Linda Paradowski MD BRONCHOSCOPY Complications Related to premeds

Linda Paradowski MD BRONCHOSCOPY

Complications Related to pre-meds & local anesthesia: Resp depressiom, arrest Tachycardia Hypotension Syncope Seizures Hyperexcitable state Laryngospsasm Anaphylaxis methemoglobinemia Cardiac arrest bradycardia Procedure-related Epistaxis Fever Hypoxemia Hypercarbia Dyspnea Resp. arrest Laryngospasm, bronchospasm Hemodynamic instability Myocardial ischemia Arrhythmias Pneumonia Aspiration Transmission of TB Barotrauma Pulm. Hemorrhage death

Risky Business Coagulopathy: Platelets < 50 K for TBBX Pulmonary: Arterial p 02 < 70 with BAL can be performed with platelets < 20 K INR > 1. 5 BUN > 50 Platelet aggregation inhibitors taken within 7 – 10 days SVC syndrome FI 02 > 70% PEEP > 10 Active bronchospasm BAL may drop p 02 by 10 -20 Pulmonary hypertension with TBBX Inability to cough Large abscesses

Risky Business II Cardiac: Recent MI < 48 hours for emergent bronchoscopy MI < 6 weeks for elective bronchoscopy Unstable arrhythmia Mean arterial pressure < 65 CNS: Evidence for increased ICP Incipient herniation Inability to handle secretions & protect airway

All about the meds Lidocaine Rapid onset of action Up to 300 mg can be given safely in small aliquots Reduce dosage with hepatic dysfunction Can induce bronchospasm in animals 2% above the cords, 1% below Midazolam Rapid onset of action, short duration, good amnesia Apnea if injected rapidly Effect with cirrhotics is even more pronounced

All about the meds cont. Meperidine Little effect on cough Metabolites seizure inducing esp. with renal insufficiency Will be off formulary soon Fentanyl Synthetic opioid with the fastest onset of action & shortest duration Good cough control 80 times more potent than morphine At high doses can cause muscle rigidity especially if given as IV push Liver & kidney disease can impair clearance

BAL cell count Normal cell count differential in nonsmokers: 80 – 90% macrophages 5 – 15% lymphocytes 1 – 3% neutrophils < 1% eosinophils < 1% mast cells Complication rate: 3% Mostly fever & chills, transient hypoxemia

BAL cell predominance Eosinophils: > 10%significant indicative of eosinophilic pneumonia other immunologic phenomena like transplant rejection Lymphocytic predominance & subsets: Elevated CD 4/CD 8 ratio suggests sarcoid but can be found in collagen vascular disease, TB, malignancy If ratio > 3. 5 then specific for sarcoid Low CD 4/CD 8 may be seen in hypersensitivity pneumonia Mast cells may be seen: asthma radiation pneumonitis BOOP HP

BAL cells Neutrophils: Acute inflammation Old literature: in UIP & with eos = worse prognosis Rare for HIV related PCP Hemosiderin – laden macrophages Hemoglobin degradation product of hemoglobin Requires two days to form Cleared from the lungs after 2 – 4 weeks Indicates chronicity & verifies not iatrogenic

BAL cell count & diseases lymph PMN eos mast Sarcoid + = = = HP ++ + =/+ ++ BOOP + + + = IPF + ++ =/+ CVD + =/+ =/+

TBBX - indications Sarcoidosis – stage II & III - > 85% yield Pulmonary histiocytosis PCP in non-AIDS patients Diffuse infection caused by mycobacteria & mycoses Lymphangitic carcinomatosis PAP Alveolar cell carcinoma Diffuse pulmonary lymphoma LAM Silicosis

TBBX - complications Increases mortality from bronchoscopy from 0. 04% to. 12% Incidence of significant hemorrhage ( > 50 ml) about 1% 29% in immunocompromised 45% in uremic patients Incidence of pneumothorax is between 2% - lessened with flouroscopy 7% in patients on mechanical ventilation Higher if patient receiving PEEP 1 -

