Figures
- 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.
Tables
- TABLE 1
Suggested cutoff values for several parameters and time interval for the interruption of different drugs prior to the most commonly performed procedures during flexible bronchoscopy
Procedure Resume therapy after BAL EBB/TBNA/EBUS-TBNA TBLB Patient-related risk factors and contraindications Pulmonary hypertension No No sPAP >50 mmHg or mPAP >30 mmHg Vena cava syndrome No Relative contraindication Haemostasis-related risk factors and contraindications Platelets ×109 per L <20 000 <75 000 INR/PT No >1.4 or <60% Drugs Heparins UFH prophylactic dose No 6-h interval period Same day UFH therapeutic dose No 6-h interval period 4–12 h LWMH prophylactic dose No 10–12-h interval period Same day LWMH therapeutic dose# No 24-h interval period 4–12 h Fondaparinux No 36–42-h interval period 4–12 h Platelet-aggregation inhibitors Acetylsalicylic acid No Do not stop Not stopped Clopidogrel No 5–7 days 4–12 h Ticagrelor No 5 days 4–12 h Prasugrel No 7–10 days 4–12 h Oral anticoagulants¶ 4-hydroxycoumarin No 5 days 4–12 h Acenocoumarol No 3 days 4–12 h Phenprocoumone No 8 days 4–12 h Oral anticoagulants+ Dabigatran§ No 3 days 4–12 h Rivaroxaban No 2 days 4–12 h Apixaban§ No 2 days 4–12 h BAL: bronchoalveolar lavage; EBB: endobronchial biopsy; TBNA: transbronchial needle aspiration; EBUS: endobronchial ultrasound; TBLB: transbronchial lung biopsy; INR: international normalised ratio; PT: prothrombin time; UFH: unfractionated heparin; LMWH: low molecular weight heparin; sPAP: systolic pulmonary arterial pressure; mPAP: mean pulmonary arterial pressure. #: normal renal function; ¶: coumadine; +: direct thrombin inhibitor and direct factor Xa inhibitor; §: creatinine clearance >30 mL·min−1.
- TABLE 2
Summary of level of evidence and grade of recommendation as suggested in the British Thoracic Society guidelines [5]
Procedure Level of evidence Grade of recommendation Ref. Perform coagulation studies, platelet count and haemoglobin concentration when there are clinical risk factors for abnormal coagulation 3 D [5] Degree of bleeding is higher after TBLB than EBB 3 [1] LTX recipiens are more likely to bleed after TBLBs (not explained by clotting values or aspirin use) 3 [24] Inspection and BAL can be performed in severely thrombocytopenic patients (platelet >20 000×109 per L−1) 3 D [10] Acetylsalicylic acid has not been shown to increase the risk of TBLB-related bleeding C [8] Clopidogrel has been associated with a significant increase in the frequency of clinically significant bleeding after TBLB 2 C [35] TBLB: transbronchial lung biopsy; EBB: endobronchial biopsy; LTX: lung transplant; BAL: bronchoalveolar lavage.
