Complications of bronchoscopy and measures for their prevention

According to most authors, bronchoscopy represents a minimal risk to the patient. The largest summary statistics, generalizing 24 521 bronchoscopy, indicates a small number of complications. All complications were divided into three groups: lungs - 68 cases (0.2%), severe cases - 22 cases (0.08%) requiring resuscitation, and fatal - 3 cases (0.01%).

According to G.I. Lukomsky et al. (1982), there were 82 complications (5.41%) for 1146 bronchoconsta, but a minimal number of severe complications (3 cases) and no lethal outcomes were observed.

S. Kitamura (1990) presented the results of a survey of leading specialists in 495 large hospitals in Japan. In one year, 47,744 bronchocarboscopies were performed. Complications were noted in 1,381 patients (0.49%). The main group of complications were 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 intoxication to lidocaine (0.061%), 137 cases of bleeding (over 300 ml) after biopsy (0.049%), 1 2 5 cases of fever (0.045%), 57 cases of respiratory insufficiency (0.020%), 53 cases of extrasystole (0.019%), 41 cases of shock on lidocaine (0.015%), 39 cases of blood pressure lowering (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 biopsy from the tumor (13 cases), pneumothorax after transbronchial lung biopsy (9 cases), after endoscopic laser surgery (4 cases), shock on lidocaine (2 cases), intubation with bronchoscope (1 case) , respiratory failure associated with performing sanation bronchoscopy (3 cases), the cause is unknown (2 cases).

Out of 34 patients, 20 patients died immediately after bronchoscopy, 5 people - 24 hours after the study and 4 people - one week after bronchoscopy.

Complications arising during bronchoscopy can be divided into two groups:

1. Complications caused by premedication and local anesthesia.
2. Complications due to bronchoscopy and endobronchial manipulation. The usual response to premedication and local anesthesia with bronchoconstriction is a slight increase in heart rate and a moderate increase in blood pressure.

Complications due to premedication and local anesthesia

• Toxic effect of local anesthetics (overdose).

With an overdose of lidocaine, clinical symptoms are due to the toxic effect of anesthetic on the vasomotor center. There is a spasm of cerebral vessels, which is manifested by weakness, nausea, dizziness, pale skin, cold sweat, frequent pulse of weak filling.

If there is irritation of the cerebral cortex due to the toxic effect of the anesthetic, the patient develops excitement, convulsions, loss of consciousness.

At the slightest signs of an overdosage of local anesthetic substances, anesthesia and examination should immediately stop, rinse the mucous membranes with sodium bicarbonate solution or isotonic sodium chloride solution, inject 2 ml of 10% caffeine-benzoate solution under the skin, lay the patient with raised lower limbs, and give moistened oxygen. The remaining activities are carried out depending on the pattern of intoxication.

In order to excite the vasomotor and respiratory centers, the introduction of respiratory analeptics intravenously: kordiamin - 2 ml, bemegrida 0,5% - 2 ml.

With a sharp decrease in blood pressure, it is necessary to slowly inject 0.1-0.3 ml of adrenaline diluted with 10 ml of isotonic sodium chloride solution or 1 ml of a 5% solution of ephedrine (better in dilution with 10 ml of isotonic sodium chloride solution). Intramuscularly inject 400 ml of polyglucin with the addition of 30 - 125 mg of prednisolone.

When cardiac arrest is performed a closed massage, intracardiac injection of 1 ml of epinephrine with 10 ml of calcium chloride and hormones, the patient is intubated and transferred to artificial ventilation of the lungs.

With symptoms of irritation of the cerebral cortex, barbiturates are intravenously injected intravenously, 90 mg of prednisolone, 10-20 mg of Relanium. In severe cases, when the indicated measures are ineffective, the patient is intubated and transferred to artificial lung ventilation.

• Allergic reaction with increased sensitivity (intolerance) to local anesthetic substances - anaphylactic shock.

