Profile of Repeat Fiberoptic Bronchoscopy

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					                                              ORIGINAL ARTICLE

                 Profile of Repeat Fiberoptic Bronchoscopy

              T. Balamugesh, A.N. Aggarwal, D. Gupta, D. Behera and S.K. Jindal

  Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

        Background. Fiberoptic bronchoscopy (FOB) is invaluable in the diagnosis of a variety of
        pulmonary diseases, but in many instances the procedure has to be repeated because of an
        inconclusive initial FOB or for reassessment.
        Methods. A retrospective analysis of all the fiberoptic bronchoscopic procedures done between
        September 2000 and February 2003 was performed and details of patients undergoing repeat
        FOB abstracted.
        Results. Of the 2,270 bronchoscopies performed on 2114 patients, 132 procedures were repeated,
        yielding an over all frequency of repeat FOB of 6.34 percent. Bronchoscopy was done twice in
        112 patients, thrice in 16 patients and four times in four patients. The commonest diagnosis in
        patients undergoing repeat bronchoscopy was bronchogenic carcinoma, followed by non-
        resolving pneumonia or presence of pulmonary infiltrates in immunocompromised host. The
        major indications for repeating FOB included obtaining specimens for pathological examination,
        pre and postoperative evaluation of airways, localization of site of bleeding in patients with
        hemoptysis, and placement of catheters for intraluminal brachytherapy. Of the 88 cases
        undergoing repeat bronchoscopy for diagnostic purposes, 41 (46.6%) yielded positive results,
        either in form of positive histology or localisation of source of hemoptysis.
        Conclusions. The frequency of repeat bronchoscopy was low. Commonest indication for a repeat
        procedure was to obtain repeat/additional diagnostic samples. A repeat procedure can yield
        positive results even when the initial FOB is nondiagnostic.

        Key words: Fiberoptic bronchoscopy, Bronchogenic carcinoma, Bronchial biopsy.

                                                                    [Indian J Chest Dis Allied Sci 2005; 47: 181-185]

               INTRODUCTION                                    comfort of the patient, greater maneuverability
                                                               of the bronchoscope, improved diagnostic
   Flexible fiberoptic bronchoscopy (FOB), the
                                                               accuracy and safety of FOB as an outpatient
most frequently performed invasive procedure
in practice of pulmonary medicine has largely
replaced rigid, open-tube bronchoscopy in the                     Besides localisation and biopsy of airway
diagnosis and management of inflammatory,                      tumours, FOB is useful in evaluation of
infectious, and malignant diseases of the                      interstitial lung diseases, non-resolving pneu-
lungs 1,2 . This has been possible due to the                  monias (especially in immunocompromised
[Received: July 28, 2003; accepted after revision: December 11, 2003]
Correspondence and reprints request: Dr S.K. Jindal, Professor and Head, Department of Pulmonary Medicine,
Postgraduate Institute of Medical Education and Research, Chandigarh-160 012, India; Tele.: 91-172-2747585-94
Extn 6821; Telefax: 91-172-2745959; E-mail: <>.
182                                       Repeat Bronchoscopy                            T. Balamugesh et al

