• Consider using the categories from the consensus statement put forth by an international working group published in CHEST (see below).¹

• Estimations of blood loss can be imprecise and there is no consensus on what constitutes “massive bleeding” by volume.^1,2,3

• Standardizing language around bleeding complications will help better communicate this important risk and complication for better tracking patient-centered outcomes. As bronchoscopy technology, techniques, and applications continue to evolve, it will also allow for more consistent capture of important safety outcomes in bronchoscopy research.

1. Folch EE, Mahajan AK, Oberg CL, et al. Standardized Definitions of Bleeding After Transbronchial Lung Biopsy: A Delphi Consensus Statement From the Nashville Working Group. Chest. 2020;158(1):393-400. doi:10.1016/j.chest.2020.01.036

2. Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013;68 Suppl 1:i1-i44. doi:10.1136/thoraxjnl-2013-203618

Ibrahim WH. Massive haemoptysis: the definition should be revised. Eur Respir J. 2008;32(4):1131-1132. doi:10.1183/09031936.00080108

• Reported bleeding rates range from 0.26 to 5%, with most events being self-limited or requiring local vasoactive substances (grade 1 or 2).^1,2

• Larger volume bleeding (100 mL or more) is generally uncommon (0.037%).³

• Mortality from bleeding complications is extremely rare (0.004%) but therapeutic bronchoscopy is associated with a higher mortality due to bleeding (0.012%) compared to diagnostic bronchoscopy (0.003%)³

• Bleeding rates vary widely based on lesion/target characteristics, procedural techniques/characteristics, patient factors and comorbidities, and antiplatelet or anticoagulant medications.^1,2

• Reviewing the above characteristics for modifiable and non-modifiable factors is essential before elective or urgent bronchoscopy.

1. Bernasconi M, Koegelenberg CFN, Koutsokera A, et al. Iatrogenic bleeding during flexible bronchoscopy: risk factors, prophylactic measures and management. ERJ Open Res. 2017;3(2):00084-2016. Published 2017 Jun 21. doi:10.1183/23120541.00084-2016

2. Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013;68 Suppl 1:i1-i44. doi:10.1136/thoraxjnl-2013-203618

3. Zhou GW, Zhang W, Dong YC, et al. Flexible bronchoscopy-induced massive bleeding: A 12-year multicentre retrospective cohort study. Respirology. 2016;21(5):927-931. doi:10.1111/resp.12784

MEDICATION HOLD TIMES BEFORE ADVANCED DIAGNOSTIC AND THERAPEUTIC BRONCHOSCOPY^1,2,3

Footnotes:

^! Multiple studies^11,12,13,14 have shown that EBUS-TBNA can be performed safely on patients taking clopidogrel at the time of the procedure.  

• Prasugrel and ticagrelor have a more rapid onset of action than clopidogrel and should be resumed with caution based on post-procedure bleeding risk.  

^# Hold times depend on patient renal function and bleeding risk of procedure.  Shorter hold times for normal renal function (GFR >60) and/or low risk procedure (EBUS-TBNA), longer for impaired renal function and/or high risk procedure (Transbronchial biopsy)

^$ Goal INR <1.5 on the day of procedure. Checking INR on the day of the procedure after a 5-day hold is controversial but consider in certain patient groups such as those with a higher goal INR and the elderly 

^% Consider a longer duration hold for patients with renal dysfunction

^& A shorter hold duration allowable for lower bleeding risk procedures and longer hold for higher bleeding risk procedures

References:

¹ Pathak V, Allender JE, and Grant MW.  Management of anticoagulant and antiplatelet therapy in patients undergoing interventional pulmonary procedures. EurRespirRev. 2017; 26(145):170020; doi: https://doi.org/10.1183/16000617.0020-2017

² Youness HA, Keddissi J, Berim I, and Awab A.  Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy.  J Thorac Dis. 2017 Sep;9(Suppl 10):S1022-S1033; doi: 10.21037/jtd.2017.05.45

³ Douketis JD, Spyropoulos AC, Murad, MH, et al.  Perioperative management of antithrombotic therapy: An American College of Chest Physicians clinical practice guideline. Chest. 2022;162 (5), E207-E243; doi: 10.1016/j.chest.2022.07.025

⁴ Herth FJF, Becker HD, and Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy.  Chest. 2002; 122(4), 1461-1464; doi: 10.1378/chest.122.4.1461

⁵ Ernst A, Eberhardt R, Wahidi M, et al. Effect of routine clopidogrel use on bleeding complications after transbronchial biopsy in humans. Chest. 2006;129(3): 734-737; doi: 10.1378/chest.129.3.734

⁶ Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013 Aug:68:(suppl 1):i1-i44; doi: 10.1136/thoraxjnl-2013-203618

⁷ Douketis JD, Spyrolpoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb; 141 (2 Suppl):e326S-e350S; doi: 10.1378/chest.11-2298

⁸ Baron TH, Kamath PS, and McBane RD. Management of antithrombotic therapy in patients undergoing invasive procedures. NEJM. 2013; 368(22):2113-2124; doi: 10.1056/NEJMra1206531

⁹ Healy JS, Eikelboom J, Douketis J, et al. Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the randomized evaluation of long-term anticoagulation therapy(RE-LY) randomized trial. Circulation. 2012;126(3):343-348; Published 2012, Jul 17. doi: 10.1161/CIRCULATIONAHA.111.090464

¹⁰ Schulman S, Carrier M, Lee AYY, et al. Perioperative management of dabigatran: a prospective cohort study. Circulation. 2015 Jul 21:132(3):167-173. doi:10.1161/CIRCULATIONAHA.115.015688

