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CONTRAINDICATIONS

Overview — Bronchoscopy is contraindicated in conditions where the potential


for a complication is high, either from the procedure itself or from the associated
sedation. The common complications of flexible bronchoscopy are tachycardia,
bronchospasm, hypoxemia, or bleeding. Sedation and partial airway occlusion
with the bronchoscope can lead to hypoxia even in normal subjects. The
contraindications discussed here are applicable to flexible bronchoscopy, BAL,
brushing, transbronchial needle aspiration, and endobronchial or transbronchial
biopsy. (See "Flexible bronchoscopy in adults: Overview".)

In general, the following are considered by most bronchoscopists as


contraindications to bronchoscopy most of which are relative rather than
absolute:

●Patients at risk of pulmonary and cardiovascular decompensation –


Patients considered at risk of decompensation during bronchoscopy include
those with severe hypoxemia, current or recent myocardial ischemia, poorly
controlled heart failure, significant hypotension or hypertension,
exacerbation of asthma or chronic obstructive pulmonary disease,
pregnancy, bradycardia or tachycardia, and life-threatening cardiac
arrhythmias. Severe refractory hypoxia with inability to maintain adequate
oxygenation during the procedure is a contraindication to bronchoscopy
unless the bronchoscopic intervention is intended to relieve an obstruction
or remove a foreign body that potentially could be therapeutic and can be
done safely. An airway management plan should be in place before
proceeding with bronchoscopy in such cases.
●Patients at high risk of bleeding – Bronchoscopic procedures such as
brushing, biopsy, or needle aspiration as opposed to airway inspection or
obtaining a BAL place patients at higher risk of bleeding during
bronchoscopy. Examples of those at higher than usual risk of bleeding in
whom bronchoscopic procedures (not necessarily bronchoscopy per se) are
contraindicated include patients on antiplatelet agents
(eg, aspirin, clopidogrel, ticlopidine), oral or parenteral anticoagulant
therapy, or patients with thrombocytopenia, coagulopathy, or with chronic
renal insufficiency. (See 'Patients at risk of bleeding' below.)
We prefer a minimum platelet count of 30,000/microL to perform a
bronchoscopy for inspection or BAL and at least 50,000/microL to perform
any other elective diagnostic procedures. However, in cases of emergency,
the decision to perform bronchoscopy should be individualized and will
depend on the skills and experience of the operator.
●Miscellaneous – Intolerance to sedation or inability to obtain an informed
consent is an absolute contraindication, especially if an elective procedure
is planned. General anesthesia can be considered, if the patient is refractory
to moderate sedation and the results of bronchoscopy is expected to change
the treatment course. Other relative contraindications include an inability to
cooperate with the procedure, malfunctioning equipment, an unstable or
immobile cervical spine, and limited motion of the temporomandibular joint.
A careful risk-benefit analysis prior to bronchoscopy is important to determine
whether the information obtained from bronchoscopy will significantly influence
the management decision. In certain circumstances, the risk factors may be
optimized prior to the procedure to avoid any impending complications. For
example, severe hypoxemia is a contraindication to bronchoscopy. However, a
patient may be intubated specifically for bronchoscopy to minimize the risk of
periprocedural hypoxemia at the known expense of exposing the patient to all the
attendant complications of intubation and mechanical ventilation. The informed
consent process should include a clear discussion of the available alternatives
with possible outcomes and the risks. (See "Informed procedural consent".)

In most cases, bronchoscopic inspection of the airways, with or without BAL, may
be safe but performing transbronchial biopsy, brushing or an advanced
bronchoscopic intervention may be contraindicated to avoid a catastrophic
outcome from asphyxia or bleeding. Specific contraindications of individual
interventional procedures (eg, laser or stent placement) performed with flexible
bronchoscopy are discussed separately. (See "Flexible bronchoscopy balloon
dilation for benign airway strictures (bronchoplasty)", section on
'Complications' and "Bronchoscopic argon plasma coagulation in the
management of airway disease in adults", section on
'Complications' and "Bronchoscopic laser in the management of airway disease
in adults", section on 'Complications'.)

Specific contraindications

Pulmonary and cardiovascular conditions

Nonemergent elective bronchoscopy should be avoided in patients who are


currently having or have had any of the following events within the past six weeks:
myocardial ischemia (ie, unstable angina, myocardial infarction), decompensated
heart failure, an exacerbation of asthma or chronic obstructive pulmonary
disease, or life-threatening cardiac arrhythmias.

