1 of 109 BTS Guideline for Diagnostic Flexible Bronchoscopy in Adults  August 2013  Appendix 3 Evidence Tables   Complications    Sedation   Specific conditions   Infection   ITU   Disinfecting   Diagnostic accuracy   Patient satisfaction      http://www.brit‐thoracic.org.uk/Guidelines/Bronchoscopy‐Guidelines.aspx   15/7/2013 2 of 109 STUDY IDENTIFICATION / CITATION TYPE QU BIAS POPULATION CHARACTERISTICS INTERVENTION COMPARISON FOLLOW OUTCOMES EFFECT SIZE FUNDING COMMENTS ALI UP TY RA AUTHORS TITLE YEAR JOURNAL CITATI TIN NUMBER PATIENT ON G CHARACTERISTICS Van Zwam, Flexible 2010 Journal of 29-32 RCT + Unkn N=107 randomised. Supine: Age 64+/-14, Comfort and safety Desaturation Up to 30 Oxygen SaO2>95% in 83% of Not J. bronchoscopy in Bronchology own 4 excluded 1 svt Males 28 Females 18, of bronchoscopy in (with and min before Saturation patients 24% received reported P.Kapteijns, supine or sitting after la 1 no FEV1 2.6L (89% supine versus without discharge and Visual prophylactic oxygen 52% E. F. position: A researcher 2 unclear predicted), duration sitting position prophylactic Severity had SaO2 decrease>4% G.Lahey, randomized on randomisation 8.2+/-3.7min, tumour supplemental scales for Oxygen decline of >4% S.Smit, H. prospective position. N=103. =24,pneumonia=9, O2) and comfort more common in sitting J. M. analysis of Supine: n=46 other =17 Sitting: Age comfort position than supine (35% safety and Sitting: n=57 63+/-12, Males 28 (dyspnoea, vs. 68%, RR1.94); if patient comfort Females 29, FEV1 2.2L fear, cough exclude prophylactic (81% predicted), comfort) in oxygen 26% vs. 64%,RR duration 9.1+/-3.8min, sitting and 2.46 Oxygen desaturation tumour supine <90% more common in =28,pneumonia=12, positions sitting position 17% vs. other =13 32%, RR1.88 No difference in cardiac arrhythmia between groups No significant difference in patient tolerance for sitting or supine position J. S. Park, Impact of 2011 International 528- RCT _ neg 143 72 prophylaxis 44 had TB (38.6%) 32 Prophylactic Fever 24 hours Primary: Incidence Unknown Fever 25.4% vs. 26.6% C. H. Lee, J. antibiotic Journal of 536 71 control 67 and 64 vs. 25% lung cancer antibiotics frequency of prophylactic vs. control J. Yim, S. C. prophylaxis on Tuberculosis & respectively after (augmentin) 30 fever and pneumonia 1.5% vs. 4.7% Yang, C. G. post Lung Disease withdrawals minutes prior to pneumonia peak frequency at 7 hours Yoo, H. S. bronchoscopy FOB temp secondary: Chung, Y. fever: a measured 4 hourly change in W. Kim, S. randomised 37.8 within 24 white cell K. Han, Y. controlled study hours Blood count, CRP S. Shim and cultures and chest D. K. Kim x-ray daily if fever McCain, T. Prospective 2001 CHEST 1671-4 RCT _ Obse N=97 nasal O2 52, Not recorded, hospital Symptom Nasal vs. oral During Average O2 Average O2 sats, lowest O2 Not Nasal vs. oral no diff in sats W.Dunagan, randomized trial rver oral O2 45 based questionnaire Between FOB Not sats, lowest sats were similar between provided but nasal easier D. P.Adair, comparing bias. premed and IV treatments specified O2 sats and two groups as were max N. E.Chin, oxygen unabl sedation transnasal but maximum O2 flow rates. No difference in R., Jr. administration e to bronchoscopy probably flow during O2 delivery relative to nasal during nasal blind supplemental O2, no longer FOB O2 disease/ congestion flexible if either oral or nasal than end saturations bronchoscopy : oral at 2l/min to SaO2 of and oxygen oral vs. nasal or 94%, increased by procedure flow rates, delivery nasal 2l every min to patient factors deliv max 8L/min ery. diffic ult to be sure whic h direct ion Peacock, A. Effect of 1990 THORAX 38-41 Cohort + Yes N=31 (21 patients , N=21 17M 16 COPD with Effects of each part Effect of 20 FEV1, Peak Topical lignocaine to Not Fall in PFT after LA most J.Benson- fibreoptic 10 controls) mean FEV1 2.18L; rest of the procedure on nasopharynge minutes inspiratory nasopharynx in 10 controls reported significant rather than FOB Mitchell, bronchoscopy fibrosing lung disease spirometric al anaesthesia post FOB flow, peak caused no change in PFTs. insertion R.Godfrey, on pulmonary FEV1 2.25. mean age 59 measurements on PFTs Effect expiratory When applied to the major R. function (36-75). FOB indicated were studied in of major flow, FVC, airways lignocaine as part of care e.g.? ca patients with lung airway SaO2 produced a significant fall in but no obstructing disease and in anaesthesia FEV (10.2 norm 10.8% lesion. History asthma normal on PFTs Effect pat), FVC (6.5 and 9.1 and recent infection nonsmokers. of respiratory), PEF (13.5 and excluded. 