It is necessary to immediately stop the study, lay the patient, adjust the inhalation of moistened oxygen. Intramuscularly inject 400 ml of polyglucin, add 1 ml of a 0.1% solution of epinephrine, antihistamines (suprastin 2 ml of a 2% solution or dimedrol 2 ml of a 1% solution, or Tavegil 2 ml of a 0.1% solution). It is necessary to use corticosteroids - 90 mg of prednisolone or 120 mg of hydrocortisone acetate.

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

When pronounced stridoroznom breath (laryngeal edema) through the mask of the anesthetic apparatus, inhalation of a mixture of nitrous oxide with fluorotane and oxygen, and perform all that as with the phenomena of bronchospasm. If these measures are ineffective, the introduction of relaxants and intubation of the patient with the continuation of all this therapy are necessary. It is necessary to constantly monitor the pulse, blood pressure, respiration rate and ECG.

• Spastic vagal reactions with insufficient anesthesia of the mucous membrane of the respiratory tract - laryngospasm, bronchospasm, cardiac rhythm disturbance.

When bronchoscopy is performed against a 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 region of reflexogenic zones (carina, spurs of segmental and segmental bronchi), with laryngo- and bronchospasm, as well as disorders of the heart rhythm .

Laryngospasm usually develops during a bronchophibroscope through the vocal cavity.

Causes of laryngospasm:

• the introduction of cold anesthetics;
• insufficient anesthesia of the vocal folds;
• rough, violent carrying out of an endoscope through a voice gap;
• toxic effect of local anesthetic substances (with overdose).

Clinical manifestations of laryngospasm:

• inspiratory dyspnea;
• cyanosis;
• excitation.

In this case, it is necessary to remove the bronchoscope from the larynx, re-establish its distal end over the vocal slit and insert an additional amount of anesthetic into the vocal folds (with insufficient anesthesia). As a rule, laryngospasm is quickly stopped. However, if after 1-2 minutes dyspnea increases and hypoxia increases, the study 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 anesthetic substances;
• the introduction of cold solutions. Clinical manifestations of bronchospasm:
• expiratory dyspnea (prolonged exhalation);
• wheezing;
• cyanosis;
• excitation;
• tachycardia;
• hypertension.

With the development of bronchospasm it is necessary:

1. Research to stop, lay the patient and adjust inhalation of moistened oxygen.
2. To give the patient to inhale two doses of a bronchodilator of beta-stimulating action (sympathomimetics: berotek, astomopent, alupent, salbutamol, berodual).
3. Intravenously, administer 10 ml of a 2.4% solution of euphyllin to 10 ml of isotonic sodium chloride solution and 60 mg of prednisolone.

With the development of asthmatic status, it is necessary to intubate the patient, translate it into artificial lung ventilation and carry out resuscitation measures.

Heart rhythm disturbances are characterized by the appearance of group extrasystoles, bradycardia and other arrhythmias (ventricular origin). In these cases, it is necessary to stop the study, lay the patient, do an ECG, call a cardiologist. At the same time, the patient should inject glucose intravenously slowly with antiarrhythmic drugs (isoptin 5-10 ml, cardiac glycosides - strophanthin or 1 ml korglikon).

With the purpose of preventing complications arising against the background of vagal spastic reactions, it is necessary:

1. It is obligatory to include atropine, which has a vagolytic effect, in premedication.
2. Use heated solutions.
3. Carefully perform anesthesia of the mucosa, especially the reflexogenic zones, taking into account the optimal timing of the onset of anesthesia (1-2 min exposure).
4. In patients with a predilection for bronchospasm, include intravenous injection of 10 ml of a 2.4% solution of euphyllin into 10 ml of isotonic sodium chloride solution, and immediately before the start of the test, give 1-2 doses of any aerosol used by the patient.