Bronchoscopy should also be avoided in the following situations:

●Severe hypoxemia – Hypoxemia is common during bronchoscopy and


results from sedation and partial occlusion of the airways from the
bronchoscope. It can also trigger arrhythmias. Nonemergent bronchoscopy
should be avoided in patients with severe hypoxemia, which is defined as
resting arterial oxygen tension (PaO2) <60 mmHg or an oxyhemoglobin
saturation (SpO2) <90 percent while receiving an FiO2 ≥60 percent. Although
severe hypoxemia has been considered an absolute contraindication, if the
treatment decision is felt to significantly depend on the results of the
bronchoscopy or if it is considered to be therapeutic (eg, mucus plug
removal), bronchoscopy may be performed either on noninvasive ventilation
or with laryngeal mask airway (LMA) placement with the informed consent
clearly stating the risk of impending respiratory failure [39]. Alternatively,
bronchoscopy can be performed after elective intubation with the attendant
complications of intubation and mechanical ventilation clearly outlined to the
patient.
In critically ill patients with acute hypoxemic respiratory failure requiring
noninvasive ventilation (NIV), bronchoscopy is occasionally performed by
some clinicians, although these patients have a high likelihood of
subsequent endotracheal intubation due to failure of NIV. A prospective
study of 40 subjects requiring noninvasive ventilation at baseline median
fraction of inspired oxygen (FiO2) of 0.5 reported a statistically significant rise
in the partial pressure of carbon dioxide (pCO2) and worsening in
oxygenation requiring an increase the FiO2 post bronchoscopy. Although no
one required intubation immediately after bronchoscopy, 10 percent were
intubated in the subsequent eight hours and 45 percent within 48 hours. The
contribution of the bronchoscopy to subsequent intubation is unknown [40].
In patients with central airway obstruction from tracheal stenosis or
endobronchial malignant lesions, the risk of hypoxia is high during
bronchoscopy. There may be complete obstruction of ventilation when a
bronchoscope is passed through the obstructed airway. However, if an
intervention is planned to treat the condition, bronchoscopy can and should
be performed provided adequate pre-procedure planning is done to address
any procedural complications. Limiting the duration of bronchoscopic
examination or intervention will also permit adequate ventilation and
oxygenation.
●Severe pulmonary hypertension – Bronchoscopy, and in particular,
transbronchial biopsy, in patients with severe pulmonary hypertension (PH)
is traditionally considered high risk. Risks include bleeding from
transbronchial biopsy as well as hemodynamic compromise secondary to
both sedation and increased mean pulmonary arterial pressure during
bronchoscopy and possible requirement for mechanical ventilation post
procedure. Pulmonary hypertension is defined as mean pulmonary arterial
pressure (mPAP) >25 mmHg. This assessment is largely based upon clinical
experience and the logic that capillary pressure is constantly elevated in this
group. There is no absolute cut-off point in pulmonary pressure over which
bronchoscopy becomes unsafe. However, in general, we prefer to avoid
bronchoscopy in patients with untreated PH. (See "Treatment of pulmonary
hypertension in adults", section on 'Surgical risk'.)
•A retrospective case-control study of 190 patients with pulmonary
arterial pressure (PAP) measured by echocardiography, who underwent
bronchoscopy with endobronchial or transbronchial biopsy, or
endobronchial ultrasound guided transbronchial needle aspiration
(EBUS-TBNA) found that the risk of complications including bleeding or
prolonged mechanical ventilation was not significantly increased in
patients with a systolic pulmonary artery pressure (sPAP) of greater than
36 mmHg compared to those with sPAP equal or less than 36 mmHg
[41].
•One older prospective study in heart transplant patients reported a 10
percent rate bleeding after transbronchial biopsy in patients with mean
pulmonary arterial pressure >17 mmHg [42]. This rate is considered
higher than that in the general population (1 to 5 percent).
•One retrospective study of 45 patients mild to moderate pulmonary
hypertension reported no difference in the rate of bleeding with
bronchoscopy when compared to controls without pulmonary
hypertension. However, only six patients in this study underwent
