What are the contraindications for bronchoscopy?

Contraindications for Bronchoscopy

Bronchoscopy should be avoided within 6 weeks of a myocardial infarction, and is relatively contraindicated in patients with severe hypoxemia, raised pre-procedure arterial CO₂, unstable cervical spine, severe maxillofacial trauma, or obstructing oral/laryngeal disease. 1

Absolute and Relative Contraindications

Cardiac Contraindications

• Recent myocardial infarction: Bronchoscopy should be avoided if possible within 6 weeks of MI due to increased risk of arrhythmias and cardiac complications 1
• Severe cardiac disease: While not an absolute contraindication, patients with severe cardiovascular disease require careful consideration and ECG monitoring during the procedure 1

Respiratory Contraindications

• Severe hypoxemia: Bronchoscopy is relatively contraindicated in patients with severe hypoxemia (SaO₂ <93%), though it may be performed with appropriate precautions including oxygen supplementation and close monitoring 1, 2, 3
• Raised arterial CO₂: Sedation should be avoided when pre-bronchoscopy arterial CO₂ is elevated, as both sedation and oxygen supplementation can further increase CO₂ levels 1
• Severe COPD: Patients with FEV₁ <40% predicted and/or SaO₂ <93% require arterial blood gas measurement before bronchoscopy, and sedation should be avoided if CO₂ is raised 1

Coagulation Contraindications

• Uncontrolled bleeding diathesis: Severe coagulopathy is a relative contraindication, particularly when transbronchial biopsy is planned 3
• Anticoagulation: If biopsy is anticipated, oral anticoagulants should be stopped at least 3 days before bronchoscopy or reversed with low-dose vitamin K 1
• Elevated INR: If anticoagulation must continue, INR should be reduced to <2.5 1

Anatomical Contraindications (Specific to Rigid Bronchoscopy)

• Unstable cervical spine: Absolute contraindication to rigid bronchoscopy due to neck extension requirements 1
• Severe maxillofacial trauma or deformity: Prevents safe passage of rigid bronchoscope 1
• Obstructing oral or laryngeal disease: Blocks access for rigid bronchoscope insertion 1

Important Clinical Considerations

High-Risk Situations Requiring Special Precautions

• Severe pulmonary hypertension: Increases risk of complications, though not an absolute contraindication 3
• Cardiac failure: Requires careful risk-benefit assessment 3
• Immunocompromised patients: May require bronchoscopy despite risks for diagnostic purposes 3

Key Safety Measures in High-Risk Patients

• Oxygen supplementation should achieve SaO₂ ≥90% to reduce arrhythmia risk 1
• Continuous oximetry monitoring is mandatory 1
• ECG monitoring should be considered in patients with severe cardiac disease or hypoxia despite oxygen supplementation 1
• Resuscitation equipment must be readily available 1
• Intravenous access should be established before bronchoscopy and maintained through recovery 1

Common Pitfalls to Avoid

• Do not sedate patients with elevated baseline CO₂, as this can precipitate respiratory failure 1
• Do not proceed without checking coagulation parameters in patients with liver disease, uraemia, immunosuppression, or pulmonary hypertension when biopsy is planned 1
• Do not forget prophylactic antibiotics in asplenic patients, those with heart valve prostheses, or previous endocarditis 1

The primary principle is that the only true absolute contraindication is when bronchoscopy will provide no useful information 3. Most other contraindications are relative and require careful risk-benefit assessment, with appropriate modifications to technique and monitoring to minimize complications.