To prevent complications caused by premedication and local anesthesia, the following rules should be observed:

• check individual sensitivity to anesthetics: anamnestic data, sample under the tongue;
• pre-measure the dose of anesthetic: the dose of lidocaine should not exceed 300 mg;
• if there is a history of intolerance to lidocaine, bronchoscopy should be performed under general anesthesia;
• to reduce the absorption of anesthetic, it is better to use an application (or installation) method of applying anesthetic than aerosol (inhalation, especially ultrasonic), since the absorption of local anesthetic substances increases in the distal direction;
• an adequate premedication, a calm state of the patient, the correct technique of anesthesia contribute to reducing the dose of anesthetic;
• to prevent the development of severe complications, careful monitoring of the patient's condition during the performance of anesthesia and bronchoscopy, immediate termination of the study at the first signs of a systemic reaction is necessary.

Complications due to bronchoconstriction and endobronchial manipulation

Complications caused by direct bronchoscopy and endobronchial manipulation include:

1. Hypoxic complications caused by mechanical obstruction of the respiratory tract as a result of the bronchoscope and, in connection with this, inadequate ventilation.
2. Bleeding.
3. Pneumothorax.
4. Perforation of the bronchus wall.
5. Feverish condition and exacerbation of the inflammatory process in the bronchi after bronchoconstriction.
6. Bacteremia.

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

Hypoxic disorders are especially dangerous in their combined development against the background of complications such as laryngo- and bronchospasm, with an overdose of local anesthetics or against a background of spasmodic vagal reactions.

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

When the patient develops laryngo- and bronchospasm, the complex of measures described above is carried out.

If the patient has convulsions, then slowly drip barbiturates (sodium thiopental or hexenal - up to 2 g of the drug on isotonic sodium chloride solution) should be administered slowly for several hours; constantly carry out inhalation of oxygen and forced diuresis (dropwise injection of 4-5% solution of soda 200-400 ml and euphyllin for strengthening diuresis); prescribe hormonal drugs to combat brain edema on the background of hypoxia.

To prevent hypoxic disorders, the following rules should be observed:

• Reduce as far as possible the study time in patients with initial hypoxia (oxygen pressure less than 70 mm Hg).
• Carry out thorough anesthesia.
• Carry out constant insufflation of moistened oxygen.

Nasal bleeding occurs with transnasal bronchoscopy. Bleeding complicates the conduct of anesthesia, but the study does not stop. As a rule, special measures to stop bleeding should not be done. The inserted bronchoscope obturates the lumen of the nasal passage, which helps stop the bleeding. If the bleeding continues and after the bronchoscope is removed after the end of the study, it is stopped with hydrogen peroxide.

For the prevention of nasal bleeding, it is necessary to carefully enter the bronchoscope through the lower nasal passage, without injuring the mucous membrane of the nasal passage. If the latter is narrow, do not force the device, but rather try to enter the endoscope through another nasal passage. If this attempt does not succeed, the bronchoscope is injected through the mouth.

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

The endoscopist's tactics depend on the source of the bleeding and its intensity. With the development of a small bleeding after taking a biopsy from a bronchial tumor, it is necessary to carefully aspirate the blood through the endoscope, rinse the bronchus with an "ice" isotonic sodium chloride solution. As haemostatic drugs, a 5% solution of aminocaproic acid can be used, topical administration of adroxone, dicinone.

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

Adroxone should be administered via a catheter conducted through the biopsy channel of the endoscope directly to the focus of bleeding, previously diluting it in 1-2 ml of an "ice" isotonic sodium chloride solution.

Dicinone (12.5% solution) is effective for stopping capillary bleeding. The drug normalizes the permeability of the vascular wall, improves microcirculation, has a hemostatic effect. Hemostatic effect is associated with an activating effect on the formation of thromboplastin. The drug does not affect prothrombin time, does not possess hypercoagulable properties and does not contribute to the formation of blood clots.

In the development of massive bleeding, the actions of the endoscopist should be as follows:

• It is necessary to remove the bronchoscope and put the patient on the side of the bleeding lung;
• if the patient has a breathing disorder, intubation and aspiration of the contents of the trachea and bronchi through a wide catheter is shown against the background of artificial ventilation;
• there may be a need for a rigid bronchoscopy and tamponade of the place of bleeding under the control of vision;
• with continued bleeding is indicated surgical intervention.