10 controls bronchoscopy 10.9), and PIF (19.3 and (6M) non smokers; insertion on 8.4) in both norm and normal PFT and no PFTs Effect of normal pat subjects (gives allergy or respiratory anaesthesia/ CI). Insertion of FOB BTS Guideline for diagnostic flexible bronchoscopy in Adults 1 15/7/2013 Evidence Tables for Complications and Specific conditions 3 of 109 disease mean age bronchoscope caused further fall but only 22(21-23) FEV1 3.9. insertion on significant in normals SaO2 PEF(33.1) and pIF(32.9). Fn improved after removal of FOB except FEV1 8%. Control PEF and PIF still reduced(17 and 15%). No effect of small and large FOB. Pattern of fall same for fibrosis. No significant change of art o2 sats. 1. significant change in %FEV1 and %FVC compared to baseline following installation of local anaesthesia and following insertion of bronchoscope in both patients and controls (p<0.05) 2. Significant % change from baseline in PEF/PIF in patients and controls (p<0.05) following anaesthesia and insertion that remained significantly reduced in controls only following removal of bronchoscope 3. No significant change in SaO2 in patient or controls with anaesthesia or insertion. Sharma, S. Effect of routine 1993 Indian Journal 03-Aug Cohort _ No N=21 Group 1, n=10, mean Severity of Serial changes 30 paO2 and Group 1 Group 2 pO2 PCO2 Not K.Pande, J. fiberoptic of Chest age 46 yrs (18-65) 90% hypoxaemia during in paO2 and minutes paCO2 pO2 PCO2 Pre bronch reported N.Sarkar, R. bronchoscopy Diseases & Male Indications: bronchoscopy and paCO2 in Gp 1 73+/-12 37+/-9 74+/-8 and Allied Unexplained BAL and Gp 2. 36+/-4 Premedication bronchoalveolar Sciences haemoptysis, suspected 68+/-12 39+/-4 70+/-10 lavage on cancer Group 2: n=11, 37+/-8 Insertion 71+/-20 arterial blood 82% Male, mean age 35+/-6 63+/-9 36+/-10 gases 49yr (26-70) During FOB/BAL 60+/-10 Indications: Bilateral 35+/-6 58+/-10 37+/-7 diffuse lung diseases Removal 53+/-12 35+/-5 including sarcoid, IPF, 56+/-8 37+/-4 30mins post Collagen vascular 57+/-6 37+/-7 63+/-11 disease, military TB and 38+/-3 lymphagitis Exclusions: PaO2 <60mmHg, recent MI, cardiac arrhythmia or CCF, hypotension or circulatory failure, FEV1<1000ml Payne, C. Effects of 1986 ENDOSCOPY 01-Mar Cohort _ No n=20 100% males, Age 57.7 Effect of transnasal Holter ECG Not Holter rate PaO2 values for transnasal Not B., Jr.Goyal, transoral and yrs, Range 25-86 and transoral and ABG recorded and rhythm significant higher p<0.05 recorded P. C.Gupta, transnasal Excluded if on oxygen, fibreoptic between 12hours than oral. No diff in cardiac S. C. fiberoptic thrombocytopaenia, bronchoscopy on transnasal before and arrhythmia between bronchoscopy uraemia, severe asthma, cardiac rhythm and and transoral after and groups, 60% prevalence of on oxygenation haemoptysis, bleeding oxygenation approach during FOB. minor arrhythmia w 5% and cardiac diathesis Transnasal n-8, ABGs one new. Lower PaO2 in oral rhythm transoral n=12 hour before group but no diff in sats or premed, when arrhythmia Transoral inserted and Transnasal PaO2 69.6 +/- 5mins and 6.6 70.4 +/- 13.7 PaCO2 2hours post 37.7 +/- 2.6 39.8 +/- 3.4 FOB. In n=13 pH 7.44 +/- 0.03 7.43 +/- samples 0.03 SaO2 93.6 +/- 1.5 obtained 92.8 +/- 3.4 No differences when FOB in cardiac rhythm removed. Meghjee, S. Influence of 2001 RESPIRATORY 05-Aug Cohort + Yes Supine Group 1 Group 1 Group 2 Age Effect of posture on Peak, trough During Measured Trough arterial oxygen Not P.Marshall, patient posture MEDICINE (n=20, 5 withdrawn) FEV1 Age FEV1 F 67.8 hypoxaemia during and plateau FOB peak, trough saturations fall significantly reported M.Redfern, on oxygen Semi recumbent [9.1] 1.37 [0.51] 74.8 bronchoscopy and oxygen and plateau with sedation in both E. saturation Group 2 (n=18, 5 [4.6] 1.17 [0.42] M 59.6 influence of saturation in sats. During groups (p<0.001) but no J.McGivern, during fibre- withdrawn) [12.6] 2.24 [0.85] 68.9 supplemental different sedation, intro significant difference in D. V. optic [8.53] 2.00 [0.61] oxygen postures, and of FOB to saturations between the BTS Guideline for diagnostic flexible bronchoscopy in Adults 2 15/7/2013 Evidence Tables for Complications and Specific conditions 4 of 109 bronchoscopy in relation to trachea, supine and semi recumbent sedation and adding group. Supplemental presence of supplementar oxygen associated with bronchoscope y O2 and significant increase in changing oxygen saturations in both position. postures (p<0.001). Similar results demonstrated using peak and plateau saturations but data not shown. Confidence intervals included in bar charts not numerically Bechara, Practice and 2005 Journal of 139- Cohort + Yes 300 18 years or over Median Complication rate AF system in 5-14 days Complication 300 sample size for 80% Not Multicentre prospective US R.Beamis, complications of Bronchology 142 age 66.4 (38-88) 60% of FOB WL mode post rate power for 20% or greater stated study. Higher mortality but J.Simoff, flexible males 