transbronchial biopsy and likely underestimated the effect [43].
●Unstable or severe obstructive airways disease – Bronchoscopy to
obtain bronchoalveolar lavage or transbronchial lung biopsy is usually safe
in patients with stable obstructive airways disease (eg, asthma, chronic
obstructive pulmonary disease [COPD], bronchiectasis). However, there is a
potential for bronchospasm and/or drop in FEV1 or FVC in patients with
severe asthma or COPD [44]. Premedication with nebulized bronchodilator
and optimization of asthma control can minimize the risks of bronchospasm
or hypoxia. Patients may benefit from CPAP or positive pressure ventilation
during recovery from sedation. Transbronchial biopsy should be avoided in
COPD patients with bullous disease due to the higher than usual risk of
pneumothorax. Nonemergent elective bronchoscopy should be avoided in
patients who are currently having or have had an exacerbation of asthma or
chronic obstructive pulmonary disease in the prior six weeks. Oxygen
supplementation during bronchoscopy should be avoided or used with
caution in those where the pre-bronchoscopy partial arterial pressure of
carbon dioxide is raised. Some clinicians advocate spirometry followed by
arterial blood gas analysis (in those found to have a forced expiratory volume
in one second [FEV1] <40 percent) prior to bronchoscopy, especially in
patients suspected to have severe obstruction at baseline. In a prospective
study of 151 patients who had bronchoscopy performed, the patients with
COPD were compared with those without COPD [45]. The patients with
COPD were significantly more likely to have fewer BAL, brushing, and
transbronchial biopsies done compared with those without COPD. Similarly,
during moderate sedation the patients with COPD were given lower doses
of midazolam and fentanyl. There was no significant difference in major
complications such as pneumothorax or respiratory failure [45].
●Hemodynamic instability and myocardial ischemia – Systemic
cardiovascular effects of bronchoscopy include increased mean systemic
pressure, increased cardiac index, and decreased oxygenation.
Consequently, bronchoscopy should be avoided in patients with acute
ongoing myocardial ischemia and elective bronchoscopy should be deferred
for six weeks after an acute myocardial infarction (MI) or unstable angina. In
addition, bronchoscopy should not be performed in patients with
severe hypertension/hypotension or uncontrolled rhythm
disturbances (tachycardia/bradycardia) in the outpatient setting.
However, major complications are uncommon such that when clinically
indicated and the benefits outweigh the risk, a recent myocardial infarction
should not always preclude bronchoscopy particularly
when results/therapies might significantly impact the management (eg,
massive hemoptysis, pre-cardiac transplant evaluation for infection). In a
retrospective study of bronchoscopy to evaluate suspected pneumonia in 21
patients with acute MI in a coronary care unit, it was found to be safe [46].
One patient had bleeding and another required intubation within 24 hours of
bronchoscopy. The risk of chest pain or post procedure MI was not increased
in this population. However, therapy was changed in 64 percent of the
patients based on the acquired information.
Another retrospective study of 21 bronchoscopies in 20 patients reported
one death in a patient with ongoing ischemia but found it to be safe when
performed on average of about 12 days after an acute MI [47]. In these
situations, it is preferred by some clinicians that careful attention to sedation
and oxygenation, as well as minimizing distress during bronchoscopy, avoids
excessive increases in heart rate or decreases on oxygenation to minimize
the risk of precipitating an acute myocardial event.
The safety of EBUS bronchoscopy within one year of percutaneous coronary
intervention (PCI) was examined in a retrospective study of 24 patients [48].
There was no significant bleeding while one patient developed atrial
fibrillation with rapid ventricular rhythm.
A study evaluated the clinical course and complications following diagnostic
BAL in critically ill mechanically ventilated patients [49]. Although there was
a significant decline in PaO2/FiO2 ratio from 29 to 25 kPa after one hour of
bronchoscopy, there was no significant decrease in hemodynamic
parameters such as mean arterial pressure, heart rate, requirement of
pressor use, or cardiac rhythm abnormalities at 1 and 24 hours following
bronchoscopy.

