Fiberoptic Bronchoscopy in Coronary Care Unit Patients: Indications, Safety, and Clinical Implications

doi:10.1378/chest.114.6.1660

Chest

Volume 114, Issue 6, December 1998, Pages 1660-1667

https://doi.org/10.1378/chest.114.6.1660 Get rights and content

Study objectives

To evaluate the indications, safety, therapeutic impact, and outcome of fiberoptic bronchoscopy (FOB) in coronary care unit (CCU) patients.

Design

Retrospective review of all CCU patients undergoing FOB during a 6-year period.

Setting

Tertiary care university hospital.

Results

Among 8,330 patients admitted to the CCU; 40 (0.5%) patients underwent FOB to evaluate pulmonary abnormalities, most often (78%) to appraise clinically suspected pneumonia. Thirty-five (88%) patients were intubated and 21 (53%) had acute myocardial infarction (MI) before FOB. There were two major complications (bleeding, intubation) occurring within 24 h of FOB, one of which appeared due to the procedure. No episodes of chest pain or ischemic events were recorded and no significant increase in major complications was noted in MI patients (3% vs 5%). Patients having FOB within 10 days of MI had higher survival (79%) than those undergoing FOB later (29%) (p = 0.05). Seven different bacterial pathogens were isolated in 6 (15%) patients, probably reflecting prior empiric antibiotics in 32 (80%) patients. Therapy was changed in 64% of patients in whom a potential pathogen was identified. Despite alterations in treatment, patients with clinically suspected pneumonia and any organisms isolated by FOB had greater mortality (79% vs 31%, p = 0.003) than those with sterile FOB cultures.

Conclusion

FOB may be diagnostically useful in the evaluation of pulmonary abnormalities in selected patients with acute cardiac disease, can be performed safely, and may influence management decisions. Positive bronchoscopy cultures often influence therapy but are associated with higher mortality, suggesting a lethal effect of nosocomial pneumonia in this subset of CCU patients. The risks of FOB must be weighed with the impact of FOB results on patient outcome, and its role requires further investigation.

Section snippets

Patient Demographics

We retrospectively studied the records of all CCU patients who underwent FOB between March 1990 and March 1997, at the Wake Forest University Baptist Medical Center, Winston-Salem, NC. Patients were identified via hospital discharge coding through the medical records department and the bronchoscopy laboratory log. Data regarding CCU admissions not requiring FOB were obtained through the medical records department computerized database. Information on all patients undergoing FOB was obtained by

Patient Demographics, Laboratory Data, and Indications for Bronchoscopy

During the period of review, 8,330 patients were admitted to the CCU. Of these, 40 (0.5%) patients underwent FOB of whom 14 (35%) were women and 26 (65%) were men. The mean age of patients undergoing FOB was 65.6 years (range, 28 to 85 years). The indications for CCU admission in patients undergoing FOB are summarized in Table 1. Mean ± SD results of laboratory data obtained the day of FOB are WBC 12.7 ± 4.2 k/μL, hematocrit 30.6 ± 4.7 mL/dL, prothrombin time 13.6 ± 2.0 s, partial

Discussion

These data provide several new insights about FOB in patients with cardiac disease. In contrast to the medical ICU, FOB is performed in only a small proportion of patients admitted to the CCU.11, 12, 13 Despite a clinical diagnosis of pneumonia in 693 (8%) patients and need for mechanical ventilation in 1,361 (8%), only 40 (0.5%) underwent FOB during the 7-year period described in this experience. The primary indication for FOB was to assist in the diagnosis of clinically suspected

Acknowledgment

The authors wish to thank Sherry Smith, Tracey Carroll, and the Medical Records Staff of North Carolina Baptist Hospital for their invaluable assistance with data collection.