The main complication in pereebronchial lung biopsy, as with direct biopsy, is bleeding. In the event of bleeding after perebronhialnoy biopsy of the lung, the following measures are carried out:

• perform a thorough aspiration of blood;
• wash the bronchus with an "ice" isotonic solution of sodium chloride, 5% solution of aminocaproic acid;
• Locally administered adroxone and lidicinone;
• apply the method of "jamming" the distal end of the bronchoscope of the mouth of the bronchus, from which the flow of blood is noted.

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

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

• Never take a biopsy from bleeding formations.
• Do not move the thrombus with a biopsy forceps or the end of the endoscope.
• Do not take a biopsy from vascular tumors.
• When taking a biopsy from an adenoma, it is necessary to choose avascular areas.
• Do not perform a biopsy for violations of the blood coagulation system.
• Care should be taken when performing an afterbrochial lung biopsy in patients who have been receiving corticosteroids and immunosuppressants for a long time.
• The risk of bleeding during a puncture biopsy is significantly reduced if small diameter needles are used.

A transbronchial lung biopsy can be complicated by pneumothorax. The cause of pneumothorax is damage to the visceral pleura with too much biopsy forceps. When the complication develops, the patient has chest pain, shortness of breath, shortness of breath, cough.

With limited parietal pneumothorax (lung collapse less than 1/3), rest and strict bed rest are shown for 3-4 days. During this time, air is absorbed. If there is a significant amount of air in the pleural cavity, the pleural cavity is punctured and air sucked. In the presence of valve pneumothorax and respiratory failure, mandatory drainage of the pleural cavity is required.

For the prevention of pneumothorax it is necessary:

1. Strict adherence to methodological peculiarities in the performance of a transbronchial lung biopsy.
2. Obligatory two-project control of biopsy forceps position, X-ray control after biopsy.
3. Do not perform an overbrochial lung biopsy in patients with emphysema, polycystic lung disease.
4. Do not perform an out-of-bronchial lung biopsy from both sides.

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

Preliminary it is necessary to study the radiographs, made necessarily in a straight and lateral projections. If the perforation of the bronchus wall occurred during the extraction of the foreign body, surgical treatment is indicated.

In order to prevent this complication when removing acute foreign bodies necessarily protect the bronchus wall from the acute end of the foreign body. To do this, press the distal end of the bronchoscope onto the bronchial wall, pushing it away from the sharp end of the foreign body. You can rotate the blunt end of the foreign body in such a way that the sharp end comes out of the mucous membrane.

After performing bronchoscopy, the temperature may worsen, the general condition may worsen, that is, "resorptive fever" may develop as a response to endobronchial manipulation and absorption of decay products or an allergic reaction to solutions that are used for bronchial sanitation (antiseptics, mucolytics, antibiotics).

Clinical symptoms: deterioration of general condition, increase in sputum.

Radiographic examination reveals focal or drainage infiltration of lung tissue.

It is necessary to carry out detoxification therapy, use of antibacterial drugs.

Bacteremia is a serious complication that occurs as a result of disruption of the integrity of the bronchial mucosa during endobronchial manipulations in the infected respiratory tract (especially when there are 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 state. Treatment is the same as in sepsis.

For the prevention of bacteremia, the bronchoscope and auxiliary instruments should be thoroughly disinfected and sterilized, and atraumatically manipulated in the bronchial tree.

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

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

The risk of research is higher the older the patient is. Especially it is necessary to take into account the age factor when performing research in outpatient settings, when the doctor does not have the ability to examine many functions of the body, which would allow an objective assessment of the patient's condition and the risk of bronchoscopy.

Before the examination, the doctor should explain to the patient how to behave during bronchoscopy. The main task of the conversation is to establish contact with the patient, to relieve his feelings of tension. It is necessary to shorten the waiting time for the forthcoming study.

In the presence of the patient, any extraneous conversations are excluded, especially information of a negative nature. As with the performance of bronchoscopy, and after it, there should be no manifestation of emotions on the part of the endoscopist.

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