Complications of bronchoscopy and measures for their prevention

According to most authors, bronchoscopy poses minimal risk to the patient. The largest summary statistics, summarizing 24,521 bronchoscopies, indicate a small number of complications. The authors divided all complications into three groups: mild - 68 cases (0.2%), severe - 22 cases (0.08%), requiring resuscitation, and fatal - 3 cases (0.01%).

According to G.I. Lukomsky et al. (1982), 82 complications (5.41%) were noted in 1146 bronchofibroscopy procedures, however, a minimal number of severe complications were observed (3 cases) and there were no fatal outcomes.

S. Kitamura (1990) presented the results of a survey of leading specialists from 495 large Japanese hospitals. Over one year, 47,744 bronchofibroscopy procedures were performed. Complications were noted in 1,381 patients (0.49%). The main group of complications consisted of complications associated with intrabronchial tumor biopsy and transbronchial lung biopsy (32%). The nature of severe complications was as follows: 611 cases of pneumothorax (0.219%), 169 cases of lidocaine intoxication (0.061%), 137 cases of bleeding (over 300 ml) after biopsy (0.049%), 125 cases of fever (0.045%), 57 cases of respiratory failure (0.020%), 53 cases of extrasystole (0.019%), 41 cases of shock due to lidocaine (0.015%), 39 cases of decreased blood pressure (0.014%), 20 cases of pneumonia (0.007%), 16 cases of heart failure (0.006%), 12 cases of laryngospasm, 7 cases of myocardial infarction (0.003%) and 34 deaths (0.012%).

The causes of death were: bleeding after taking a biopsy from a tumor (13 cases), pneumothorax after transbronchial lung biopsy (9 cases), after endoscopic laser surgery (4 cases), shock to lidocaine (2 cases), intubation with a bronchoscope (1 case), respiratory failure associated with performing sanation bronchoscopy (3 cases), cause unknown (2 cases).

Of the 34 patients, 20 died immediately after bronchoscopy, 5 people died 24 hours after the examination, and 4 people died a week after bronchoscopy.

Complications that arise during bronchoscopy can be divided into two groups:

1. Complications due to premedication and local anesthesia.
2. Complications associated with bronchoscopy and endobronchial manipulations. A mild increase in heart rate and a moderate increase in blood pressure are common reactions to premedication and local anesthesia during bronchofibroscopy.

Complications due to premedication and local anesthesia

• Toxic effects of local anesthetics (in case of overdose).

In case of lidocaine overdose, clinical symptoms are caused by the toxic effect of the anesthetic on the vasomotor center. A spasm of the cerebral vessels occurs, which is manifested by weakness, nausea, dizziness, pale skin, cold sweat, and a rapid pulse of weak filling.

If irritation of the cerebral cortex occurs due to the toxic effect of the anesthetic, the patient experiences agitation, convulsions, and loss of consciousness.

At the slightest sign of overdose of local anesthetics, it is necessary to immediately stop the anesthesia and examination, wash the mucous membranes with a solution of sodium bicarbonate or isotonic solution of sodium chloride, inject 2 ml of a 10% solution of sodium caffeine benzoate under the skin, lay the patient with raised lower limbs, and give humidified oxygen. Other measures are carried out depending on the picture of intoxication.

In order to stimulate the vasomotor and respiratory centers, intravenous administration of respiratory analeptics is indicated: cordiamine - 2 ml, bemegride 0.5% - 2 ml.

In case of a sharp decrease in blood pressure, it is necessary to slowly administer 0.1-0.3 ml of adrenaline diluted in 10 ml of isotonic sodium chloride solution or 1 ml of 5% ephedrine solution (preferably diluted in 10 ml of isotonic sodium chloride solution) intravenously. 400 ml of polyglucin with the addition of 30-125 mg of prednisolone are administered intravenously by jet stream.

In case of cardiac arrest, closed massage is performed, 1 ml of adrenaline with 10 ml of calcium chloride and hormones are administered intracardiacly, the patient is intubated and transferred to artificial ventilation.

In case of symptoms of cerebral cortex irritation, barbiturates, 90 mg of prednisolone, 10-20 mg of relanium are administered intravenously at one time. In severe cases, if the above measures are ineffective, the patient is intubated and transferred to artificial ventilation.

• An allergic reaction due to increased sensitivity (intolerance) to local anesthetic substances is anaphylactic shock.

It is necessary to immediately stop the examination, put the patient to bed, and establish inhalation of humidified oxygen. 400 ml of polyglucin are administered intravenously by jet stream, 1 ml of 0.1% adrenaline solution, antihistamines (suprastin 2 ml of 2% solution or diphenhydramine 2 ml of 1% solution, or tavegil 2 ml of 0.1% solution) are added to it. It is necessary to use corticosteroids - 90 mg of prednisolone or 120 mg of hydrocortisone acetate.

