Risk factors and management of bleeding associated with transbronchial lung biopsy in lung transplant recipients.

Comments: The aim of this prospective study was to assess specific risk factors associated with bleeding during BLB in 69 lung transplant recipients who underwent 363 consecutive BLBs over a 2-year period. No patient had a previously documented bleeding diathesis or coagulation disorder, and no patient included in the study received antiplatelet agents or anticoagulants periprocedurally. Furthermore, all patients had normal platelet counts. Coagulation profiles were not checked routinely before each procedure. The study analyzed the risk factors such as gender, type of transplant, acute rejection, bronchiolitis obliterans, infections, number of biopsy specimens obtained per procedures, serum creatinine level and postoperative day since transplantation. The bronchoscope was not wedged to obtain BLB, and associated bleeding was managed using the “back-and-forth” technique. All BLBs were obtained with a 2.4-mm crocodile or fenestrated ellipsoid forceps under uniplanar fluoroscopic guidance. The FB was positioned just above the desired segment from which the BLBs were taken. The “back-and-forth” technique used (after obtaining BLB) consisted of moving the tip of FB back and forth intermittently, application of suction, and withdrawal of FB in one motion. The FB was moved back and forth in this fashion intermittently until the bleeding stopped spontaneously. The authors claim that this “back-and-forth” movement prevents blood from adhering to the lens and obscuring vision. The observations revealed that none of the risk factors analyzed were significantly associated with bleeding during BLB. Blood loss more than 25 mL occurred during 89 procedures (25%; maximum, 400 mL). Blood loss of 50 to 99 mL occurred during 65 procedures (18%) and was ≥100 mL in 13 procedures (4%). None of the patients with bleeding during BLB were treated with instillation of vasoconstrictors or with balloon tamponade or any type of surgical intervention. There were no deaths attributed to the procedure and all patients had an uneventful course in the recovery room. Adequate biopsy material (>100 alveoli per low-power field) was obtained in 361 of 363 procedures (99%). The overall incidence of pneumothorax was 0.6% (2 of 363). The authors concluded that the severity of bleeding is independent of any specific risk factor and the back-and-forth technique can be safely used in lung transplant recipients to manage bleeding associated with BLB performed without wedging of the bronchoscope. BLB is often required to diagnose the acute rejection process in lung allograft recipients. Some include BLB as one of the diagnostic techniques to exclude opportunistic infection in lung transplant recipients. BAL is perhaps sufficient to diagnose opportunistic infections. BAL can be safely performed in this group of patients even in the presence of coagulation disorders, renal dysfunction, and immunosuppression. The histologic diagnosis of acute rejection of the transplanted lung recipients usually requires BLB. These risk factors are among the contraindications for BLB in this group of patients. One report indicated that BLB in lung transplant recipients carries with it higher risk of bleeding (Chest 1999;115:397–402). However, specific risk factors responsible for the increased bleeding have not been identified. The study discussed here does not provide the average number of biopsy specimens obtained per patient or the rate of bleeding after BLB in the patients who were not lung transplant recipients. Therefore, it is somewhat difficult to compare the rate of post-BLB bleeding in the hands of the same group of bronchoscopists. As implied earlier, the number of biopsy specimens obtained may determine the rate of bleeding after BLB. Most medical centers that specialize in lung transplantation obtain larger number of BLBs (often more than six to eight biopsy specimens per patient per session) in lung transplant recipients in contrast to smaller number of biopsy specimens in other disorders (less than six biopsy specimens per patient per session). It is intuitive to expect an increased risk of bleeding with a larger number of biopsy specimens.