Printer Friendly

Safety and usefulness of bronchoscopy in ventilator-dependent patients with severe thrombocytopenia.

SUMMARY

Flexible bronchoscopy is a useful diagnostic procedure in patients with respiratory failure due to unexplained pulmonary infiltrates, but its safety and usefulness in ventilator-dependent patients with severe thrombocytopenia have not been established. A retrospective review of the medical records of all patients who underwent bronchoscopy while receiving mechanical ventilation support at Samsung Medical Centre, Seoul, Korea between January 2002 and July 2006 was conducted. The medical records of 37 patients with severe thrombocytopenia (platelet count <50,000 /[micro]l) at the time of bronchoscopy were analysed. Mean platelet count was 27,300[+ or -]12,500 /[micro]l. The most common underlying condition was haematologic malignancy, which occurred in 21(56.7%) patients, followed by severe sepsis in five (13.6%) and post-liver transplantation complications and autoimmune disease in four each (10.8%). The procedures performed were bronchoalveolar lavage in 33 patients, washing in three and transbronchial lung biopsy in five. Two patients died within 24 hours of completing the procedure. In patients surviving longer than 24 hours, there was no significant decline in oxygenation index ([P.sub.a][O.sub.2]/Fi[O.sub.2]), sequential organ failure assessment score or simplified acute physiological score II after the procedure. Lung compliance significantly decreased at two hours post-bronchoscopy but recovered to the pre-bronchoscopy level by 24 hours. Intensive care unit mortality was 51.4% (19 of 37 patients). Bronchoscopy was helpful in confirming the diagnosis in 17 patients (45.9%). Therapeutic modifications were made in 14 patients (37.8%) after bronchoscopy. Severe thrombocytopenia per se should not preclude bronchoscopy, even inpatients receiving mechanical ventilation.

Key Words: bronchoscopy, intensive care unit, mechanical ventilation, safety, thrombocytopenia

**********

Flexible bronchoscopy is a useful diagnostic procedure in patients with unknown pulmonary infiltrates and in recent years, it has been performed much more frequently in the intensive care unit (ICU) (1). Along with inspection of the airways, bronchoscopy provides the opportunity to sample the lower airways and alveoli via bronchial washing, bronchoalveolar lavage (BAL) and/or transbronchial lung biopsy (TBLB). Moreover, flexible bronchoscopy has been reported to provide clinically useful information and to be well-tolerated in mechanically ventilated patients with unexplained pulmonary infiltrates (2-6).

With an increased number of organ transplantations and cytoreductive therapy for malignancy, the number of immunocompromised patients has been increasing steadily. In these patients, pulmonary complications are the major causes of morbidity and mortality (7-12), with many eventually requiring mechanical ventilation. In this situation, flexible bronchoscopy is often considered in an attempt to reach a specific diagnosis. However, as many of these patients have thrombocytopenia, it is often difficult to decide whether to proceed with bronchoscopy in this clinical setting. Although flexible bronchoscopy can be performed with relative safety, despite the presence of significant thrombocytopenia in stable patients (13), the safety and utility of flexible bronchoscopy in ventilator-dependent patients with thrombocytopenia have not been established. This study was undertaken to evaluate the safety, feasibility and utility of bedside flexible bronchoscopy in patients with severe thrombocytopenia (platelet count <50,000 /[micro]l) receiving mechanical ventilation.

METHODS AND MATERIALS

Patients

Approval for this study was obtained from the International Review Board and patient consent was waived due to retrospective nature of the study.

Medical records were searched for all patients who underwent bronchoscopy during mechanical ventilation support at the Medical or Surgical ICU of Samsung Medical Centre (a 1250-bed university-affiliated tertiary referral centre in Seoul, Korea) between January 2002 and July 2006. Patients were included in the study if they had severe thrombocytopenia (platelet count <50,000 /[micro]l) just prior to the procedure.

Procedures

All procedures were performed by an internal medicine specialist trained in pulmonary and critical care. The bronchoscopy protocol used was as follows. Preoxygenation was performed by increasing the fraction of inspired oxygen (Fi[O.sub.2]) to 1.0 for at least 15 minutes prior to the procedure and this level was maintained throughout the procedure. All patients were premedicated with midazolam (0.05 mg/kg, intravenously) and/or vecuronium (0.1 mg/kg, intravenously) at five minutes before the procedure. Additional sedative and/or neuromuscular blocking agents were used as indicated. In some patients, platelet transfusions were performed prior to bronchoscopy, at the discretion of the attending physician.

The bronchoscope (BF 1T240, BF240; Olympus, Japan) was passed through a tight-sealing connector (Swivel Adapter; Portex, Hythe, U.K.) placed between the Y-connector of the ventilator circuit and the endotracheal tube. Servo9000 (SV900; Siemens, Sweden), Servo300 (SV300; Siemens) or PB840 (Puritan Bennett, Pleasanton, CA, U.S.A.) ventilators were used. The general principles of mechanical ventilation during bronchoscopy were as follows: volume- or pressure-controlled mode, respiratory rate of 20 /minute, ratio of inspiratory time to total respiration of 25 to 33%, positive end-expiratory pressure (PEEP) identical to pre-bronchoscopy level and tidal volume of 4 to 6 ml/kg of predicted body weight. Expiratory tidal volume was monitored. Inspiratory pressure was increased until the target expiratory tidal volume was achieved. Peak pressure was limited to <65 cm[H.sub.2]O. Oxygen saturation, electrocardiography and blood pressure (measured by an indwelling arterial catheter or intermittent automated blood pressure cuff) were monitored continuously during the procedure. After the procedure, the ventilator was returned to settings identical to those in the pre-bronchoscopy period, except for Fi[O.sub.2], which was returned to the pre-bronchoscopy level at 30 minutes post-oxygenation.

