antidrug antibodies, indicating high local immunogenicity, and local pathology within the lung and draining lymph nodes. Microscopic changes were characterized by perivascular (PV) and peribronchiolar (PB) mononuclear inflammatory cell (MIC) infiltrates that were principally lymphocytic in nature and mixed inflammatory cell infiltrates and/or inflammation within the alveoli. Immunohistochemical investigation revealed a predominantly CD68-positive macrophage and CD3- and CD8>CD4-positive T-cell response in the alveoli, whereas within the airways, there was a variable mixture of CD3-positive T cells, CD20-positive B cells, and CD68-positive macrophages. Increased cellularity of the draining lymph nodes was also noted, indicating the presence of an immune response to the inhaled test article. Morphologic changes did not progress over time, and all changes partially recovered. Increased leukocytes (principally macrophages) in BALF cytology correlated with the changes seen by histopathology.

Prophylactic use of tranexamic acid for prevention of bleeding during transbronchial lung biopsies - A randomized, double-blind, placebo-controlled trial

BACKGROUND

Although massive bleeding following transbronchial lung biopsies (TBLB) is rare, even minor hemorrhage may prolong the procedure and result in inadequate sampling. Tranexamic acid (TXA) is an antifibrinolytic agent, which reduces bleeding in numerous scenarios, however, its prophylactic use in mitigating post-TBLB bleeding has not been investigated. We conducted a prospective, randomized, double-blind, placebo-controlled trial to determine whether topical infusion of TXA prior to TBLB would reduce bleeding, shorten procedure duration and increase the number of biopsies obtained.

METHODS

We blindly randomized patients undergoing TBLB to receive topical TXA or placebo in the lobar bronchus prior to biopsies. Vital signs, procedure length, fluid balance (as a measure of the amount of bleeding), operator's assessment of bleeding, and number of biopsies obtained were measured. Data was analyzed using the two-tailed Student's T-Test, Chi-square or Mann-Whitney tests as appropriate.

RESULTS

Fifty patients were randomized, 26 to the TXA arm. The bleeding in the TXA group was significantly lower (P = 0.0037), with more specimens being obtained (placebo 7 (6, 9) (median and interquartile range) vs. TXA 9 (8, 10), P = 0.023) and no difference in procedure length (placebo 30 min (29.3, 34.3) vs. TXA 30 (24.8, 36), P = 0.90). There were no clinically significant adverse events in any of the groups up to one month of follow up.

CONCLUSION

Endobronchial installation of TXA prior to obtaining TBLB results in less bleeding and allows more biopsies to be obtained with no additional adverse events. The prophylactic use of TXA during TBLB may be considered as standard.

Esophageal Bronchial Artery Fistulaization: A Complication of an Endobronchial Ultrasound

Bronchial artery pseudoaneurysms are an extremely rare cause of upper gastrointestinal bleeding. The presence of a bronchial artery pseudoaneurysm resulting in an esophageal fistula is an entity that, to our knowledge, has yet to be described. Successful management requires an interdisciplinary approach to guide closure of the defects. We present a novel case of an esophageal fistula and bronchial artery pseudoaneurysm resulting from an endobronchial ultrasound-guided transbronchial needle aspiration successfully managed by endoscopic therapy and coil embolization.

Incidence of Bleeding Complications With Flexible Bronchoscopy in Cancer Patients With Thrombocytopenia

BACKGROUND

Bronchoscopy is a safe procedure, but current guidelines recommend transfusion for platelets <20 K/μL. Studies of bronchoscopy in thrombocytopenia are limited.

OBJECTIVES

Our objective was to evaluate the incidence of bleeding with flexible bronchoscopy in those with thrombocytopenia especially those <20 K/μL.

METHOD

We performed a retrospective review of all flexible bronchoscopies between June 1, 2008 and December 31, 2010. Biopsies and therapeutic procedures were excluded. The χ, Fisher exact, and Rank-sum test were conducted to evaluate associations of clinically significant bleeding.