In case of bronchospasm, 10 ml of 2.4% solution of euphyllin per 10 ml of 40% glucose solution, calcium preparations (10 ml of calcium chloride or calcium gluconate), hormones, antihistamines, and adrenaline are administered intravenously.

In case of severe stridor breathing (laryngeal edema), a mixture of nitrous oxide with fluorothane and oxygen is inhaled through the anesthesia mask, and everything that is done for bronchospasm is also performed. If these measures are ineffective, it is necessary to administer relaxants and intubate the patient with continuation of all the indicated therapy. Constant monitoring of pulse, blood pressure, respiratory rate and ECG is necessary.

• Spastic vagal reactions with insufficient anesthesia of the respiratory tract mucosa - laryngospasm, bronchospasm, cardiac arrhythmia.

When performing bronchoscopy against the background of insufficient anesthesia of the mucous membrane of the respiratory tract, spastic vagal reactions develop as a result of irritation of the peripheral endings of the vagus nerve, especially in the area of reflexogenic zones (carina, spurs of the lobar and segmental bronchi), with the development of laryngo- and bronchospasm, as well as cardiac arrhythmia.

Laryngospasm usually develops when a bronchofibroscope is inserted through the glottis.

Causes of laryngospasm:

• introduction of cold anesthetics;
• insufficient anesthesia of the vocal folds;
• rough, forced insertion of an endoscope through the glottis;
• toxic effects of local anesthetics (in case of overdose).

Clinical manifestations of laryngospasm:

• inspiratory dyspnea;
• cyanosis;
• excitation.

In this case, it is necessary to remove the bronchoscope from the larynx, re-install its distal end above the glottis and inject an additional amount of anesthetic onto the vocal folds (if anesthesia is insufficient). As a rule, laryngospasm is quickly relieved. However, if shortness of breath increases and hypoxia increases after 1-2 minutes, the examination is stopped and the bronchoscope is removed. Bronchospasm develops when:

• inadequate anesthesia of reflexogenic zones;
• overdose of anesthetics (toxic effect of local anesthetics);
• intolerance to local anesthetics;
• introduction of cold solutions. Clinical manifestations of bronchospasm:
• expiratory dyspnea (prolonged exhalation);
• wheezing;
• cyanosis;
• excitation;
• tachycardia;
• hypertension.

If bronchospasm develops, it is necessary:

1. Stop the examination, lay the patient down and establish inhalation of humidified oxygen.
2. Give the patient two doses of a beta-stimulating bronchodilator to inhale (sympathomimetics: berotek, astmopent, alupent, salbutamol, berodual).
3. Intravenously administer 10 ml of a 2.4% solution of euphyllin in 10 ml of isotonic sodium chloride solution and 60 mg of prednisolone.

If asthmatic status develops, it is necessary to intubate the patient, transfer him to artificial ventilation and carry out resuscitation measures.

Cardiac arrhythmia is characterized by the appearance of group extrasystoles, bradycardia and other arrhythmias (of ventricular origin). In these cases, it is necessary to stop the examination, lay the patient down, do an ECG, call a cardiologist. At the same time, the patient should be given glucose with antiarrhythmic drugs (isoptin 5-10 ml, cardiac glycosides - strophanthin or corglycon 1 ml) intravenously.

In order to prevent complications arising against the background of vagal spastic reactions, it is necessary to:

1. It is essential to include atropine, which has a vagolytic effect, in the premedication.
2. Use warmed solutions.
3. Carefully perform anesthesia of the mucous membrane, especially reflexogenic zones, taking into account the optimal timing of the onset of anesthesia (exposure 1-2 minutes).
4. In patients with a tendency to bronchospasm, include in the premedication the intravenous administration of 10 ml of a 2.4% solution of euphyllin in 10 ml of isotonic sodium chloride solution, and immediately before the start of the study, give 1-2 doses of any aerosol that the patient uses to inhale.

To prevent complications caused by premedication and local anesthesia, the following rules must be followed:

• check individual sensitivity to anesthetic drugs: anamnestic data, sublingual test;
• measure out the dose of anesthetic in advance: the dose of lidocaine should not exceed 300 mg;
• If there is a history of lidocaine intolerance, bronchoscopy should be performed under general anesthesia;
• to reduce the absorption of the anesthetic, it is better to use the application (or installation) method of applying the anesthetic than the aerosol (inhalation, especially ultrasound) method, since the absorption of local anesthetic substances increases in the distal direction;
• Adequate premedication, a calm state of the patient, and the correct technique of anesthesia help to reduce the dose of anesthetic;
• To prevent the development of severe complications, it is necessary to carefully monitor the patient's condition during anesthesia and bronchoscopy, and immediately stop the examination at the first signs of a systemic reaction.

