Contraindications and Safety of Transbronchial Lung Biopsy via Flexible Bronchoscopy

Wahidi, Momen M.; Rocha, Ana Thereza; Hollingsworth, John W.; Govert, Joseph A.; Feller‐Kopman, David; Ernst, Armin

doi:10.1159/000085370

Cited by 89 publications

(71 citation statements)

References 122 publications

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“…Bronchoscopy is not usually a routine investigation in patients with PAH, and transbronchial biopsy is considered contraindicated [62]. Patients with PAH and associated parenchymal lung disease may, however, undergo BAL as part of routine investigation, and there may be a role for BAL in patients with suspected PVOD [9].…”

Section: Balmentioning

confidence: 99%

Pulmonary veno-occlusive disease

Montani¹,

Price²,

Dorfmüller³

et al. 2009

European Respiratory Journal

269

250

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Pulmonary veno-occlusive disease (PVOD) is currently classified as a subgroup of pulmonary arterial hypertension (PAH) and accounts for 5-10% of cases initially considered to be idiopathic PAH. PVOD has been described as idiopathic or complicating other conditions, including connective tissue diseases, HIV infection, bone marrow transplantation, sarcoidosis and pulmonary Langerhans cell granulomatosis. PVOD shares broadly similar clinical presentation, genetic background and haemodynamic characteristics with PAH. Compared to PAH, PVOD is characterised by a higher male/female ratio, higher tobacco exposure, lower arterial oxygen tension at rest, lower diffusing capacity of the lung for carbon monoxide, and lower oxygen saturation nadir during the 6-min walk test. High-resolution computed tomography (HRCT) of the chest can be suggestive of PVOD in the presence of centrilobular ground-glass opacities, septal lines and lymph node enlargement. Similarly, occult alveolar haemorrhage is associated with PVOD. A noninvasive diagnostic approach using HRCT of the chest, arterial blood gases, pulmonary function tests and bronchoalveolar lavage could be helpful for the detection of PVOD patients and in avoiding high-risk surgical lung biopsy for histological confirmation. PVOD is characterised by a poor prognosis and the possibility of developing severe pulmonary oedema with specific PAH therapy. Lung transplantation is the treatment of choice. Cautious use of specific PAH therapy can, however, be helpful in some patients.KEYWORDS: Alveolar haemorrhage, BMPR2, computed tomography, diffusing capacity of the lung for carbon monoxide, pulmonary arterial hypertension, pulmonary veno-occlusive disease P ulmonary arterial hypertension (PAH) is a severe condition characterised by elevated pulmonary artery pressure leading to right heart failure and death [1,2]. Pulmonary veno-occlusive disease (PVOD) is classified as a subgroup of PAH and accounts for 5-10% of histological forms of cases initially considered to be idiopathic PAH. Even though the first welldocumented case of PVOD was described .70 yrs ago, the characteristics and pathophysiology of this disease remain poorly understood [3,4]. While pulmonary vascular pathology of idiopathic or familial PAH is characterised by a major remodelling of small pre-capillary pulmonary arteries with typical plexiform and/or thrombotic lesions, PVOD preferentially affects the post-capillary venous pulmonary vessels [5,6]. Despite this anatomical histological difference, PVOD has a very similar clinical presentation to PAH but is characterised by a worse prognosis and the possibility that severe pulmonary oedema can develop with specific PAH therapy, justifying the importance of diagnosing this disease. A definitive diagnosis of PVOD requires histological analysis of a lung sample [7,8]; however, surgical lung biopsy is a high-risk procedure in these patients and the development of a less invasive diagnostic approach would be preferable [9][10][11]. The present manuscript will summa...

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Section: Balmentioning

confidence: 99%

Pulmonary veno-occlusive disease

Montani¹,

Price²,

Dorfmüller³

et al. 2009

European Respiratory Journal

269

250

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“…Moreover, transbronchial biopsy obtained via bronchoscopy is relatively contraindicated in patients with PH (mean Ppa .30 mmHg), due to increased risk of bleeding [119]. Similarly, the morbidity and mortality risk of surgical lung biopsy (video-assisted thoracic surgical or open) is increased in patients with ILD and PH [6].…”

Section: Histologymentioning

confidence: 99%

Pulmonary hypertension in interstitial lung disease

Behr

Ryu

2008

European Respiratory Journal

238

173

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In the lungs, parenchymal and vascular remodelling share pathomechanisms that may explain the relatively high prevalence (30-40%) of pulmonary hypertension (PH) in interstitial lung disease (ILD) patients. Notably, PH significantly contributes to exercise limitation and dismal prognosis of ILD patients. The absence of specific clinical symptoms commonly leads to delayed diagnosis. Besides clinical judgment and out-of-proportion reduction in diffusing capacity, severe hypoxaemia or exercise oxygen desaturation, echocardiography and biomarkers such as B-type natriuretic peptide (BNP) and N-terminal pro-hormone BNP are potentially helpful tools in identifying PH. However, right heart catheterisation is still necessary to confirm the diagnosis. Management of PH in ILD comprises treatment of the underlying disease process and long-term oxygen therapy. Affected patients should be listed for lung transplantation without delay, when appropriate. However, due to age and comorbidities only a minority of ILD patients will be eligible for lung transplantation. In the absence of satisfactory therapies for many ILDs, and considering the clinical burden of PH in affected patients, specific vasomodulatory therapies presently approved for PAH may be promising options for ILD patients. Consequently, there is an urgent need for adequately designed clinical trials to assess the effectiveness of specific PH therapy in the context of ILDs.

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“…In mild-to-moderate airway stenosis, fiberoptic bronchoscopy can be used to visualize the entire lesion, determine the location and extent of the stenosis, obtain biopsy specimens, and administer local tumor ablation therapy. In severe airway stenosis, however, the fiberoptic bronchoscope cannot be passed through the stenosed segment and details about the stenosed segment cannot be ascertained, especially vascularity of the stenosed segment, leading to a high risk of hemorrhage, which may be difficult to control and even cause death due to asphyxiation (10,11). Therefore, fiberoptic bronchoscopy is a high-risk procedure in patients with severe airway stenosis.…”

Section: Discussionmentioning

confidence: 99%