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Utility of fiber-optic bronchoscopy in pulmonary infections among abdominal solid-organ transplant patients: A comprehensive review
2019, Respiratory Medicine
Citation Excerpt :
In the setting of pulmonary hypertension, bronchoscopy is considered to be a high-risk procedure, particularly when transbronchial lung biopsy (TBB) is performed. Higher than expected bleeding under high pressures may occur with consequent hemodynamic instability [13]. In general, systemic anticoagulation increases bleeding risk and should be preferably avoided or reversed prior to FOB.
Pulmonary infections are frequent complications in abdominal solid-organ transplantation (aSOT) which may threaten patient and allograft survival. Accurate diagnosis and treatment of pulmonary infections in this population can be challenging. Immunosuppressive therapy not only increases the risk of acquiring opportunistic and non-opportunistic infections, but it also impairs the inflammatory responses associated with microbial invasion which in an otherwise normal host produce clinical and radiologic responses that allow for early identification of the offending pathogen. Serologic testing is not a reliable diagnostic modality. Direct microbiological sampling is often necessary to make a definitive diagnosis early in the clinical course to optimize timely, targeted therapy while reducing the risk of developing antimicrobial resistance, and minimize adverse effects of therapy, if any. Fiber-optic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) or transbronchial lung biopsy (TBB) offers such diagnostic advantage and possesses a potential therapeutic value too. This comprehensive review discusses the potential benefits of FOB alongside its risks and complications, indications and contraindications, and techniques. Additionally, the essay highlights FOB's utility and yield specifically with regard to type and timing of infections in aSOT patients.
Flexible Bronchoscopy
2018, Clinics in Chest Medicine
Citation Excerpt :
Complications were rare with only 2 patents developing arrhythmias related to the bronchoscopy. Only 5 patients in this review were not already intubated and 1 (20%) in this subgroup required intubation after the procedure.116 This paper does not necessarily imply that the procedure is safe, but rather that it is safer in the previously intubated and deeply sedated patient because much of the theoretic risks are associated with the underlying adrenergic response and hypoxemia attributable to bronchoscopy in the moderately sedated patient.
Fiberoptic bronchoscopy in a respiratory intensive care unit
2012, Medicina Intensiva
Describir las indicaciones, rentabilidad diagnóstica y complicaciones de la fibrobroncoscopia (FBS) en una unidad de vigilancia intensiva respiratoria (UVIR).
Estudio prospectivo observacional.
UVIR de 6 camas en un hospital universitario de tercer nivel.
Pacientes admitidos en una UVIR a los que se les realizó una FBS.
Ninguna.
Indicaciones y complicaciones de la FBS, técnicas endoscópicas realizadas y tiempo empleado en la FBS.
Se realizaron 107 (23%) FBS a 69 de los 297 pacientes admitidos en la UVIR. El 68% de las FBS se practicaron a pacientes con ventilación mecánica. La FBS se realizó con fines diagnósticos en 88 ocasiones (82%) y terapéuticos en 19 (18%). La indicación más frecuente para la FBS diagnóstica fue el estudio de infiltrados pulmonares (44 casos; 50%), particularmente en pacientes inmunodeprimidos (24 casos; 27%). Para esta indicación, la rentabilidad diagnóstica de la FBS fue significativamente mejor en los pacientes inmunodeprimidos, respecto a los inmunocompetentes (48% vs 30%; p < 0,01). La FBS no causó complicaciones mayores; únicamente se observó un descenso significativo en la PaO₂/FiO₂ (182 ± 74 vs 163 ± 79; p < 0,005) cuando se realizó un lavado broncoalveolar. La mortalidad global en la UVIR fue del 14%; del 25% en los pacientes que precisaron FBS y del 45% en aquellos que precisaron FBS adicionales.
La FBS es un procedimiento seguro y rápido que se utiliza con frecuencia en la UVIR y que contribuye significativamente al manejo clínico. Los pacientes de la UVIR que requieren FBS adicionales tienen una elevada mortalidad.
To describe the indications, diagnostic performance and safety of fiberoptic bronchoscopy (FOB) performed in a respiratory intensive care unit (RICU).
A prospective, observational study was carried out.
A 6-bed RICU in a tertiary university hospital.
Patients admitted to RICU who required FOB.
None.
FOB indications and complications, endoscopic procedures, time required to perform FOB.
Sixty-nine out (23%) of the 297 patients admitted to the RICU underwent a total of 107 FOB. Sixty-eight percent of FOB were performed in patients on mechanical ventilation. FOB was performed for diagnostic and therapeutic purposes in 88 (82%) and 19 cases (18%), respectively. The study of pulmonary infiltrates was the main indication for diagnostic FOB (44 cases; 50%), particularly in immunocompromised patients (24 cases; 27%). In immunocompromised patients the diagnostic performance of FOB was significantly higher than in immunocompetent subjects (48% vs 30%; p < 0.01). No major complications were recorded. Only a significant drop in PaO₂/FiO₂ ratio was observed (182 ± 74 vs 163 ± 79; p < 0.005) in patients undergoing bronchoalveolar lavage. Overall mortality in patients in the RICU was 14%. In patients requiring a single FOB procedure, mortality was 25%, versus 45% among those requiring more than one FOB procedure.
These results show that FOB is used commonly in the RICU. It is a safe and fast procedure that contributes significantly to clinical management. Patients requiring additional FOB during admission to the RICU show high mortality.
Management of nosocomial pneumonia on a medical ward: A comparative study of outcomes and costs of invasive procedures
2009, Clinical Microbiology and Infection
Citation Excerpt :
Previous studies of bronchoscopy in general medical wards show that it can cause significant cardiovascular changes, especially in elderly patients [22]. In one study [23], major complications ensued in 5% of 40 coronary patients undergoing bronchoscopy, mainly for diagnosis of NP. On the other hand, a large review of complications during 4273 bronchoscopy procedures performed at a university hospital (52% for diagnosis of suspected infection) found no bronchoscopy-related deaths.