82% white versus AF procedure difference in sensitivity for previous studies retrospective M.Mathur, bronchoscopy Hispanic 1.7% Black mode visit AF FOB. and may be underestimates P.Yung, with biopsy 14% Asian 1.3% 6% due to under reporting and R.Feller- procedures non smokers; 60.3% non inclusion Kopman, previous 33.7% current D.Ernst, A. 67% respiratory disease 15.7% lung Cancer 6% dermatological disease 25.7% Endocrine disease 4.7% autoimmune 22.7% neuromuscular 59% cardiovascular 11.4% CNS Capable of giving informed consent Able to attend follow up meetings Life expectancy of at least 6 weeks Suspected of having bronchogenic cancer or history of completely resected stage 1 or 2 cancers with symptoms suggesting recurrence. Georgiades, Temperature 2003 LUNG 35-47 Cohort + Yes 30 patients 15 Patients: mean age 63, Effect of BAL on Differences in 24hours Differences in No change in lung sounds Not None had additional lung G.Myrianthe and serum healthy volunteers 57% male, 88% body temperature clinical clinical No change in oxygen described sounds,SaO2 or fs, proinflammator smokers, average 55 and serum examination, examination, saturations or haemodynamic change. BAL P.Venetsano y cytokine pack years, 57% cytokines axillary axillary haemodynamics at 4 or 24h associated with stat significant u, changes in cardiorespiratory temperature, temperature, compared with baseline No increase in temp 36.6% 1 K.Kythreoti, patients with comorbidity Undergoing haemodynami haemodynami new radiological findings at degree 4(13.3% 38 degree. A.Kyroudi, NSCLC after FOB for haemoptysis+/- cs, gas cs, gas 24h compared with baseline and systemic production of A.Kittas, BAL radiographic exchange at exchange at Significant increase in body TNF, IL6 not IL1. Only those C.Baltopoul abnormalities Controls: baseline, 4h baseline, 4h temperature at 4 and 24h with rise in temp have os, G. mean age 37, 53% and 24 hr and 24 hr compared with baseline increased CKs BAL associated male, 80 smokers, post BAL. post BAL. (p<0.05, absolute values with systemic inflammatory average 25 pack years, Differences in Differences in not given) Significant effects and increase in temp no comorbidity or CXR from CXR from increase in serum TNFalpha symptoms 30 adults baseline and baseline and at 4 and 24h after BAL, and requiring FOB and BAL at 24h post at 24h post in IL6 at 4h after BAL for diagnostic purposes: BAL BAL (p<0.05) No significant minor haemoptysis and Differences in Differences in change in total or radiographic change, total WBC and total WBC and differential WBC between suspected to have lung differential, differential, baseline, 4h or 24hr (no cancer. 15 healthy blood cultures blood cultures data provided) No controls Exclusions: and serum and serum significant changes seen in <18; recent or current proinflammato proinflammato controls infection; known or ry cytokines ry cytokines suspected diffuse at baseline, at baseline, inflammatory lung 4h and 24h 4h and 24h disease; using immunomodulatory drugs oral or inhaled steroids. Patients: mean age 63, 57% male, 88% smokers, average 55 pack years, 57% cardiorespiratory comorbidity Undergoing FOB for haemoptysis+/- radiographic abnormalities Controls: BTS Guideline for diagnostic flexible bronchoscopy in Adults 3 15/7/2013 Evidence Tables for Complications and Specific conditions 5 of 109 mean age 37, 53% male, 80 smokers, average 25 pack years, no comorbidity or symptoms Smith, M. Is fibreoptic 1985 British Journal 368-73 Case- ++ Yes 18 9 hepatomagaly Cases Mean age 64=/-4 lignocaine levels Current or 6hrs Total dose, Mean lignocaine dose admin Augustus J.Dhillon, D. bronchoscopy in of Diseases of controlled and/or liver Males 7/9. Lung cancer and time to reach past liver peak plasma similar in all groups. A,, Newman P.Hayler, A. patients with the Chest dysfunction. 9 (8/9 oat cell), liver peak Effect of liver dysfunction levels, time to 325 f 25 mg; A, 3 10 & 10 Foundati M.Holt, D. lung cancer and controls dysfunction Controls dysfunction on versus no peak mg; B 323 + 18 mg. The on W.Collins, J. hepatic Mean age 63.8=/-2.6 liignocaine toxicity dysfunction concentration, maximum total dose given V. metastases males 7/9 Lung cancer at bronchoscopy % in toxic to any patient was 410 mg. potentially (4/9 oat cell), no liver range Over 75% of the total dose dangerous? dysfunction was administered within the first 10 minutes None had plasma levels>4. Well below critical toxicity levels. Used 5mg/kg in our patients Lin, C. Pulmonary 1988 CHEST 1049- Case- ++ Yes 9 FOB only; 9 FOB 25-35 year olds Effect of BAL & Change in <24hours PFTs and ABG No change in PFTs (FEV1, Not BAL is safe. Causes C.Wu, J. function in 1053 controlled +25 degree BAL; 9 presented to outpatient BALF temp on PFTs spirometry/AB FVC, PEFR) after reported