Complications caused by bronchofibroscopic and endobronchial manipulations

Complications caused by the direct performance of bronchoscopy and endobronchial manipulations include:

1. Hypoxic complications caused by mechanical obstruction of the airways as a result of the insertion of a bronchoscope and the resulting inadequate ventilation.
2. Bleeding.
3. Pneumothorax.
4. Perforation of the bronchial wall.
5. Feverish condition and exacerbation of the inflammatory process in the bronchi after bronchofibroscopy.
6. Bacteremia.

As a result of mechanical obstruction of the airways during the introduction of a bronchoscope, oxygen pressure decreases by 10-20 mm Hg, which leads to hypoxic disorders, which in patients with initial hypoxemia (oxygen pressure of 70 mm Hg) can reduce the partial pressure of oxygen in the blood to a critical value and cause myocardial hypoxia with increased sensitivity to circulating catecholamines.

Hypoxic disorders are especially dangerous when they develop in combination with complications such as laryngospasm and bronchospasm, with an overdose of local anesthetics, or against the background of spastic vagal reactions.

Myocardial hypoxia is extremely dangerous for patients with coronary heart disease, chronic obstructive bronchitis and bronchial asthma.

If a patient develops laryngospasm and bronchospasm, a set of measures described above is carried out.

If the patient has seizures, it is necessary to slowly administer barbiturates intravenously by drip (sodium thiopental or hexenal - up to 2 g of the drug in an isotonic solution of sodium chloride) over several hours; constantly perform oxygen inhalation and forced diuresis (drip administration of 4-5% soda solution 200-400 ml and euphyllin to increase diuresis); prescribe hormonal drugs to combat cerebral edema against the background of hypoxia.

To prevent hypoxic disorders, it is necessary to follow the following rules:

• Reduce, if possible, the examination time in patients with initial hypoxia (oxygen pressure less than 70 mm Hg).
• Perform thorough anesthesia.
• Provide continuous insufflation of humidified oxygen.

Nosebleeds occur when a bronchoscope is inserted transnasally. Bleeding complicates anesthesia, but the examination is not stopped. As a rule, special measures to stop bleeding should not be taken. The inserted bronchoscope obstructs the lumen of the nasal passage, which helps stop the bleeding. If bleeding continues after the bronchoscope is removed at the end of the examination, it is stopped with hydrogen peroxide.

To prevent nosebleeds, it is necessary to carefully insert the bronchoscope through the lower nasal passage, without damaging the mucous membrane of the nasal passage. If the latter is narrow, do not force the device through, but rather try to insert the endoscope through another nasal passage. If this attempt is also unsuccessful, the bronchoscope is inserted through the mouth.

Bleeding after taking a biopsy occurs in 1.3% of cases. Bleeding is a one-time release of more than 50 ml of blood into the lumen of the bronchial tree. The most severe bleeding occurs when taking a biopsy from a bronchial adenoma.

The tactics of the endoscopist depend on the source of bleeding and its intensity. If minor bleeding develops after taking a biopsy from a bronchial tumor, it is necessary to carefully aspirate the blood through the endoscope, wash the bronchus with an "ice" isotonic solution of sodium chloride. As hemostatic drugs, you can use a 5% solution of aminocaproic acid, local administration of adroxone, dicynone.

Adroxon (0.025% solution) is effective in capillary bleeding, characterized by increased permeability of the capillary walls. Adroxon does not work in massive bleeding, especially arterial. The drug does not cause an increase in blood pressure, does not affect cardiac activity and blood clotting.

Adroxon should be administered through a catheter inserted through the biopsy channel of the endoscope directly to the site of bleeding, after first diluting it in 1-2 ml of “ice-cold” isotonic sodium chloride solution.

Dicynone (12.5% solution) is effective in stopping capillary bleeding. The drug normalizes the permeability of the vascular wall, improves microcirculation, and has a hemostatic effect. The hemostatic effect is associated with an activating effect on the formation of thromboplastin. The drug does not affect prothrombin time, does not have hypercoagulation properties, and does not promote the formation of blood clots.

If massive bleeding develops, the endoscopist should take the following actions:

• it is necessary to remove the bronchoscope and place the patient on the side of the bleeding lung;
• if the patient has respiratory distress, intubation and aspiration of the contents of the trachea and bronchi through a wide catheter are indicated against the background of artificial ventilation of the lungs;
• it may be necessary to perform rigid bronchoscopy and tamponade of the bleeding site under visual control;
• If bleeding continues, surgery is indicated.

