Do we need to withhold antiplatelet (anti-clotting) agents before performing a bronchoscopy?

Management of Antiplatelet Agents Before Bronchoscopy

Aspirin does not need to be withheld before bronchoscopy, but clopidogrel and other P2Y12 inhibitors should be discontinued 5-7 days prior to the procedure if biopsies are planned.

Aspirin Management

Aspirin can be safely continued for all bronchoscopic procedures, including those with tissue sampling. Multiple lines of evidence support this approach:

• Growing evidence demonstrates that aspirin is safe and does not increase bleeding during bronchoscopy, even with transbronchial biopsies 1
• A retrospective study of 108 patients undergoing therapeutic bronchoscopy found no significant difference in estimated blood loss between aspirin users and non-users (mean 6.0 vs 6.7 ml, p=0.36), with no difference in overall complications 2
• Aspirin use was not associated with increased risk of bleeding or procedure-related complications after therapeutic bronchoscopy 2

Clopidogrel and P2Y12 Inhibitor Management

Clopidogrel must be discontinued 7 days before elective bronchoscopy when biopsies are anticipated. This is a critical safety measure:

• A prospective cohort study was stopped early due to excessive bleeding rates in the clopidogrel group: 89% (16/18 patients) experienced bleeding compared to 3.4% (20/574) in controls (p<0.001) 3
• Bleeding rates were significantly elevated across all severity levels: mild (27% vs 1.5%), moderate (34% vs 1.5%), and severe (27% vs 0.3%) 3
• When clopidogrel and aspirin were combined, 100% of patients (12/12) had bleeding complications - 6 with moderate and 6 with severe bleeding 3
• Despite small studies suggesting safety for low-risk procedures like EBUS-TBNA on clopidogrel, it remains recommended to hold it for 7 days prior to elective bronchoscopy 1

Oral Anticoagulant Management

If biopsy is anticipated, oral anticoagulants should be stopped at least 3-4 days before bronchoscopy:

• The British Thoracic Society recommends stopping oral anticoagulants at least 3 days before bronchoscopy or reversing with low-dose vitamin K if biopsies are planned 4
• For percutaneous lung biopsy, warfarin should be stopped at least 4 days before the procedure, as it typically takes 4 days for INR to reach 1.5 5
• If anticoagulation must continue, INR should be reduced to <2.5 4
• The short-term risk of thromboembolism in patients with mechanical heart valves when not anticoagulated is very small 5

Risk Stratification for Bleeding

Routine coagulation screening is only required in patients with specific bleeding risk factors:

• Patients at increased risk include those with uraemia, immunosuppression, pulmonary hypertension, liver disease, coagulation disorders, or thrombocytopenia 5
• In these high-risk patients, check platelet count, prothrombin time (PT), and activated partial thromboplastin time (APTT) before bronchoscopy 5
• Routine preoperative coagulation screening is unjustified in those with no risk factors undergoing routine bronchoscopy 5

Procedure-Specific Considerations

The type of bronchoscopic procedure influences bleeding risk:

• Significant hemorrhage (>50 ml) occurred in 1.6-4.4% of patients undergoing transbronchial biopsy for diffuse lung disease 5
• Profuse bleeding was more likely after transbronchial than endobronchial biopsies 5
• The risk of bleeding during transbronchial biopsies is unrelated to forceps size but slightly higher in mechanically ventilated patients 5

Common Pitfalls to Avoid

• Do not assume aspirin needs to be stopped - this outdated practice increases thrombotic risk without reducing bleeding complications 1, 2
• Do not proceed with transbronchial biopsy in patients on clopidogrel - the bleeding risk is unacceptably high at 89% 3
• Do not combine aspirin with clopidogrel during bronchoscopy - this resulted in 100% bleeding rate with 50% severe bleeding 3
• Do not forget to check coagulation parameters in patients with liver disease or other bleeding risk factors when biopsy is planned 4