¹¹ Swiatek K, Guthrie R, Elliott J, et al. Antiplatelet therapy in patients undergoing ebus-tbna: risk vs benefit. Chest. 2016; 150(4): 1017A; http://dx.doi.org/10.1016/j.chest.2016.08.1123

¹² Stather DR, MacEachern P, Chee A, and Tremblay A. Safety of endobronchial ultrasound-guided transbronchial needle aspiration for patients taking clopidogrel: a report of 12 consecutive cases. Respiration. 2012; 83(4):330-334; doi: 10.1159/000335254Martin RT Am Thoracic Soc 2014 A2503-A

¹³ Martin RT, Parks, C, Sharaf C, et al. Safety of ebus/tbna in patients with mediastinal and hilar adenopathy receiving clopidogrel. B22 The Golden Gun? Advances in interventional bronchoscopy. Am Thoracic Soc. 2014: A2503-A.

¹⁴ Meena N, Abouzgheib W, Patolia S, et al. EBUS-TBNA and EUS-FNA: risk assessment for patients receiving clopidogrel. J Bronchology Interv Pulmonol. 2016; 23(4):303-307; doi: 10.1097/LBR.0000000000000312

• Although it depends on the type of intervention that is performed bronchoscopically as well as its complexity, patients with known coagulation disorders, use of anticoagulant or antiplatelet drugs, low platelet counts of  <50,000/mm3, uremia, and immunocompromisation are associated with increased risk of bleeding during bronchoscopy.¹

• Critical illness alone is not associated with an increased risk of bleeding.²

• Underlying lung disease: patients with known interstitial lung disease may have a moderate (non-severe) increased risk of bleeding.³

• A meta-analysis of bleeding complications in patients undergoing transbronchial lung biopsy did not show a difference in bleeding rate based upon pulmonary hypertension (PH) alone.⁴ There are, however, other safety concerns to consider such as risk of undergoing general anesthesia or positive pressure ventilation for patients with PH.

1. Li C, Li Y, Jin F, Bo L. Expert Rev Respir Med. 2022 Nov-Dec;16(11-12):1257-1262. doi: 10.1080/17476348.2022.2159382. Epub 2022 Dec 18.

2. Ghiani A, Neurohr C. BMC Pulm Med. 2021 Jan 7;21(1):15. doi: 10.1186/s12890-020-01357-7.

3. Hetzel J, Eberhardt R, Petermann C, Gesierich W, Darwiche K, Hagmeyer L, Muche R, Kreuter M, Lewis R, Ehab A, Boeckeler M, Haentschel M. Respir Res. 2019 Jul 5;20(1):140. doi: 10.1186/s12931-019-1091-1.

Ali MS, Sethi J, Ghori UK, De Cardenas J, Wayne MT, Maldonado F. Safety of Transbronchial Biopsies in Patients with Pulmonary Hypertension: Systematic Review and Meta-Analysis. Ann Am Thorac Soc. 2023;20(6):898-905. doi:10.1513/AnnalsATS.202211-965OC

Overall effectiveness is difficult to gauge due to data limitations and treatment generalization related to de novo or iatrogenic hemoptysis.  The information below is a compilation of personal experience, discussion with Pulmonary colleagues, and literature review.  Amount delivered may be variable dependent upon location in the airway.  References are available for your personal review.

Items to consider up to more advanced endotracheal/bronchial therapies:

1. Bronchoscope suction/tamponade: Up to 3-5 minutes with at least 1 minute airway monitoring prior to withdrawal of bronchoscope.
2. Endobronchial instillation therapies: USE A SLIP TIP SYRINGE

1. Ice-cold saline (4℃) is most commonly used
   1. No consensus on instilled volume (suggestion: 20cc syringe filled with 0.9% NaCl 3-10cc aliquots delivered as felt necessary)

Advantage is likely related to accessibility and clinician training/familiarity.

References:

1. Alfaiate A, Clerigo V, Noivo D, et al. Pharmacological approach to iatrogenic bleeding during bronchoscopy: what do we know so far and where do we go from here? J Bras Pneumol. 2023; 49(2): e20220195; https://dx.doi.org/10.35616/1806-3756/e20220195
2. Bernasconi M, Koegelenberg CFN, Koutsokera A, et al. Iatrogenic bleeding during flexible bronchoscopy: risk factors, prophylactic measures and management. ERJ Open Res. 2017; 3: 00084-2016; https://doi.org/10.1183/23120541.00084-2016
3. Cao A, Silverman J, Zahtz G, and Smith LP. Otolaryngology Case Reports 2022; 23. https://doi.org/10.1016/j.xocr.2022.100409
4. Lee J, Rhee CK, Kim SC, Kim YK, et al. Medicine (Baltimore) 2020 May15; 99(20): e20284. doi:10.1097/MD0000000000020284
5. Prey B, Francis A, Williams, J, and Krishnadasan B.  Evaluation and treatment of massive hemoptysis. Surg Clin N Am. 2022; 102: 465-481; https://doi.org/10.1016/j.suc.2021.11.002
6. Zhang P, Zheng J, Shan X, and Zhou B. Eur J Clin Pharmacol. 2024 Nov 30; 81(2): 237-246. doi:10.1007/s00228-024-03784-5

Bronchoscopic Interventions in the Management of Hemoptysis

Adapted from: Davidson K, and Shojaee, S. Managing Massive Hemoptysis. Chest. 2020;157(1): 77-88; https://doi.org/10.1016/j.chest.2019.07.012