The main complication of transbronchial lung biopsy, as with direct biopsy, is bleeding. If bleeding occurs after transbronchial lung biopsy, the following measures are taken:

• perform thorough blood aspiration;
• the bronchus is washed with an “ice-cold” isotonic solution of sodium chloride, a 5% solution of aminocaproic acid;
• Adroxone and lidicinone are administered locally;
• The method of “jamming” the distal end of the bronchoscope at the mouth of the bronchus from which blood is flowing is used.

Bleeding may also occur during a puncture biopsy. If the needle during a puncture of the bifurcation lymph nodes is not strictly sagittal, it may penetrate the pulmonary artery, vein, left atrium and cause, in addition to bleeding, an air embolism. Short-term bleeding from the puncture site can be easily stopped.

To avoid bleeding during a biopsy, the following rules must be followed:

• Never take a biopsy from a bleeding lesion.
• Do not displace thrombi with biopsy forceps or the end of an endoscope.
• Do not take biopsies from vascular tumors.
• When taking a biopsy from an adenoma, it is necessary to select avascular areas.
• A biopsy cannot be performed if there are any disorders of the blood coagulation system.
• Caution should be exercised when performing transbronchial lung biopsy in patients receiving long-term corticosteroids and immunosuppressants.
• The risk of bleeding during a puncture biopsy is significantly reduced if small diameter needles are used.

Transbronchial lung biopsy may be complicated by pneumothorax. Pneumothorax is caused by damage to the visceral pleura when biopsy forceps are inserted too deeply. When complications develop, the patient experiences chest pain, difficulty breathing, shortness of breath, and cough.

In case of limited parietal pneumothorax (lung collapse by less than 1/3), rest and strict bed rest for 3-4 days are indicated. During this time, air is absorbed. If there is a significant amount of air in the pleural cavity, a puncture of the pleural cavity and suction of air are performed. In the presence of valvular pneumothorax and respiratory failure, mandatory drainage of the pleural cavity is required.

To prevent pneumothorax it is necessary:

1. Strict adherence to methodological features when performing transbronchial lung biopsy.
2. Mandatory two-projection control of the position of biopsy forceps, X-ray control after performing a biopsy.
3. Transbronchial lung biopsy should not be performed in patients with emphysema or polycystic lung disease.
4. Transbronchial lung biopsy should not be performed on both sides.

Perforation of the bronchial wall is a rare complication and may occur when removing sharp foreign bodies such as nails, pins, needles, wire.

It is necessary to study the radiographs in advance, which must be taken in direct and lateral projections. If perforation of the bronchial wall occurs during the removal of the foreign body, surgical treatment is indicated.

To prevent this complication, when removing sharp foreign bodies, it is necessary to protect the bronchial wall from the sharp end of the foreign body. To do this, press the distal end of the bronchoscope on the bronchial wall, moving it away from the sharp end of the foreign body. You can turn the blunt end of the foreign body so that the sharp end comes out of the mucous membrane.

After performing a bronchoscopy, the temperature may rise, the general condition may worsen, i.e., “resorptive fever” may develop as a response to endobronchial manipulations and absorption of decay products or an allergic reaction to solutions used in bronchial sanitation (antiseptics, mucolytics, antibiotics).

Clinical symptoms: deterioration of general condition, increased amount of sputum.

X-ray examination reveals focal or confluent infiltration of lung tissue.

Detoxification therapy and the use of antibacterial drugs are necessary.

Bacteremia is a severe complication that occurs as a result of damage to the bronchial mucosa during endobronchial manipulations in infected respiratory tract (especially in the presence of gram-negative microorganisms and Pseudomonas aeruginosa). Invasion of microflora from the respiratory tract into the blood occurs.

The clinical picture is characterized by a septic condition. Treatment is the same as for sepsis.

To prevent bacteremia, the bronchoscope and auxiliary instruments should be thoroughly disinfected and sterilized, and the bronchial tree should be manipulated atraumatically.

In addition to all the above measures, additional precautions must be taken to avoid complications, especially when performing bronchoscopy on an outpatient basis.

When determining indications for bronchoscopy, one should take into account the volume of expected diagnostic information and the risk of the study, which should not exceed the danger of the disease itself.

The risk of the examination is higher, the older the patient is. It is especially necessary to take into account the age factor when performing the examination in an outpatient setting, when the doctor does not have the opportunity to examine many functions of the body, which would allow an objective assessment of the patient's condition and the degree of risk of bronchoscopy.

Before the examination, the doctor should explain to the patient how to behave during the bronchoscopy. The main goal of the conversation is to establish contact with the patient, relieve his feeling of tension. It is necessary to reduce the waiting time for the upcoming examination.

In the presence of the patient, any extraneous conversations are excluded, especially information of a negative nature. Both during and after the bronchoscopy, there should be no display of emotion on the part of the endoscopist.

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