RESULTS

There were 1711 patients who underwent 2053 flexible bronchoscopies. Cancer diagnosis included hematologic (61.3%) and solid organ malignancy (34.9%). Half of the bronchoscopies had moderate to severe thrombocytopenia (<100 K/μL) with the following ranges: 14.7% with 50 to <100 K/μL, 20.6% with 20 to <50 K/μL, 10.6% with 10 to <20 K/μL, 4.1% with <10 K/μL. Platelet transfusion was given in 90.6% of those with platelets <10 K/μL and 55.5% of those with platelets 10 to <20 K/μL. The nasal route for bronchoscopy was used in 92.4%. Bleeding complication rate however was 1.1% (0.2% major) and not affected by platelets.

CONCLUSION

Bronchoscopy with lavage can be safely performed without platelet transfusion in those with platelets of ≥10 K/μL. In the absence of nasal bleeding, trauma, or deformity, the nasal route can be used for bronchoscopy.

Low-density lipoprotein cholesterol levels are positively associated with the risk of endobronchial biopsy-induced refractory hemorrhage in patients with lung cancer

Background

Lipoprotein concentrations have been associated with the major risk of bleeding events. However, whether plasma levels of LDL-C are associated with the risk of biopsy-related endobronchial hemorrhage remain elusive. Therefore, the present study was initiated to investigate the explicit association of low-density lipoprotein cholesterol (LDL-C) with endobronchial biopsy (EBB)-induced refractory hemorrhage in patients with lung cancer.

Methods

This retrospective study included a total of 659 consecutive patients with lung cancer who had undergone EBB at a tertiary hospital between January 2014 and April 2018. Using multiple regression analysis, the association between LDL-C and the risk of EBB-induced refractory hemorrhage was assessed after adjusting for potential confounding factors.

Results

A significant proportion (13.8%, 91/659) of the patients experienced refractory hemorrhage following EBB. In multivariate regression analysis, higher plasma LDL-C concentrations were associated with increased risk of EBB-induced refractory hemorrhage in patients with lung cancer after adjusting for potential confounders (P < 0.05). Using the lowest quartile of plasma LDL-C as the reference group, the odds ratio (95% confidence interval) of Q2, Q3, and Q4 were 2.32 (1.07, 5.03), 2.37 (0.94, 5.95), and 3.65 (1.16, 11.51), respectively (P for trend < 0.05). Moreover, this association was noticeably more pronounced in male patients with lung cancer in the subgroup analysis (P < 0.05).

Conclusions

Plasma LDL-C was positively correlated with the increased risk of EBB-induced refractory hemorrhage in patients with lung cancer; predominantly, the associated risk was more pronounced in male patients with lung cancer.

Intrathoracic amyloid tumors that presented as yellowish multinodular endobronchial protrusions with irregular vascularity and easy bleeding

Immunoglobulin light‐chain (AL) amyloidosis is a monoclonal plasma cell neoplasm that has a tendency to bleed easily. However, the potential risks of transbronchial biopsy in such cases have not been fully proven. Here, we report a case of parotid and intrathoracic AL amyloid tumors that presented as endobronchial protrusions that bled easily. Bronchoscopy under conventional white light and narrow band imaging revealed yellowish multinodular protrusions, in which irregular tortuous or dotted vessels were observed. Unexpectedly, biopsy of the lesion resulted in persistent bleeding. The biopsy specimen showed a large amount of amyloid deposition and calcification directly under the bronchial epithelium, as well as amyloid deposits in the blood vessel walls. In patients suspected to have amyloidosis, the presence of yellowish multinodular endobronchial protrusions, particularly with irregular vascularity, should prompt careful attention to avoid fatal postprocedural bleeding.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Factors affecting survival in patients with endobronchial malignant mass after flexible Bronchoscopic cryotherapy: a cohort study

Background

Malignant endobronchial mass (MEM) has poor prognosis, cryotherapy is reportedly to diagnose MEM, however, the therapeutic role of cryotherapy impacts on survival has not be well addressed.

Methods

Cohort data on post-cryotherapy MEM patients in a university-affiliated hospital between 2007 and 2012 were evaluated. Factors that impact survival of these subjects were analyzed using multivariate regression analysis.

