From the Guidelines
No, it is not safe to perform a bronchoscopy in a patient with an INR of 14. Bronchoscopy should be postponed until the coagulopathy is corrected to an INR of less than 1.5, ideally closer to normal range (0.8-1.2). The patient requires urgent correction of their coagulopathy with vitamin K and/or fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC) before any invasive procedure. For rapid reversal, 10mg of IV vitamin K along with PCC (25-50 units/kg) or FFP (15-20 mL/kg) should be administered, as recommended by recent guidelines 1. An INR of 14 indicates severe impairment of the clotting cascade and creates an extremely high risk of significant bleeding during and after bronchoscopy, even with simple diagnostic procedures. Bronchoscopy involves manipulation of the airways and potentially biopsies, which can cause trauma to the mucosa. With severely impaired coagulation, even minor trauma could lead to life-threatening hemorrhage that would be difficult to control within the airway. The procedure should only be performed after documented normalization of coagulation parameters and reassessment of the risk-benefit ratio.
Some key points to consider:
- The British Thoracic Society guidelines on diagnostic flexible bronchoscopy recommend that the INR should be reduced to <2.5 and heparin should be started if it is necessary to continue with anticoagulants 1.
- The guidelines for radiologically guided lung biopsy suggest that a PT or international normalized ratio (INR) or APTT ratio of more than 1.4 and a platelet count below 100 000/ml should be relative contraindications to percutaneous lung biopsy 1.
- Recent studies have shown that 4-factor PCC is preferred over 3-factor PCC for warfarin reversal due to its more successful INR reversal and fewer adverse events 1.
- The use of PCC has been associated with a reduction in requirement of packed red blood cell and decline in mortality compared to FFP 1.
The most recent and highest quality study, published in 2024, provides the most up-to-date guidance on the management of coagulopathy in patients on warfarin 1. Therefore, the recommendation is based on this study.
From the Research
Bronchoscopy in Patients with Coagulopathy
Safety Considerations
- The safety of performing a bronchoscopy in a patient with a coagulopathy, specifically an International Normalized Ratio (INR) of 14, is a concern due to the increased risk of bleeding 2, 3, 4.
- Studies have shown that prothrombin complex concentrate (PCC) can be effective in rapidly reversing INR in patients on vitamin K antagonist therapy, which may be beneficial in this scenario 2, 3, 5, 6.
- However, the use of PCC may be associated with thromboembolic complications, and its safety and efficacy in patients with an INR of 14 have not been specifically studied 2, 6.
Management of Coagulopathy
- The management of coagulopathy in patients undergoing bronchoscopy typically involves correcting the INR to a safe level, which may require the use of PCC or fresh frozen plasma (FFP) 2, 3, 4, 5, 6.
- The choice of agent and dosing regimen will depend on the individual patient's circumstances and the specific procedure being performed 2, 3, 4, 5, 6.
- Close monitoring of the patient's INR and clinical status is essential to minimize the risk of bleeding or thromboembolic complications 2, 3, 4, 5, 6.
Specific Considerations for Bronchoscopy
- Bronchoscopy is a relatively low-risk procedure for bleeding, but the risk may be increased in patients with coagulopathy 2, 3, 4, 5, 6.
- The use of PCC or FFP to correct the INR prior to bronchoscopy may be considered, but the decision should be made on a case-by-case basis, taking into account the individual patient's risk factors and the potential benefits and risks of the procedure 2, 3, 4, 5, 6.
- The availability of experienced personnel and equipment to manage potential bleeding complications is essential when performing bronchoscopy in patients with coagulopathy 2, 3, 4, 5, 6.