Patients at risk of bleeding

● Anticoagulants/coagulopathy – Nonemergent brushing, biopsy, and


EBUS or needle aspiration should preferably be avoided in patients who
have taken an antiplatelet agent within the past four to five days or
subcutaneous low molecular weight heparin in the past 12 hours, or who
have a platelet count of 50,000 platelets/mm3 or lower, an international
normalized ratio (INR) of 1.3 or greater, or an elevated partial thromboplastin
time (PTT) 1.5 times baseline [50,51]. In general, bronchoscopy with
bronchoalveolar lavage may be performed safely in those with platelet
counts between 30,000 and 50,000 platelets/mm3 but entry via the nasal
passage should be avoided in all patients with counts ≤50,000/mm3 due to
the higher risk of epistaxis [51]. For patients who receive platelets or fresh
frozen plasma (FFP) to correct an abnormality, the relevant laboratory study
can be repeated to confirm that the abnormality has been corrected, before
proceeding with a non-emergent procedure.
The recommendation to hold antiplatelet agents prior to bronchoscopy is
supported by a prospective cohort study of 604 patients who underwent
flexible bronchoscopy with transbronchial biopsy [50]. The study found that
the risk of bleeding was significantly higher among patients
taking clopidogrel alone (89 percent) and clopidogrel plus aspirin (100
percent), compared to the control (3.4 percent). However, the possibility that
the bleeding risk associated with antiplatelet medications is agent-specific
cannot be excluded, since another study found no increased risk of bleeding
among patients taking aspirin [52].
EBUS bronchoscopy performed within one year of percutaneous coronary
intervention (PCI) while on anti-thrombotic agents in 24 patients found that,
while aspirin or clopidogrel were held for at least three days prior to the
procedure in five patients after a careful cardiac evaluation, the EBUS
bronchoscopy was performed on 15 patients on aspirin and clopidogrel or
other anti-thrombotic agents without any significant bleeding [48].
Certain chemotherapy agents such as sunitinib or bevacizumab may
increase the risk of bleeding. A careful review of all medications prior to
bronchoscopy is important and should be held prior to bronchoscopy with
biopsy or any other intervention.
The risk of bleeding can be minimized by holding oral warfarin for 3 to 5 days
and Clopidogrel for five to seven days prior to the procedure, having an INR
<1.3, holding low molecular weight heparin for 24 hours, holding IV heparin
for two to four hours, and possibly the administration of platelets in those with
thrombocytopenia. Blood tests for coagulation and platelet count should be
done in those with known risk factors or those requiring biopsy.
●Renal insufficiency – Bronchoscopy with biopsy in uremic patients can
increase the risk of bleeding because of dysfunctional platelets. However, a
recent retrospective study of 25 patients who underwent bronchoscopic
biopsy with underlying uremia and end stage renal failure requiring dialysis,
reported a bleeding complication rate of 8 percent [53]. No complication was
noted in patients requiring dialysis. Bronchoscopic biopsy may be performed
without an increased risk if additional bleeding disorders are screened and
addressed appropriately.
In patients with blood urea nitrogen (BUN) >30 mg/dL or serum creatinine
>2 mg/dL, administration of desmopressin(DDAVP) approximately 30
minutes before the procedure will minimize risk of bleeding when brushing,
biopsy, or needle aspiration is anticipated.
Most of flexible bronchoscopy is done under moderate sedation. Patients on
dialysis could have adverse effects of sedative effects from altered clearance
of drugs used for moderate or deep sedation. In a retrospective study of eight
patients on dialysis, who received moderate doses of pethidine intravenously
or hydroxyzine intramuscularly, no significant respiratory depression was
noted. However, the procedure provided a diagnosis of cancer in three out
of four patients with suspected lung cancer [54].
●Superior vena cava syndrome – When superior vena cava (SVC) is
stenotic or compressed by an intrathoracic mass, it can lead to collateral
vessel formation. Enlarged vasculature can potentially lead to bleeding if
biopsy is planned. However, a retrospective study of bronchoscopy in 11 out
of 18 patients with SVC syndrome did not report any complication [55].