patients), and unexplained hemoptysis. FOB is          bronchial biopsy, and bronchoalveolar lavage
also useful in the assessment of response to           (BAL) were obtained after thorough evaluation
treatment and placement of catheters for               of the endobronchial anatomy.
intraluminal brachytherapy for bronchogenic
                                                         Depending on clinical, radiologic and
carcinoma, and placement of stents in airway
                                                       bronchoscopic findings, patients not diagnosed
                                                       after FOB were subjected to either a repeat
   Although FOB is invaluable in the diagnosis         procedure, or advised other diagnostic tests. The
of a variety of pulmonary diseases, the                outcome of these other tests were not available
procedure is required to be repeated in several        for most patients. For intraluminal brachy-
situations, either because of an inconclusive          therapy, the catheter with its guidewire was
initial study or for reassessment. We have             inserted through the working channel of the
analysed the frequency and indications of repeat       bronchoscope and placed at the site of tumor.
bronchoscopic procedures performed at our
institute over a two and half year period. Such
an analysis has been infrequent in published                             RESULTS
literature. The significance of nondiagnostic
bronchoscopies as well as the efficacy of serial         Of the 2,270 bronchoscopies performed on
procedures has not been well addressed in the          2114 patients over a period of two and half
past.                                                  years, 132 procedures were repeated, yielding
                                                       an over all frequency of repeat FOB of 6.34%. Six
                                                       patients were known to be seropositive for
      MATERIAL AND METHODS                             human immunodeficiency virus (HIV). None of
                                                       these patients underwent a repeat procedure.
   We analysed all fiberoptic bronchoscopic            Bronchoscopy was done twice in 112 patients,
procedures performed on a nonemergent basis            thrice in 16 patients and four times in four
between September 2000 and February 2003.              patients. No procedure-related complications
Records of all patients who underwent repeat           were observed in any of the repeat
bronchoscopies were identified and analysed.           bronchoscopies.
Bronchoscopy was done as an outpatient
                                                          The commonest diagnosis in patients
procedure in all instances. Assessment of
                                                       undergoing a repeat bronchoscopy was
coagulation profile and pulmonary function
                                                       bronchogenic carcinoma (69 patients, 52.3%).
tests was carried out before bronchoscopy in
                                                       Forty-three patients underwent repeat proce-
patients where transbronchial lung biopsy was
                                                       dures to obtain a repeat (40) or fresh (3) bron-
planned. Electrocardiogram was done in all
                                                       chial biopsy specimen. A positive diagnosis was
patients above 35 years of age. Informed
                                                       made in 15 instances. Five patients underwent
consent was taken, and was repeated in those
                                                       transbronchial biopsies, two of which yielded
requiring repeat bronchoscopy. After
                                                       the diagnosis. Ten patients received
premedication with intramuscular atropine (0.6
                                                       intraluminal brachytherapy.
mg) and promethazine (25 mg), bronchoscopy
was performed with a flexible fiberoptic                  Sixteen (11.4%) patients had hemoptysis. FOB
bronchoscope (Olympus 1T 20) under topical             had to be repeated in 14 of these as the initial
lidocaine anaesthesia. All procedures were             assessment did not localise the site of bleeding.
performed by senior residents of the                   The site of bleeding could be ascertained in
department under supervision of a consultant.          seven instances. No active bleeding was noticed
Oxygenation was monitored during and                   in six patients. In one patient, both the airways
immediately after the procedure with pulse             were filled with clots and blood, and it was not
oximetry and oxygen administered wherever              possible to localise the site of bleeding. Two
required to maintain a saturation above 90%.           other patients underwent repeat FOB as part of
Appropriate samples such as the lung or                preoperative assessment.
2005; Vol. 47                             The Indian Journal of Chest Diseases & Allied Sciences                  183