desaturation but no diff in PFT L.Huang, W. normal subjects FOB +37 degree BAL clinic with non specific G before and bronchoscopy, BAL @25C unless 25 degree. But unusual C. after N=27 complaints and all after BAL or 37C Bronchoscopy premed bronchoalveolar examination, CXR and stratified by associated with significant lavage PFT normal. BALF decrease in pa02 94.4+/- temperature 4.75 to 85.5+/-7.48, p<0.02 BAL fluid at 25C significantly decreases paO2 – 95.4+/-6.9 to 67.0+/-12.8, p<0.001 BAL fluid at 37C significantly decreases paO2 – 92.3+/- 5.5 to 77.4+/-10.6, p<0.001 Significant change in FEF and RV for BALF at 25C but not bronchoscopy or BALF 37C Van Vyve, Safety of 1992 American 116-21 Case- + Yes N=75, 50 cases, 25 50 asthmatics age 18-71 Safety of BAL and SaO2 over 3 hours saturations Tolerance excellent with Grant no T.Chanez, bronchoalveolar Review of controlled controls mean 34+/-14 (ATS biopsy in severe time in plus phone throughout. mild asthma symptoms in 2 89 MRD4 P.Bousquet, lavage and Respiratory criteria and 15% asthma, and asthma/ contact PFT before with mild-mod Aas2-3 did from the J.Lacoste, J. bronchial Disease reversibility) no current whether nebulised controls SaO2 and 5 minutes not require cessation and Fonds Y.Michel, F. biopsies in smokers or 2 yrs ex. bronchodilator over time post. resolved with neb post fob. Special B.Godard, patients with Excluded if taken premedication is according to 3 patients 2asthmatic and 1 de P. asthma of theophlline 48hrs before required asthma control developed fever and Maladies variable beta agonists withheld severity resolved. BAL recovery: Respirato severity for 8hrs. FEV1<35% Change in 93.5+/-32.8ml 37.5%+/- ires excluded due to highest FEV1 pre and 13.3% in asthmatics vs. risk of complication with post 124.2+/-16.8ml (49.6+/- BAL Bx. 25 normal non bronchoscopy 7%) in controls p=0.0008 smoking 18-76 44+/- 16 Asthmatics: Art sats mean. Normal PFTs no decreased significant from allergic disease/asthma. 97(91-99)% T1 to 92(79- Characteristics of 98)% T8 after through vs. asthma patients: Aas 1 and procedures. Increased n=6 age 45+/-14 3M 3F back to 96(85-98%) 5 min FEV1 83+/-2.9; Aas2 after fob but significant n=23 age 30+/-12 8M lower than at start. No 15F FEV1 82.1+/-14.2; correlation with asthma Aas3 n=12 age 34+/-13 score, pft,fev1 symptom 7M 5F FEV1 69.1+/- score or b2 use. Significant 17.6; Aas4 n=6 age correlation between fall in 40+/-17 5M 1F fev1 sats and fall in fev1 65+/-19.7; Aas 5 n=3 p=0.0465. No diff in sats age 25+/-10 2F 1M fev1 fall if FEV1< or >60% or 51.5+/-20.5. none had aas< or>4. Controls: taken steroids in last 2 significant fall 97% to 93% months. 26 allergics. T1 vs. T8 especially with Mild asthma (n=6) age bal biopsy and increased 45+/-14, M:F 3:3, FEV1 back to baseline. No diff 83.0+/-2.9 moderate between asthmatic and asthma (n=23), age controls PFTs: asthmatics: 30+/-12, M:F 8:15, decrease in FVC 86.2+/- FEV1 82.1+/-14.2 mod 14.6% to 64+/-17.1% severe asthma (n=12), p=0.0001 FEV1 75.6+/- BTS Guideline for diagnostic flexible bronchoscopy in Adults 4 15/7/2013 Evidence Tables for Complications and Specific conditions 6 of 109 age 34+/-13, M:F 7:5, 16.8% to 55.3+/-17.2 FEV1 69.1+/-17.6 p=0.0002 no decrease in Severe asthma (n=6), ratio. Fall in fev1 not Age 40+/-17, m:f 5:1, correlated with basal fev1 FEV1 65.0 +/-19.7 Very or aas score. Falls in severe asthma (n=3), fvc,fev1 and fef25-75 were age 25+/-10, M:F 2:1, 30.6+/-15.5% , 29.4+/- FEV1 51.5+/-20.5 No 13.1% and 34.7+/-18.5% prior oral or inhaled respiratory and no steroids for 2 months different. No correlation (except very severe with basal fev1, symptom group) Controls age 18- score, aas score and b2 76, median 44, consumption. No difference nonsmokers, normal in falls if fev1< or >60%. PFTS Controls: FVC decreased significant 99.6+/-14.3% to 82.3+/-19% p=0.0125 fev1 decreased 97.1+/-14% to 80.3+/-16.2% p=0.0071 ratio no decrease. Percentage falls greater in asthmatics than controls p=0.0121, 0.0124 0.0217 FVC fev1 fef25-75. Huang, J. C. Acute phase 2006 CHEST 1565- Qualitative + Yes 28 (14 men and 14 women; Acute phase None 24hours Changes in Data are expressed as Not WBCs, primarily neutrophils, T.Bassett, reaction in 1569 research mean age, 24.8 4.8 response after and post FOB blood cell mean SD except where known increased by approximately M. A.Levin, healthy years). The average 24hrs post FOB values Fe specified otherwise. The 50%. Fibrinogen increased by D.Mantilla, volunteers after height was 169.4 9.2 ferritin two-tailed paired t test was 25% while CRP increased by T.Ghio, A. J. bronchoscopy cm, and the average fibrinogen used to evaluate for more than sevenfold. Serum with lavage weight was 74.3 14.1 CRP significant changes ferritin increased by 25% kg. The average duration