How should bronchoscopy be performed in an HIV‑positive adult with low CD4 count, thrombocytopenia and possible coagulopathy, including pre‑procedure laboratory assessment, prophylaxis, sedation, infection‑control measures, and post‑procedure care?

Bronchoscopy Protocol for HIV-Positive Patients

Pre-Procedure Laboratory Assessment

In HIV-positive patients with low CD4 counts and suspected thrombocytopenia or coagulopathy, check platelet count, prothrombin time (PT), and activated partial thromboplastin time (APTT) before bronchoscopy, especially if transbronchial biopsy is anticipated. 1

• Routine coagulation screening is only required for patients with known bleeding risk factors (including immunosuppression, which applies to HIV patients with low CD4 counts) or when transbronchial biopsy is planned 1, 2
• Patients with HIV infection and low CD4 counts are at increased risk of bleeding complications due to potential thrombocytopenia and coagulopathy 2
• If oral anticoagulants are being used, stop them at least 3 days before bronchoscopy or reverse with low-dose vitamin K 1
• If anticoagulation must continue, reduce INR to <2.5 and initiate heparin 1

Prophylactic Antibiotics

Administer prophylactic antibiotics if the patient is asplenic, has prosthetic heart valves, or a history of endocarditis. 1, 3

• Standard HIV infection alone does not require prophylactic antibiotics for bronchoscopy 1
• However, assess for these specific high-risk cardiac conditions that mandate prophylaxis 1

Pre-Procedure Fasting and Preparation

Patients should have no solid food for 4 hours and may have clear fluids up to 2 hours before bronchoscopy. 1, 3, 4

• Establish intravenous access before bronchoscopy begins and maintain it throughout the recovery period 1, 3, 4
• Provide verbal and written patient information to improve tolerance of the procedure 1, 3

Sedation Considerations

Offer sedation to HIV-positive patients unless contraindicated by elevated baseline arterial CO₂. 1, 3

• Use incremental dosing to achieve adequate sedation and amnesia 1, 3
• Avoid sedation if pre-bronchoscopy arterial CO₂ is elevated, as both sedation and oxygen supplementation can further increase CO₂ levels and precipitate respiratory failure 1, 2, 4
• If the patient has suspected COPD (FEV₁ <40% predicted or SaO₂ <93%), measure arterial blood gases before bronchoscopy 1, 3
• Atropine is not required routinely 1, 3

Anesthetic Dosing

• Limit total lidocaine dose to 8.2 mg/kg (approximately 29 ml of 2% solution for a 70 kg patient) 1, 3
• Use extra caution in elderly patients or those with hepatic or cardiac impairment 1, 3
• Prefer 2% lidocaine gel for nasal anesthesia rather than spray 1, 3
• Use the minimum necessary lidocaine when instilled through the bronchoscope 1, 3

Procedural Monitoring

Continuous pulse oximetry monitoring is mandatory throughout the procedure. 1, 3, 4

• Provide oxygen supplementation to maintain SaO₂ ≥90% to reduce arrhythmia risk 1, 3, 4
• Consider ECG monitoring in patients with severe cardiac disease or persistent hypoxia despite oxygen supplementation 1, 3
• Ensure resuscitation equipment is readily available 1, 3
• Have at least two assistants present, with at least one qualified nurse 1, 3

Diagnostic Sampling Strategy

Perform both bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) to maximize diagnostic yield in HIV-positive patients with respiratory symptoms. 5, 6, 7

• BAL alone has a sensitivity of 78-85% for Pneumocystis carinii pneumonia (PCP), the most common pulmonary complication in HIV patients 5, 7
• Combining BAL with TBB increases diagnostic yield to 88-94% for PCP 5, 7
• TBB provides incremental diagnostic information not available from BAL alone, especially in patients pretreated with cotrimoxazole or pentamidine 5, 6
• TBB is necessary for diagnosing non-infectious disorders such as Kaposi's sarcoma and lymphocytic pneumonitis 6
• For diffuse lung disease, obtain 4-6 transbronchial biopsy samples from one lung 1, 3

Common Pitfall to Avoid

• Do not rely on BAL alone in HIV patients who have received empiric PCP treatment, as diagnostic yield drops significantly 5
• The overall diagnostic yield of bronchoscopy in HIV patients is 65-82% for all pathogens 5, 7

Infection Control Measures

Use extended disinfection protocols for bronchoscopes after procedures on HIV-positive patients with respiratory symptoms. 1

Equipment Disinfection

• Immerse bronchoscopes in 2% glutaraldehyde for 60 minutes (not the standard 20 minutes) for HIV-positive patients with respiratory symptoms, as they may be infected with Mycobacterium avium intracellulare or other atypical mycobacteria that are more resistant to glutaraldehyde 1
• Thorough cleaning with detergent before disinfection is the most important initial stage 1
• Use sterile or bacteria-free water (autoclaved or filtered through 0.2 μm filters) for rinsing bronchoscopes 1
• Wipe external surfaces and flush lumens with 70% alcohol after disinfection to destroy non-sporing bacteria including mycobacteria 1
• Perform bronchoscopy on patients with suspected tuberculosis at the end of the list 1

Staff Protection

• All staff must be vaccinated against hepatitis B and tuberculosis, with documented immunity 1, 3
• Staff should wear protective clothing including nitrile gloves, plastic aprons, and eye protection during the procedure 1, 3
• Do not re-sheath injection needles; use disposable accessories wherever possible 1, 3
• Bronchoscopes should be disinfected in a dedicated room using automated, well-ventilated systems, preferably inside a fume cabinet 1, 3
• Keep records of which bronchoscope was used on each patient and the decontamination procedure performed 1

Key Infection Control Principle

• No cases of HIV transmission have been reported following bronchoscopy when proper decontamination protocols are followed 1
• HIV has been isolated from bronchoscopes immediately after use, but after cleaning with detergent, viral recovery is minimal 1

Post-Procedure Care

Obtain a chest radiograph at least 1 hour after transbronchial biopsy to exclude pneumothorax. 1, 3

• Continue oxygen supplementation as needed, particularly in patients with impaired lung function or who received sedation 1, 3
• Maintain intravenous access throughout the recovery period 1, 3
• Continue monitoring until the patient is stable and alert 3
• Advise sedated patients not to drive, sign legal documents, or operate machinery for 24 hours 1, 3

Complication Rates in HIV Patients

• Bronchoscopy is well tolerated in HIV patients with few complications, even in those with thrombocytopenia or requiring mechanical ventilation 7
• Pneumothorax occurs in 3.9-6% of cases, bleeding in 7.8%, and hypoxemia in 2.6% 5
• High serum lactate dehydrogenase (LDH) levels correlate with increased risk of pneumothorax 5
• Temperature elevation after the procedure occurs in 22% of patients but is typically benign without sepsis 7
• The risk of moderate pulmonary hemorrhage after TBB is approximately 1.5% 7

Critical Safety Point

• Despite thrombocytopenia being common in HIV patients, bronchoscopy with TBB can be performed safely when coagulation parameters are checked and corrected beforehand 7