   Twenty (15.2%) patients undergoing repeat                     repeat bronchial biopsy, 11 (73.3%) were positive
FOB had nonresolving pneumonia. Fifteen of                       on second biopsy, 4 (26.7%) on third biopsy and
these underwent repeat (11) or fresh (4)                         none on fourth biopsy. Patients not diagnosed
transbronchial biopsies, of which seven yielded                  on bronchoscopy were subjected to other
a positive diagnosis. Twelve (9.1%) had inter-                   diagnostic tests as indicated. Details of these are
stitial lung diseases. Nine patients underwent a                 not available.
transbronchial biopsy, which was a repeat
procedure in all except one patient. A positive                                      DISCUSSION
histological diagnosis could be made in five of
these. Fifteen other patients underwent repeat                      We found that 6.34% of patients subjected to
FOB for other indicatons.                                        FOB had to undergo a repeat procedure due to
   Overall, the major indications for repeating                  a variety of reasons. This is comparable to the
FOB included obtaining specimens for                             frequency of 6.1-10.1% reported from a tertiary
pathological examination (bronchial or lung                      care hospital from United States3. In another
biopsy, 34.6% and 23.5% respectively), pre and                   series of patients with acquired immuno-
postoperative evaluation of airways (6.8%)                       deficiency syndrome (AIDS), 23% of patients
localisation of site of bleeding in patients with                had repeat bronchoscopies, and a diagnosis was
hemoptysis (10.6%), and placement of catheters                   established in 59% of cases if the repeat
for intraluminal brachytherapy (7.6%). Other                     procedure was performed within a month of the
infrequent indications included the suspicion of                 initial FOB 4 . This high frequency could be
a problem other than the initial disease, to                     attributed to increased frequency of pulmonary
document response to therapy of endobronchial                    infections in HIV positive patients. The overall
lesions or an inadequate initial evaluation in an                diagnostic yield of repeat bronchoscopy was
uncooperative patient.                                           46.59% in our study, although none of these
                                                                 patients was HIV seropositive.
   Of the 88 cases undergoing repeat bronchos-
copy for diagnostic purposes, 41 (46.59%)                           The commonest indication for a repeat
yielded positive results, either in form of a                    bronchoscopy was to obtain a second bronchial
positive histology or localisation of source of                  biopsy specimens in cases of bronchogenic
hemoptysis (Table 1). The yield of repeat                        carcinoma (31.1%). In such cases the overall
bronchial biopsy was significantly higher in                     yield in obtaining positive histology was 36.6%.
those with a visible growth (12 of 23 patients,                  The yield was significantly greater in cases with
52.2%) than in those with mucosal infiltration (3                visible intraluminal growth than in cases with
of 18 patients, 16.7%, p<0.05). Among the 26                     mucosal or submucosal infiltration. This is
cases with negative repeat biopsy, four                          consistent with most reports on FOB yield in
specimens showed necrosis and one specimen                       bronchogenic carcinoma5. Usually the diagnos-
was inadequate. In the remaining cases, no                       tic yield of endoscopically visible carcinoma is
definite opinion could be given despite                          over 90 percent. Greater the number of biopsies,
adequate biopsy material. Of the 15 cases in                     the higher is the yield. Five direct forceps biopsy
whom a positive histology could be obtained on                   specimens allow a greater than 90% probability

Table 1. Yield of repeat diagnostic bronchoscopic procedures
                                                  Positive             Negative                Total    Yield (%)
Repeat bronchial biopsy                               15                   26                      41     36.6
Repeat transbronchial lung biopsy                      7                    7                      14     50.0
Fresh bronchial biopsy                                 2                    0                       2    100
Fresh transbronchial lung biopsy                       9                    8                      17     52.9
Localise bleeding                                      8                    6                      14     57.1
Total                                                 41                    47                     88      46.6
184                                         Repeat Bronchoscopy                             T. Balamugesh et al

of obtaining at least one positive sample. But           introduced into the catheter and positioned.
forceps biopsy of a tumor causing extrinsic              Single large fractions have been associated with
compression is positive in only about one fourth         a large risk of massive hemoptysis and,
of cases because the device does not reach the           therefore, frequently 2-4 fractions are given11-14.
tumour6-8. Other reasons for a negative biopsy
                                                           To summarize, the frequency of repeat
include the presence of necrosis in the tumour
                                                         bronchoscopy is low at our institute and is at
mass. This was an important reason for a
                                                         par with the Western reports. Commonest
negative result even on repeat sampling.
                                                         indication for a repeat procedure is to obtain
   In cases where a repeat FOB was done for              repeat/additional diagnostic samples. A repeat
obtaining a transbronchial lung biopsy (TBLB)            procedure may yield positive results even when
which was not done during the first procedure,           the initial FOB is nondiagnostic. Therefore, a
a positive diagnosis could be obtained in 50% of         repeat FOB should be considered if the likeli-
cases. Transbronchial biopsy provides a                  hood of a positive bronchoscopic yield is high.
significantly higher diagnostic yield than that
obtained by BAL in all categories of diffuse lung
diseases, and it has been suggested that TBLB
should be routinely carried out in these
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