immediately after and 24 h while serum iron, total iron- of bronchoscopy was after the procedure, binding capacity, and 19.3 3.1 min. adjusted for multiple transferrin saturation comparisons using the decreased, indicating Bonferroni correction. To dysregulation of iron determine acute phase homeostasis. There were no reactants associated with changes in IL-8, ACE, sICAM- changes in WBC count, 1, or nitrite/nitrate plasma stepwise multiple linear levels. Conclusions: regression was used to Bronchoscopy with BAL correlate changes in WBC induces a variety of acute count after the procedure phase responses that includes (dependent variable) with peripheral neutrophilia, changes in CRP, fibrinogen, dysregulation of iron iron, ferritin, and iron homeostasis, and increased saturation (independent levels of fibrinogen and CRP. variables). Only linear Human research that employs terms of the independent BAL may need to consider the variables were considered. biological effects induced by Both R2 and forward the procedure-related acute elimination (exit of 0.10) phase response. model selection procedures were used to screen the independent variables for significant associations with the dependent variable. Matsushima Alterations in 1984 CHEST 184-8 Qualitative + Yes N=35. 15 FOB via Males 13/15 Age 57+/- Changes in Measurements 5 min post VC, FIF, FEV1, Decreased VC after ETT and Not , Y.Jones, R. pulmonary research ETT. 15 transnasal 14 %FEV1 60.4 +/-14.1 pulmonary function are made SaO2. FRC transnasal as well as fEv1. reported L.King, E. mechanics and FOB 5 ETT Pa02 66.0+/- 7.7 VC associated with before Change in 30% increase FRC. No G.Moysa, gas exchange 2.96+/-0.97 FRC 2.57 FOB transnasally examination, pulmonary change PaO2 Control G.Alton, J. during routine +/-0.74 IM atropine and and to determine during and function Insertion After exam D. fiberoptic pethidine, 10% lidocaine whether the after associated Removal FEV1 1.93+/- bronchoscopy spray, 1% lidocaine changes in with fibreoptic 0.78,5.5+/-16.8,81.9+/- solution,PFTs in sitting pulmonary function bronchoscopy 21.7,87.0+/-22.6 FEF25-75 position (pre) and supine could account for transnasally 1.74+/-1.51,84.6+/- (during bronch) the decrease in 20.6,89.1+/-34.2,81.9+/- Pa02 35.4 FRC 2.82+/- 1.3,116.9+/-21.1, - ,100.1+/-15.1 VC 2.89+/- 0.9, 87.7+/-9.6, 82.1+/- 14.8,87.6+/-8.4 PaO2 70.4+/-12.5,98.0+/- BTS Guideline for diagnostic flexible bronchoscopy in Adults 5 15/7/2013 Evidence Tables for Complications and Specific conditions 7 of 109 12.8,89.7+/-18.9,90.2+/- 9.9 Dweik, R. Analysis of the 1996 CHEST 825-8 Qualitative _ Yes N=20 14M 6F mean age 63.8 Safety of FOB after None Till Complications No procedure was Not Bronchoscopy within 30 days A.Mehta, A. safety of research All had MIs within recent MI discharge terminated prematurely 5 known of AMI appears safe in the C.Meeker, bronchoscopy 30days of FOB. 8CABG or death deaths – 1 death 4 hrs post absence of active ischaemia D. after recent 2PTCA. Mean 11.7days procedure (active ischaemia Not in modern era, antiplatelet P.Arroliga, acute between AMI and FOB. known) , 4 deaths 6-15 agents. A. C. myocardial 14 performed in ICU 6 days post procedure (from infarction bronch 1 theatre. 14/21 VF, ARDS) No reported new mechanically ventilated. ischaemic events or Indication 10 pulmonary arrhythmia in the 24hr post infiltrates’; 6haemop; procedure 4atelect; bronchopleural fistula 1. 21 examinations; 12 BAL; 2TBB 3EBB 4Brushings. Schiffman, Arterial oxygen 1982 Journal of the 723-6 Qualitative _ No N=55 (5 dropouts, Consecutive patients Effect of arterial None Not stated ECG, SaO2, GpA GpB Initial O2 sat Not P. saturation and Medical research n=50) Transoral approach saturation on pH, pO2 and 93.4+/-3.0 95.7+/-2.7 reported L.Westlake, cardiac rhythm Society of Group A (no cardiac rhythm pCO2 Lowest O2 sat 88.0+/-4.0 R. E.Fourre, during transoral New Jersey supplemental oxygen, 94.0 +/-2.7 Sinus J. fiberoptic n=38) Group B tachycardia 55% 58% A.Leonard, bronchoscopy (supplemental oxygen, Sinus bradycardia 5% 8% E. T. n=12) Age GpA 50.9+/- VEs 8% 8% Atrial Ectopics 16.8 vs. GpB 53.4 +/- 5% 8% No p-values 18.5 p=ns Haematocrit provided GpA 38.4 +/-6.8% vs. GpB 35.4+/-8.7% No history coronary ischaemia or infarction, in sinus rhythm Performed with IM atropine, meperidine and topical cocaine via ET tube (not GA) Cole, Bronchoalveolar 1980 British Journal 273-8 Qualitative _ Yes N=120 N=6 (recurrent infection Effect of BAL on None For FOB Complication Mean baseline paO2 Not P.Turton, lavage for the of Diseases of research 1, IPF 2, Ca 3) n=30 gas exchange, only rate (11.2kPa) fell following known C.Lanyon, preparation of the Chest (not reported, patient acceptability and lavage by a mean of 3.0kPa H.Collins, J. free lung cells: acceptability