Results

During study period, 67 patients (47 males), with median age was 63 years (range, 50–77 and median performance status of 2 (inter-quartile range [IQR], 2–3). Twenty-five had primary lung squamous cell carcinoma, 14 primary had lung adenocarcinoma, seven had metastatic colon adenocarcinoma, four had sarcoma, four had non-small cell lung cancer, four had small cell lung cancer, three had large cell carcinoma, two had lymphoma, one had muco-epidermoid carcinoma, two had esophageal squamous cell carcinoma, and one had metastatic renal cell carcinoma. MEM were observed as follows: 15 at the trachea, 14 at the left main bronchus, 12 at the right main bronchus, 12 at the right upper lobe bronchus, five at the right intermediate bronchus, three at the right lower lobe bronchus, three at the left upper lobe bronchus, two at the left lower lobe bronchus, and one at the right middle lobe bronchus Post-cryotherapy complications included minor bleeding (n = 14) and need for multiple procedures (n = 12); outcomes were relief of symptoms (n = 56), improved performance status (n = 49) and ability to receive chemotherapy (n = 43). After controlling for other variables, performance status improved after cryotherapy (odds ratio [OR] 3.7; p = 0.03; 95% confidence interval [CI] 1.2~10.7) and ability to receive chemotherapy (OR 4.3; p = 0.02; 95% CI 1.4~13.7) remained significant survival factor. Patients who received chemotherapy and cryotherapy had better survival than patients who received only cryotherapy (median, 472 vs. 169 days; log-rank test, p = 0.02; HR 0.37; 95% CI 0.16–0.89).

Conclusion

Cryotherapy could be useful management of MEM by flexible bronchoscopy. The performance status after cryotherapy improved and caused further chemotherapy possible for the study patients and thereby, improved survival. However, the mechanism in detail of cryotherapy improve survival should be explored in the future.

Management of severe hemoptysis

INTRODUCTION

Though rare, severe hemoptysis (SH) is associated with a mortality rate exceeding 50% when not managed properly. Areas covered: This paper reviews the recent epidemiological data regarding SH, the role of multidetector computed tomography angiography (MDCTA), and fiberoptic bronchoscopy (FOB) in its management, as well as the value of current treatments. Expert commentary: MDCTA is becoming an essential modality, since it allows determining the location, etiology, and mechanism of the bleeding. FOB can be delayed, except when local control of bleeding is required. Emergency treatment relies on interventional radiology. Both bronchial and non-bronchial arteries should be explored during bronchial arteriography. Surgery must be considered in all operable patients if the cause of hemoptysis persists.

Optimize Transfer Learning for Lung Diseases in Bronchoscopy Using a New Concept: Sequential Fine-Tuning

Bronchoscopy inspection, as a follow-up procedure next to the radiological imaging, plays a key role in the diagnosis and treatment design for lung disease patients. When performing bronchoscopy, doctors have to make a decision immediately whether to perform a biopsy. Because biopsies may cause uncontrollable and life-threatening bleeding of the lung tissue, thus doctors need to be selective with biopsies. In this paper, to help doctors to be more selective on biopsies and provide a second opinion on diagnosis, we propose a computer-aided diagnosis (CAD) system for lung diseases, including cancers and tuberculosis (TB). Based on transfer learning (TL), we propose a novel TL method on the top of DenseNet: sequential fine-tuning (SFT). Compared with traditional fine-tuning (FT) methods, our method achieves the best performance. In a data set of recruited 81 normal cases, 76 TB cases and 277 lung cancer cases, SFT provided an overall accuracy of 82% while other traditional TL methods achieved an accuracy from 70% to 74%. The detection accuracy of SFT for cancers, TB, and normal cases are 87%, 54%, and 91%, respectively. This indicates that the CAD system has the potential to improve lung disease diagnosis accuracy in bronchoscopy and it may be used to be more selective with biopsies.

The use of bronchoscopy in critically ill patients: considerations and complications

INTRODUCTION

Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.