Chest
Volume 70, Issue 5, November 1976, Pages 584-588
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Clinical Investigations
Pulmonary Hemorrhage in Fiberoptic Transbronchial Biopsy

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Transbronchial forceps biopsy via the flexible fiberoptic bronchoscope is described as a “safe,” high-yielding procedure, but the potential danger of serious hemorrhage is of concern to chest physicians. In a collected series of 438 patients, the incidence of mild to “explosive” hemorrhage was 9 percent in “routine” cases, 29 percent (eight) in 31 immunosuppressed patients, and 45 percent (five) in 11 uremic patients. One death resulted from massive hemorrhage. A new “wedge” method of transbronchial forceps biopsy is now being utilized in our bronchoscopic unit The tip of the flexible fiberoptic bronchoscope is lodged into the appropriate segmental bronchus to tamponade any bleeding and, thus, prevent blood from flooding the airway. Careful screening of patients and competence in procedural techniques are necessary. Otherwise, transbronchial forceps biopsy should be performed through a rigid open-tube bronchoscope or lung tissue should be obtained via thoracotomy.

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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    2018, Clinics in Chest Medicine
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    After biopsy, the bronchoscope is kept wedged with several biopsies performed in rapid succession. After biopsies are completed, the bronchoscope should remain in the wedged position for at least 1 minute before it is slowly retracted.69 If continued bleeding is encountered, the bronchoscope should be rewedged to allow clot to for an additional 4 to 5 minutes.

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Manuscript received June 1; accepted June 23.

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