cohort) morbidity Affect on to 8.2kPa, and remained technique and N=42 (not reported, pulmonary gas low 120 minutes post complications morbidity cohort) exchange 6 procedure. Mean PaCo2 did Omnopon and atropine patients only not change significantly premed Patients Morbidity Patient during and following lavage attending clinic for acceptability 30 Mean acceptability score chronic pulmonary patients only Cell was 5.3 [as expected]. Only infections The procedure yields 6.7% found the experience was considered to be unacceptable Respiratory contraindicated under distress 3/120 (2.5%) the following procedure terminated circumstances: 1. prematurely 2.5% pallor, 'Respiratory risk', LOC, bradycardia and defined as: a. Severe hypotension (vasovagal) ventilatory defect (FEV1 8/42 (19%) patients fever, < 1.0 liters). b. 6 (14%)with radiographic Hypoxaemia at rest shadowing (Pao~ < 70 mmHg = 9.3 kPa). 2. 'Cardiac risk', defined as: a. Myocardial infarction within the previous six months. b. Unstable angina pectoris. c. Left or right ventricular failure. Cordasco, Bronchoscopical 1991 CHEST 1141-7 Qualitative _ Yes 6,969 FOBs and Retrospective cases to better define the None Not stated Bleeding rate % Not Degree of bleeding related to E. M., ly induced research 3,096 identified according to patient population known type of Biopsy performed Jr.Mehta, A. bleeding. A bronchoscopically presence of bleeding and most prone to TBB>EBBx FOB low0.5% high C.Ahmad, summary of guided biopsies were notes reviewed to better bleeding, factors 1.3% yearly FOB/TBB low 1% M. nine years' performed from 1981 define the patient predisposing to this high 2.8% NO DEATHS NO Cleveland clinic to 1989. population most prone to complication and COMMON UNDERLYING experience and bleeding, factors management of DISEASE OR CONDITION review of the predisposing to this bronchoscopically PREDISPOSED TO BLEEDING. BTS Guideline for diagnostic flexible bronchoscopy in Adults 6 15/7/2013 Evidence Tables for Complications and Specific conditions 8 of 109 literature complication and induced Low incidence of haemorrhage management of hemorrhage, and low mortality. Screen for bronchoscopically coagulation disorders and Rx induced hemorrhage, with platelet>50,000 Immunosuppressed high risk as are Ca. Nayci, Bronchoscopy is 2008 CRITICAL 2517- Qualitative + Yes N=47 32M 15F. Age 56.2+/- Does Fibreoptic None 3 days Superior Fever (T>37.5C) in 19.1% Not FOB is associated with AliAtis, associated with CARE 22 research 12(27-70). 4(8.5%) bronchoscopy mesenteric within 24 hours, resolved reported decreased mesenteric blood SibelDuce, decreased MEDICINE smokers. Final diagnosis cause mesenteric artery Doppler within 3 days Bacteria flow which may put patient at Meltem mesenteric after FOB Lung cancer, n ischaemia and sonography, detected in blood cultures risk of mesenteric ischaemia NassBayindi arterial flow (%) 34 (72.3) Metastatic bacterial oxidative in 10.6% 60% of isolates and bacterial translocation. r, cancer, n (%) 3 (6.3) translocation? stress, were gram negative Hypoxia correlates with this SuzanTamer Tuberculosis, n (%) 2 antioxidant organisms bacteraemia was reduction , (4.3) Idiopathic status, rarely associated with fever LuluferOztur interstitial pneumonia, n arterial blood PaO2 decreased compared k, Candan (%) 3 (6.3) Others, n gas analysis, with Vaseline by 21.8% +/- (%) 5 (10.6) excluded blood cultures 1.5%. PaCO2, pH and from the study for the pre- HCO3 did not change following reasons: body bonchoscopy compared to baseline temperature and post- Doppler flow volume (FV) _37.3°C,radiologic bronchoscopy decreased by 38.8+/- evidence of pneumonic (1hr, 4hr, 14.9% of baseline , despite consolidation, positive 24hr) normal arterial BP. FV hepatitis B virus, decreased by <50% in hepatitis C virus, human 31.2% of patients, 50-59% immunodeficiency virus in 21.2%, 60-69% in 8.5% findings, use of and >70% in 2.1% Markers immunosuppressive of oxidative stress agents, corticosteroids (neutrophil activation and and antibiotics (including lipid peroxidation) antituberculosis increased and reached a chemotherapy), unstable peak at 1 hr post circulation, mechanical bronchoscopy (p=0.0001) ventilation, discharge or and remained significantly surgical/ diagnostic elevated to 4 hours procedures within 24 hrs (p=0.037). Antioxidant of FOB. status decreased (glutathione and catalase levels) in the first hour (p=0.0001) remaining low at 4 hours (p=0.0001) and 24 hours (p=0.003). There was a positive correlation between SMA FV and change in PaO2 (r=0.71, p=0.0001) Bj,x00F,rtuf Bronchoscopy 1998 EUROPEAN 1025-7 Qualitative _ Yes 51 patients 104 TBB 63F 41M Mean age 50, Bleeding volume 1) to quantify During Bleeding Mean bleeding volume 7+/- Congress No correlation between t, with RESPIRATORY research