Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy

Abstract

Although, bronchoscopy is a relatively safe procedure, small amount of bleeding in the airway can have serious consequences. Careful consideration of the risks of diagnostic and therapeutic bronchoscopic intervention can help minimize potential complications. With increasing number of patients using antiplatelet and anticoagulation therapies, strategies for minimizing thromboembolic and operative bleeding events need to be included in the risk and benefit analyses. Growing evidence suggests that aspirin is safe and does not increase bleeding during bronchoscopy. In addition, despite small studies reporting that it may be safe to perform bronchoscopic procedures that have low risk for bleeding such as endobronchial ultrasound with transbronchial needle aspiration on clopidogrel, it is still recommended to hold it for 7 days prior to performing elective bronchoscopy. It is recommended to hold vitamin K antagonist, as well as new oral anticoagulation agents prior to bronchoscopy. The timing for pre-procedural discontinuation of anticoagulation therapy and the decision to bridge depend on the agent used, the renal function and the thromboembolic risk. In this review article, we will discuss available data regarding management of anticoagulation and antiplatelet therapy as it applies to bronchoscopic procedures.

Keywords: Anticoagulation; antiplatelet therapy; bronchoscopy; newer oral anticoagulation agents (NOAC).

Figure 1

Management of oral anticoagulant therapy prior to bronchoscopy. INR, international normalized ratio; LMWH, low molecular weight heparin; UH, unfractionated heparin; NOAC, new oral anticoagulation agents. Modified based on the British thoracic society guidelines for diagnostic flexible bronchoscopy in adults (23), the American college of chest physician guidelines(antithrombotic therapy and prevention of thrombosis) (42) and the European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular AF (45).

Figure 2

Management of oral antiplatelet therapy prior to bronchoscopy. Modified based on the British thoracic society guidelines for diagnostic flexible bronchoscopy in adults (7) and the American college of chest physician guidelines (antithrombotic therapy and prevention of thrombosis) (35).