Special populations — Flexible bronchoscopy is a high risk procedure in select


populations but can be performed safely with certain provisions. As examples:

●Raised intracranial pressure – Intracranial pressure (ICP) rises during


flexible bronchoscopy. Thus, we avoid bronchoscopy with conscious
sedation in this population. However, it is often performed safely without any
adverse neurologic effects using either deep sedation with propofol or
general anesthesia [56-58].
As an example, safety of bronchoscopy has been documented in a study of
15 intubated patients with severe head injury who were paralyzed during the
procedure with continuous ICP monitoring [56]. Although ICP almost doubled
during bronchoscopy, it returned to baseline post bronchoscopy without any
changes in Glasgow coma score or neurological examination. Another
prospective study of 26 flexible bronchoscopies in 23 patients with brain
injury performed under general anesthesia did not report any acute
neurologic event due to bronchoscopy. Despite adequate sedation,
analgesia, and paralysis a transient rise in ICP and mean arterial pressure
occurred during the bronchoscopy, without a substantial change in the
cerebral perfusion pressure (CCP) [57].
●Mechanical ventilation – A bronchoscopy for bronchoalveolar lavage
(BAL) or airway inspection can be performed on mechanical ventilation with
moderate or high ventilatory settings (FiO2 100 percent and positive end
expiratory pressure [PEEP] >10). The vitals should be monitored closely, so
the procedure could be aborted or held when a significant oxygen
desaturation develops. Elevations in mean airway pressure are frequent but
are rarely associated with barotrauma. Additional procedures such as
transbronchial or endobronchial biopsy may increase the risk of
complications, particularly, pneumothorax.
Transbronchial biopsy should be done with caution in patients with
emphysematous bullous disease who are on a mechanical ventilator
requiring high PEEP (>10) to avoid a pneumothorax. In intubated patients,
the endotracheal tube may be shortened by cutting the proximal end of the
tube, to allow the bronchoscope to reach the peripheral airways. The suction
time should be limited to less than two to three seconds to minimize loss of
tidal volume.
In support of this approach, a retrospective study of 38 patients who
underwent BAL and transbronchial biopsy on mechanical ventilation to
evaluate pulmonary infiltrate, reported etiologic diagnosis obtained in 63
percent with an increased rate of pneumothorax (9 of 38) without any
fatalities [59].
●Large anterior mediastinal masses – Bulky lymphadenopathy or large
masses of the anterior mediastinum may compress and block the airway
during sedation. It may be difficult to ventilate these patients during the
procedure or post recovery resulting in respiratory failure and intubation.
While some clinicians prefer deep sedation or general anesthesia in such
cases, one case report describes the use of dexmedetomidine (avoids
muscle relaxation; awake intubation) for the performance of bronchoscopic
procedures on anterior mediastinal masses [60]. Thus, in this population we
prefer performing bronchoscopy in a sitting position with spontaneous
respiration. An awake bronchoscopy with topical sedation or regional
anesthesia (glossopharyngeal block) may also be an acceptable alternative.
●Pregnancy – Decrease in residual volume and expiratory reserve volume
along with an increased demand of oxygen by the fetus and the placenta
during pregnancy may lead to rapid oxygen desaturation during
bronchoscopy. Medications used for sedation also may pose an adverse risk
to the fetus. Nonemergent bronchoscopy should be postponed until delivery
or at least after 28 weeks of pregnancy [61]. However, if it is considered
lifesaving (acute airway obstruction or massive hemoptysis) and needs to be
performed during pregnancy, bronchoscopy should be preferably done in the
operating room with anesthesia and an obstetrician available with continuous
fetal monitoring. Placement in the left lateral decubitus position and oral
approach (if not intubated) will minimize risks.
●Older patients – Flexible bronchoscopy is safe in the older adult
population. The predominant risk may be oversedation. A retrospective study
showed that the use of supplemental oxygen, rate of fever, hypertension, or
bleeding were not significantly different between those >75 years and those
between 50 and 75 years of age [62].
Another retrospective study compared the safety and utility of flexible
bronchoscopy outside the intensive care unit, among patients 85 years or
older with those ages 65 to 79 years old. Although the older adult population
had a higher American Society of Anesthesiologists (ASA) class compared
with the younger group there was no significant difference in complication
rates, diagnostic yield or indications between the two groups suggesting that
the flexible bronchoscopy is safe among those older than 85 years old
compared with the younger cohort [63].
●Patients requiring prophylactic antibiotics – The value of prophylactic
antibiotics in patients who typically require them for other procedures is
unknown. Some clinicians advocate for their use in patients who are
asplenic, have a mechanical heart valve prosthesis, or who have a history of
endocarditis [64]. In some patients with artificial prosthesis (eg, hip or knee
replacement), some clinicians use prophylactic antibiotic to prevent a
transient bacteremia and potential seeding of the prosthetic with bacteria.
However, the value of the practice is of unclear benefit.

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