range 25-78 Consecutive prospectively FOB volume, PT, 10ml (range 0-61ml) Eight Chairman coagulation tests and the O.Brosstad, transbronchial JOURNAL TBBs Single lung the bleeding APTT, patients clinically significant s Award likelihood of bleeding following F.Boe, J. biopsies: transplantation 24 associated bleeding time, bleeding (>20ml) 7.7% ERS TBB. This indicates that measurement Bilateral lung with platelet count (22-61ml) No difference in normal coagulation test results of bleeding transplantation 3 Heart– bronchoscopy bleeding volume between do not guarantee that bleeding volume and lung transplantation 2 and TBB; 2) transplant and non- will not occur. As withKozak evaluation of Sarcoidosis 7 Fibrosing to evaluate transplant patients [0- ppr. Bleeding associated with the predictive alveolitis 6 the capacity 61ml] vs. [0-44ml] No TBB usually minimal <20ml. value of Carcinomatosis 2 of coagulation coagulation test can predict Although probably coagulation Lymphangioleiomyomato tests such as bleeding risk. None – underestimated due to tests sis 2 Fibrosis due to bleeding time, serious or life threatening haemorrahge into lung; radiation therapy or platelet count, (no hypotension, coughing up loss in suction nitrofurantoin 2 prothrombin intubation, transfusion) No system etc. Definition of Uncertain diagnosis 3 All time (PT) and correlation between significant bleeding is variable. patients had platelet, activated bleeding time and volume Life threatening bleeding after bleeding time PT APTT. partial TBB is rare None had renal liver thromboplasti disease bleeding n time (aPTT) tendency or to predict anticoagulation. clinically significant bleeding; and 3) to compare bleeding volume in TBB performed in patients with and without BTS Guideline for diagnostic flexible bronchoscopy in Adults 7 15/7/2013 Evidence Tables for Complications and Specific conditions 9 of 109 lung transplants. Alamoudi, Bronchoscopy, 2000 SAUDI 1043-7 Qualitative _ Yes 160 consecutive Consecutive FOBs over 3 Complication rate None Until Complication Numbers and percentage Unknown To use as reference for FOB O. S.Attar, indications, MEDICAL research FOBs. 36 excluded years in Western Saudi of FOB Discharge rate safety. S. safety and JOURNAL due to insufficient Arabian Teaching - no time M.Ghabrah, complications data. 124 Hospital (60 FOBs/year). frame T. 69% male Mean age given M.Kassimi, 49.9+/-17.7 45%Saudis M. A. 14% current smokers 17% Ex-smokers 57% No comorbidities 18.5% COPD 10.5% Diabetes Katz, A. Cardiac 1981 ARCHIVES OF 603-6 Qualitative _ Yes 50 53 +/- 18 years (mean Cardiac rhythm None FOB Cardiac % Grant AE/VE preprocedure 12% S.Michelson arrhythmias. INTERNAL research +/- SD rhythm and 820, AE/VE during or post , E. Frequency MEDICINE saturations Division procedure 80% (p<0.001) L.Stawicki, during of Major cardiac arrhythmia J.Holford, F. fiberoptic Chronic (atrial: 5 or more ectopics/ D. bronchoscopy Diseases, SVT, or ventricular: 5 or more and correlation Universit VE, multiform ectopic beats, with hypoxemia y of couplets or VT) 4% pre- Pennsylv procedure, 40% during or post ania procedure p<0.001 10% ventricular ectopics (inc 1 couplets and 1 nonsustained VT) vs. 1 patient pre- bronchoscopy, p=0.004 Atrial arrhythmias 32% (1 with PAF, 1 with PAT) vs. 1 patient pre- bronchoscopy, p=0.001 Atrial arrhythmias occur at widely differing stages of the procedure, ventricular arrhythmias mainly on passage through vocal cords Arterial oxygen saturation remained below prebronchoscopy levels post procedure for 1hr or more in 68%, 2hrs 58%, >3hrs 30%. Maximum ventricular arrhythmia correlated with minimum oxygen saturation, p<0.001. No significant association for atrial arrhythmias. No association with length of procedure, amount topical anaesthesia or medical history Davies, Cardiovascular 1997 EUROPEAN 695-8 Qualitative _ Yes 45 unselected 45 unselected pat(26M The purpose of this None Duration Change in HR Statistical comparisons Not CARDIOVASC STRESS ESP L.Mister, consequences RESPIRATORY research 19F). Median age 65(17- study was to of FOB BP and ECG were performed with known HYPERTENSION COMMON AND R.Spence, of fibreoptic JOURNAL 81). Mean FEV1 investigate the nonparametric techniques CAN CONTRIBUTE TO CARD D. bronchoscopy 78%(28-122) mean cardiovascular using Wilcoxon or Kruskal CHANGES ESP ELDERLY AND P.Calverley, smoking duration 43(0- consequences of Wallis methods via the THOSE W CVD. The magnitude P. M.Earis, 155) pack yrs. Indication FOB, to determine Microstat 1 package. A p- of change could not be J. 50% haemoptysis; 32% whether they were value of less than 0.05 was predicted from the resting E.Pearson, shadowing on CXR 18% confined to patients considered significant. FEV1, baseline Sa,O2, ECG or M. G. cough sob. 4 non with a previous cuff blood pressure at the smokers 21ex. history of cardiac onset of the procedure. In disease, and most patients, there were no whether they could ECG abnormalities observed be predicted and during these hypertensive observed by episodes but multichannel routine screening recordings did show that 21% and monitoring of patients over 60 yrs of age methods. developed potentially serious, albeit transient, cardiac ischaemic events/rhythm disturbances. 