From the Guidelines
Bronchoscopic lung biopsies in patients with pulmonary hypertension should be performed with caution due to the increased risk of complications, and a thorough pre-procedure evaluation is necessary to assess the benefits and risks of the procedure. When considering bronchoscopic lung biopsies in patients with pulmonary hypertension, several key factors must be taken into account to minimize risks and ensure the best possible outcomes.
- The patient's pulmonary hypertension status, including the severity of the condition, as indicated by mean pulmonary artery pressure, is crucial in determining the suitability for the procedure 1.
- A thorough pre-procedure evaluation, including echocardiography to assess pulmonary artery pressure and right ventricular function, is essential to understand the patient's current cardiovascular status.
- The procedure should ideally be performed in a controlled setting with access to critical care support, given the potential for complications such as bleeding or respiratory failure.
- Medication management is critical, with the continuation of pulmonary vasodilators through the perioperative period to maintain stable pulmonary artery pressures.
- Sedation must be administered with caution, using agents that have minimal effects on hemodynamics, such as midazolam and fentanyl, to avoid precipitating right heart failure.
- Limiting the number of biopsies to the minimum necessary and avoiding transbronchial biopsies in severe cases can help mitigate the risk of bleeding.
- Post-procedure monitoring should be extended to watch for potential complications such as pneumothorax or hemorrhage, with close attention to the patient's oxygenation and hemodynamic status. These precautions are based on the understanding that patients with pulmonary hypertension have a reduced pulmonary vascular reserve and an increased risk of bleeding and other complications during and after the procedure, as highlighted in guidelines for radiologically guided lung biopsy 1.
From the Research
Considerations for Bronchoscopic Lung Biopsies in Pulmonary Hypertension
- The safety of performing bronchoscopic lung biopsies in patients with pulmonary hypertension (PH) has been evaluated in several studies 2, 3, 4.
- A study published in 2009 found that flexible bronchoscopy, including transbronchial biopsies, can be performed safely in patients with mild to moderate PH, with no significant increase in the risk of hemorrhage or other complications 2.
- A systematic review and meta-analysis published in 2023 found that patients with PH do not have a significantly elevated risk of bleeding with transbronchial lung biopsies (TBLB) compared to patients without PH, but may be at a higher risk of developing hypoxia and requiring longer duration of mechanical ventilation 3.
- Another study published in 2016 found that bronchoscopy with transbronchial and endobronchial biopsy and transbronchial needle aspiration is safe in patients with echocardiographic evidence of PH, with no difference in the incidence of minor or major bleeding compared to patients without PH 4.
- The management of PH involves a multidisciplinary approach, including the use of targeted therapies such as phosphodiesterase type-5 inhibitors, soluble guanylate cyclase stimulators, and endothelin receptor antagonists 5, 6.
- Patients with PH should be referred to a specialist center for further evaluation and management, and surgical pulmonary endarterectomy may be considered for eligible patients with chronic thromboembolic PH (CTEPH) 5.
Key Findings
- TBLB can be performed safely in patients with mild to moderate PH 2, 3, 4.
- Patients with PH may be at a higher risk of developing hypoxia and requiring longer duration of mechanical ventilation after TBLB 3.
- The incidence of bleeding after TBLB is not significantly increased in patients with PH compared to patients without PH 2, 3, 4.
- The management of PH involves a multidisciplinary approach, including the use of targeted therapies and referral to a specialist center 5, 6.