Chest
Clinical InvestigationsPulmonary Hemorrhage in Fiberoptic Transbronchial Biopsy
Section snippets
Patient Safety and Contraindications
Transbronchial forceps biopsy via the flexible fiberoptic bronchoscope, although relatively safe, is definitely more hazardous than routine fiberoptic endoscopic examination and bronchial brushing. The chief potential danger is bleeding, with resultant hypoxemia and cardiac arrest (Table 1). Pneumothorax usually poses no real threat, since this easily can be corrected by insertion of a chest tube with tidal drainage. A set of guidelines will help to prevent disaster. Pulmonary hypertension is a
Methodologic Factors
The major items to be stressed are as follows:
- 1.
The most important premedication is atropine (0.8 to 1.0 mg given intramuscularly 30 minutes before the biopsy). This rather large dose is required to reduce bronchial secretions, block the vasovagal reflex, and prevent bronchospasm. Asthmatic patients with irritable airways constitute an increased risk, even if their asthma is in remission! Any patient with a history of wheezing who is not receiving therapeutic doses of theophylline should be
Incidence of Hemorrhage
The high-risk group is composed of those patients who have been receiving immunosuppressive and cytotoxic therapy for renal transplantation, leukemia, lymphoma, polycythemia vera, carcinoma, etc, or of those patients who are azotemic from any cause. Advancing pulmonary infiltrates, fever, and severe hypoxemia complete the clinical picture. These “compromised hosts” are especially prone to “opportunistic” infections, such as pneumonia due to Pneumocystis carinii, cytomegalic inclusion disease,
Management of Hemorrhage
Mild bleeding can be treated effectively by suctioning through the fiberoptic bronchoscope, by local instillation of a 1:20,000 solution of epinephrine, and by oxygen therapy. This method is totally inadequate if the bleeding is severe. The narrow 2-mm suction channel of the fiberoptic instrument simply cannot handle a large amount of blood.
In an effort to find a better way to manage hemorrhage, two different approaches have been tested in our bronchoscopy unit. The first method is a tracheal
ACKNOWLEDGMENT
I wish to thank my colleague, Mitchell L. Rhodes, M.D., for his critical reading of this manuscript and helpful suggestions and Ms. Shirley Stout for her secretarial skills.
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Manuscript received June 1; accepted June 23.