6 of the 7 (86%) patients developing cardiac stress in this study, there was no history of ischaemic heart disease, and in 5 of the 7 BTS Guideline for diagnostic flexible bronchoscopy in Adults 8 15/7/2013 Evidence Tables for Complications and Specific conditions 10 of 109 (71%) resting ECGs were normal. Yildiz, Changes in 2002 CHEST 1007-8 Qualitative _ Indet N=44 33 Males, mean age changes in oxygen between not SaO2/ ABG No difference in SaO2 Not PinarOzg,x0 oxygen research ermi 51+/-17 Transnasal, low saturation during pO2and SaO2 recorded before and values between ABG and recorded 0Fc,l, saturation in nable to mod IM midazolam bronchoscopy after FOB oximetry before and after AkifYilmaz, patients Teaching hospital Age, gender, SaO2 significantly Veysel undergoing primary decreased after FOB fiberoptic disease, (96.5+/-1.0 to 91.6+/-3.6, bronchoscopy presence of p<0.001) and desaturation effusion/ <90% was detected in 50% atelectasis, duration and basal SaO2 Hue, S. H. Complications 1987 KOREAN 209-13 Qualitative _ Yes N=68 All males Age 41-50 4 Adverse events None FOB Adverse % Unknown in JOURNAL OF research 51-60 24 61-70 30 71- events transbronchial INTERNAL 80 9 <80 1 Mean 62 32 lung biopsy MEDICINE Caucasian 31 Black 5 other pack year History 0-10 4 11-20 21 21-30 38 >30 5 Lukomsky, Complications 1981 CHEST 316-21 Qualitative _ Yes N=2143 patients Not fully reported Mean Complications of Major vs. 24hrs Minor, major Complications overall in Not Complications divided as G. of research (1146 flexible and Age 53 Tumours 38%, bronchoscopy minor or fatal 5.4% Minor complications recorded related to anaesthesia or I.Ovchinnik bronchoscopy: 3449 rigid nonspecific inflammatory complications complications (5.1%) - anaesthetic bronchoscopic procedure. ov, A. comparison of procedures) 37%, asthma 4%, related (n=6) - Divided as major or minor. A.Bilal, A. rigid pleural 8%, Haemoptysis laryngospasm (n=3) - nasal FOB: 62 (5.4%) complications. bronchoscopy 5%, others 8% haemorrhage (n=4) - 59 (5.1%) minor. 25 (2.2%) under general tachycardia (n=13) - related to anaesthesia(dizzy, anesthesia and laryngitis (n=1) - nausea, tachycardia 13; flexible hypoxaemia (n=1) - vomiting,hypotonia 3; fiberoptic haemorrhage after biopsy psychomotor excitation 2; bronchoscopy (n=5) - bronchospasm after faint 1; laryngospasm 1; under topical anaesthesia (n=12) Major bronchospasm 1 34 (2.9%) anesthesia complications 0.3% - due to FOB. major 0.3% RB: exacerbation of asthma, 173 (5%) complications. 125 pneumonia, drug reaction 3.6% minor. 63 1.8% related to anaesthesia. major 48 1.4% 16 0.46% related anaesthesia Pue, C. Complications 1995 CHEST 430-2 Qualitative _ Indet N=4273 Not reported Tertiary Indications and Indication, 4 hours Diagnostic Fatalities 0% Major Not A.Pacht, E. of fiberoptic research ermi care university hospital complications of and severity post FOB procedures complications 0.53% - reported R. bronchoscopy nable fibreoptic of (suspected pneumotnorax 0.16% (TBB at a university bronchoscopy complication infection 52%, 4%) - haemorrhage >50ml hospital according to abnormal CXR 0.12% (TBB 2.8%) - diagnostic or 17%, respiratory failure 0.2% therapeutic haemoptysis (TBB 0%) Minor bronchoscopy 4%, ILD 3%, complications 0.79% staging 2%), (laryngospasm 0.6%, therapeutic vomiting 0.1%, vasovagal procedures 0.05%, epistaxis 0.02%, 10.4%, bronchospasm 0.02%) research 3.3% BAL in 2493, TBB in 173 Prickett, Complications 1984 Alabama 25-Jul Qualitative _ No N=122 Age 16-73 Pulmonary complication rate: None Not Major and Mortality 1/122 =0.8% Not C.LeGrand, of fiberoptic Medicine research infiltrate n=50, major and minor reported minor Major complication 3/122 reported P. bronchoscopy in haemoptysis n=26, Major complication: complications, (2.5%) - seizure n=1, a community mass/nodule n=18, haemoptysis>50cc; mortality pneumonia n=1, hospital atelectasis n=10, pneumothorax haemoptysis>50ml n=1, therapeutic n=6, hilar require ICD; pneumothorax with ICD adenopathy n=3, pleural pneumonia and n=0 Minor complication effusion n=3, cough seizure. Minor: 15/122 (12.3%) - fever n=2, misc n=4 fever resolving in n=14, pneumothorax 48hrs; without ICD n=1 pneumothorax not require drain. BTS Guideline for diagnostic flexible bronchoscopy in Adults 9 15/7/2013 Evidence Tables for Complications and Specific conditions