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

Abstract

Significant iatrogenic bleeding during flexible bronchoscopy is fortunately rare and usually self-limiting. Life-threatening bleeding, however, can occur, especially after conventional or cryoprobe-assisted transbronchial biopsy. The aim of this review is to provide the practising pulmonologist with a concise overview of the incidence, severity and risk factors for bleeding, to provide sensible advice on prophylactic measures and to suggest a plan of action in the case of significant bleeding. Bronchoscopy units should have a standardised approach and plan of action in the case of life-threatening haemorrhage. Wedging the bronchoscope in the bleeding segment, turning the patient in an anti-Trendelenburg position and onto the side in order for the bleeding lung to be in the dependent position, installing vasoconstrictors and using a tamponade balloon early are the recommended first-line strategies. Involving a resuscitation team should be considered early in the case of massive bleeding, desaturation and haemodynamic instability.

FIGURE 1

a) Factors influencing the risk of bleeding. b) Risk of bleeding for different procedures. Risk of bleeding is given as an estimated risk inferred from the available literature and according to the authors’ experience. BAL: bronchoalveolar lavage; EBB: endobronchial biopsy; EBUS: endobronchial ultrasound; TBNA: transbronchial needle aspiration; TBLB: transbronchial lung biopsy.

FIGURE 2

Proposed plan of action in the case of iatrogenic bleeding during flexible bronchoscopy originating from the periphery. ^#: adrenaline solution f.e. 1:25 000=0.04 mg·mL⁻¹=40 μg·mL⁻¹. Maximum volume allowed for instillation: 1 mL/10 kg body weight (e.g. 7 mL for 70 kg of body weight). ^¶: terlipressin (glypressin) 0.2 mg·mL⁻¹, e.g. 2 mL, to be repeated if needed.

FIGURE 3

Different types of haemostatic balloon catheters. a) Decomposable haemostatic endoscopic balloon catheter (size 6 French (2 mm), minimum working channel size 2.4 mm) allowing placement of the catheter through the working channel and removal of the bronchoscope without removal of the catheter (Rüsch Bronchus Blocker; Teleflex Medical, Kernen, Germany). b) Haemostatic endoscopic balloon catheter (size 4 French (1.4 mm), minimum working channel size 2 mm, maximal diameter of the inflated balloon 11 mm) for blocking lobar or segmental bronchi (haemostatic balloon catheter; Olympus, Tokyo, Japan). The blockage of a main bronchus can be achieved with the larger Arndt and Cohen endobronchial blockers (7–9 French, Cook Medical, Bloomington, IN, USA). c) Fogarty arterial embolectomy catheter (size 4 French (1.35 mm), minimum working channel size 2 mm). Fogarty catheters are available in sizes ranging from 2 to 8 French.