The goal of this study was to compare outcomes and costs of two management strategies for non-ventilator-associated nosocomial pneumonia (NP) in a medical ward. In this single-centre study, NP patients (n = 68) were randomized to receive non-invasive management (NIM) with immediate empirical antibiotic treatment (n = 34), or invasive management (IM) based on protected brush sampling of specimens (n = 34). The economic analysis adopted the hospital's perspective and took into account only direct costs. Baseline characteristics did not differ significantly between the two patient groups. The most frequently isolated organisms were Staphylococcus (25.4%), Streptococcus (23.7%) and Pseudomonas (18.6%) species. The 28-day clinical cure rate did not differ notably between the two groups (NIM, 79.4%; IM, 73.5%). Mortality at 28 days tended to be lower in the NIM group (10.0% vs. 21.8%). Mean antibiotic costs were lower in the IM group (€194 ± 355 vs. €300 ± 335, p <0.001) but overall management costs were similar (respectively, €367 ± 355 and €346 ± 363 in the IM and NIM groups, p = 0.08). With respect to both outcome and cost, this study does not support routine management of NP in medical wards using invasive procedures.
Prospective risk-adjusted morbidity and mortality outcome analysis after therapeutic bronchoscopic procedures: Results of a multi-institutional outcomes database
2008, Chest
Citation Excerpt :
It stands to argue that the number of interventions for nonmalignant indications may rise even further, if other procedures such as endoscopic lung volume reduction enter clinical practice. Data available to date have either been retrospectively collected, addressed only the safety of single-type interventions, were a single-institution experience, only included few patients, or did not go out to 30 days, and most importantly did not report risk-adjusted or disease-specific outcomes.15–17 In our model, multiple different interventions are collected prospectively, and a 30-day window was chosen to reflect current beliefs that procedure outcomes data cannot just be limited to a few days perioperatively.18
Interest in databases is growing to allow for outcomes research, assess health-care quality, and determine best practices and resource allocation, and they are increasingly considered as a tool to potentially tie reimbursement to outcome parameters. Little is known about resource use and risk-adjusted morbidity and mortality after therapeutic bronchoscopic interventions.
Data were extracted and reviewed from an ongoing prospective, multi-institutional outcomes database for therapeutic bronchoscopic interventions. All consecutive patients are entered into this database, and information on demographics, indications, procedures and anesthesia, comorbidities and general health status, urgency of intervention, morbidity and mortality to 30 days, increase in levels of care, and procedural resources is documented.
From December 2005 to May 2007, 554 therapeutic procedures were performed in four hospitals. Most procedures were done under general anesthesia (n = 362) and rigid bronchoscopy (n = 483), and the most common intervention was airway stent placement (n = 258). Forty-two percent of procedures were done urgently or emergently. Complications were common (19.8%), and 30-day mortality was 7.8%, correlating with underlying health status and urgency of intervention.
Prospective and ongoing data analysis for bronchoscopic procedures is feasible and valuable. Risk-adjusted and disease-specific outcomes can be documented and potentially used for quality assessment, benchmarking, and quality improvement initiatives. Appropriate use of resources and effect of interventions can be documented. Extending the number of participating centers as well as inclusion of quality of life tools and technical success are the next steps.
Good practices of diagnostic flexible bronchoscopy
2007, Revue des Maladies Respiratoires
Les bonnes pratiques de la bronchoscopie souple diagnostique décrivent les éléments importants à connaître et prendre en compte lors de la réalisation d’une bronchoscopie souple diagnostique, programmée, chez l’adulte. Il s’agit d’une mise au point pratique.
Les conditions de sécurité, les complications, l’anesthésie, les risques infectieux, le nettoyage désinfection sont développés à partir d’une revue de la littérature. La pratique de la bronchoscopie en soins intensifs qui nécessite peut être plus d’attention du fait des terrains plus fragiles fait l’objet d’une discussion étendue.
Les performances des différentes techniques de prélèvement complètent ce travail.
Les indications, la bronchoscopie interventionnelle, la bronchoscopie en pédiatrie ne sont pas développées.
These guidelines on flexible bronchoscopy depict important clues to be known and taken into account while practicing flexible bronchoscopy, in adult, except in emergency situations. This is a practical clarification.
Safety conditions, complications, anesthesia, infectious risks, cleaning and disinfection are detailed from a review of the literature. Intensive care practice of bronchoscopy requires more attention due to higher risks patients and is discussed extensively. Standards and performances of the various sampling techniques complete this work. Indications for bronchoscopy, therapeutic and paediatric bronchoscopy are not covered in these guidelines.

View all citing articles on Scopus

: Presented at the Annual Meeting of the American Thoracic Society, May 1996, New Orleans, LA.

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Chest

Clinical Investigations in Critical CareFiberoptic Bronchoscopy in Coronary Care Unit Patients: Indications, Safety, and Clinical Implications

Study objectives

Design

Setting

Results

Conclusion

Section snippets

Patient Demographics

Patient Demographics, Laboratory Data, and Indications for Bronchoscopy

Discussion

Acknowledgment

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Clin Chest Med

Mayo Clin Proc

Am J Cardiol

Chest

Chest

Chest

Chest

Mayo Clin Proc

Infect Dis Clin North Am

Clin Chest Med

Clin Chest Med

Chest

Am J Med

Chest

Chest

Clinical Investigations in Critical Care
Fiberoptic Bronchoscopy in Coronary Care Unit Patients: Indications, Safety, and Clinical Implications