Retained secretions & atelectasis Significant improvement in 41 – 81% Superiority of FOB over CPT not clearly established with lobar atelectasis especially with air bronchograms Can be life saving in whole lung atelectasis especially if patient is hypoxemic Radiographic response is delayed 6 – 24 hours & follows improved gas exchange

Mucous plugs

Hemoptysis Highest chance for visualizing sources is within 12 – 18 hours of event Major causes: Bronchogenic carcinoma – 29% Bronchitis – 23% No specific cause – 22% Direct therapeutic interventions: saline, epinephrine, thrombin, fibrinogen-thrombin combination, balloon tamponade Yield for bronchoscopy in diagnosing an occult malignancy in a patient with hemoptysis & a normal Xray is about 10% if the patient is older than 40 & has smoked > than 40 pack years

Chronic cough Low yield for bronchoscopy if chest X-ray is normal Most common causes: asthma, GERD, postnasal drip 90 % response rate to specific therapy 20% have more than one cause Some advocate a 4 week trial of GERD therapy for any unexplained cough

Pleural effusions Irish study: retrospective review of 3 K FOBs 50 performed for lone pleural effusion. 7 pts. had bronchogenic cancer only one was visualized endobronchially Rochester study: 115 pts. With suspected bronchogenic carcinoma with pleural effusion underwent FOB was useful only with hemoptysis obvious mass with infiltrated &/or atelectasis if the effusion was massive in cytology positive effusion without obvious primary

Ventilator associated pneumonia Mortality can be up to 60% & broad spectrum antibiotics can encourage resistance PSB & BAL give similar results False negatives & false positives are around 30% Results may not be valid if patient on antibiotics for 72 hours Invasive diagnostics have had no influence on mortality, ICU stay or time on ventilator with VAP Mortality is influenced by inadequate anti-microbial treatment Bronchoscopy most useful for drug-resistant & opportunistic pathogens, noninfectious conditions like EP, DAH, HP & possibly for failure to respond to initial antimicrobials

Tracheo-esophageal fistula

Tracheo-pleural fistula

Post intubation stenosis

Bronchopleural fistula

Bronchomalacia

Airway inflammation

Scleroderma & BAL Hopkins study in Annals of Int. Med 2000 69 scleroderma pts. followed a minimum of 6 mos. Alveolitis diagnosed by BAL if PMNs > 3% or eos > 2. 2% Those diagnosed with alveolitis had improved survival & PFTs if treated with cyclophosphamide Ann Rheum Dis 1999 73 pts. with diffuse scleroderma Pts with BAL PMNs > 3% but not those with lymphocytes > 15% had deterioration in lung function especially DLCO Authors concluded that the group with neutrophils should be aggressively treated

Scleroderma & BAL AM Journal of R&CCM 2002 Classified the histologic appearance of lung biopsies in 80 pts & compared prognostic value with clinical indices Most pts. had fibrotic NSIP but 5 year survival was 80% BAL did not identify future progression Changes in DLCO were linked to survival but probably reflected pulm. vascular disease

Scleroderma & ILD Most patients with SS & ILD have fibrotic NSIP but a minority develop UIP with poorer survival Both are associated with a neutrophilic or eosinophilic BAL Cytoxan appears to be beneficial in terms of stabilization of PFTs for some patients It is unclear if BAL can identify a subset of patients who will have a good response to cyclophosphamide It is also unclear if BAL is more sensitive or specific than HRCT in identifying ILD

Endobronchial Neoplasms

Hamartoma Most common benign tumor of lungs Contains a mixture of cartilage, smooth muscle, fat, epithelial & mesenchymal cells Slow growing Malignant transformation is rare

Pulmonary carcinoid Neuro-endocrine tumor that presents most frequently with bronchial obstruction obstructive pneumonitis pleuritic pain atelectasis dyspnea Carcinoid syndrome extremely rare & indicates metastatic disease Diagnose via endobronchial biopsy has 1% risk of significant bleeding diagnostic yield is 80% because the tumor may be covered by normal bronchial mucosa

Carcinoid & Mucoepidermoid tumors

More neoplasms

Brachytherapy

Stents

The end