Diagnostic procedures during bronchoscopy were performed as indicated and included bronchial washing, BAL and TBLB.

Data collection

Data collected from a bronchoscopy database and medical records, included baseline patient characteristics: age, gender, underlying disease, ICU admission diagnosis, coagulation status, platelet count, blood chemistry and blood gases. Indications, procedures performed and diagnostic outcomes of bronchoscopy were recorded. To evaluate changes in physiological parameters, the mean blood pressure, heart rate, body temperature, PEEP, peak inspiratory pressure (PIP) and lung compliance were compared at two hours before bronchoscopy (Pre-2H), two hours after bronchoscopy (Post-2H), and 24 hours after bronchoscopy (Post-24H). In addition, the oxygenation index ([P.sub.a][O.sub.2]/Fi[O.sub.2]; PF ratio), sequential organ failure assessment (SOFA) score and simplified acute physiological score (SAPS) II were evaluated at the time of broncoscopy and after.

Procedure-related complications were identified from the medical records and examination of the nursing observational charts. The complications included nasal/airway trauma or bleeding, pneumothorax, new pulmonary infection, increase in body temperature of 1[degrees]C to >38[degrees]C within 24 hours, severe hypotension (mean arterial pressure < 60 mm Hg), bradycardia (< 50 bpm) and tachycardia (> 150 bpm). Major bleeding was defined as that needing intervention for control of active bleeding. Procedure-associated death was defined as death of a patient within 24 hours of the procedure. The definition of ICU survival was recovery from illness and discharge from ICU. The addition, withdrawal and change of therapy based on bronchoscopic results were defined as therapeutic modifications.

Statistical analysis

Statistical analyses were performed using SPSS 13.0 (SPSS, Chicago, IL, U.S.A.). Numerical variables are expressed as the mean[+ or -]S.D. When comparing data with three time points, one-way analysis of variance for repeated measures was used to evaluate the significance of differences. To evaluate which time points differed, a paired t-test with a Bonferroni correction was peformed for multiple comparisons (P <0.017 was regarded as significant). A comparison between two groups was evaluated by a Student's t-test and chi square test as appropriate, with P <0.05 being considered as significant.

RESULTS

Baseline clinical characteristics

Between January 2002 and July 2006, a total of 467 patients underwent bronchoscopy at the Medical or Surgical ICU of Samsung Medical Centre. Among these patients, 37 (7.9%) had severe thrombocytopenia. The baseline characteristics of the patients are listed in Table 1. There were 20 male and 17 female patients. The mean age was 46.9[+ or -]15.2 years. Haematologic disease was the most common underlying condition (n=21, 56.7%), followed by severe sepsis (n=5, 13.6%), post-liver transplantation complications (n=4, 10.8%), autoimmune disease (n=4, 10.8%), liver cirrhosis (n=2, 5.4%) and idiopathic pulmonary fibrosis (n=1, 2.7%). The mean baseline SOFA score and SAPS II score were 11.4[+ or -]2.8 and 46.9[+ or -]14.2, respectively.

The mean platelet count at the time of bronchoscopy was 27,300[+ or -]12,500 /[micro]l. Nine patients (24.3%) had platelet counts of < 20,000 /[micro]l. The mean activated partial thromboplastin time was 51.1[+ or -]10.6 seconds and the mean international normalised ratio of prothrombin time was 1.42[+ or -]0.3. The mean fibrinogen concentration was 327.5[+ or -]160.0 mg/dl. Just prior to the procedure, a mean of 8.3[+ or -]2.1 units of platelet concentrate (1 unit of platelet concentrate contains 50 to 100 billion platelets in 50 ml of plasma) were infused to 19 patients. Compared with patients who did not receive a platelet transfusion, patients who did receive a platelet transfusion had a significantly lower platelet count (23,500[+ or -]14,500 /[micro]l vs. 31,500[+ or -]8500 /[micro]l, P=0.027), prolonged international normalised ratio (1.58[+ or -]0.38 vs. 1.27[+ or -]0.20, P=0.006) and more haematologic malignancies (n=15 vs. n=7, P=0.017). In addition to platelets, eight patients received 4.4[+ or -]3.1 units of fresh frozen plasma and four patients received 16.5[+ or -]9.4 units of cryoprecipitate before the procedure. Twenty-seven patients received a transfusion with 7.2[+ or -]5.8 units of platelet concentrate while 4.6[+ or -]3.4 units of fresh frozen plasma and 30.8[+ or -]23.7 units of cryoprecipitate were transfused to eight and seven patients, respectively within 24 hours after bronchoscopy.

Patients exhibited mild tachycardia at the time of bronchoscopy, with a mean heart rate of 115.8[+ or -]26.3 bpm. The mean blood pressure was 82.4[+ or -]12.1 mmHg.

The ventilator mode before bronchoscopy was pressure-controlled in 21 patients and pressure-support ventilation in 16. Patients were ventilated with a PIP of 20.3[+ or -]7.5 cm[H.sub.2]O, a PEEP of 8.7[+ or -]4.2 cm[H.sub.2]O and dynamic compliance of 42.0[+ or -]27.1 ml/cm [H.sub.2]O. The baseline [P.sub.a][O.sub.2]/Fi[O.sub.2] (PF) ratio was 187.1[+ or -]96.4.

Indications for bronchoscopy included evaluation of undiagnosed lung infiltrate in 36 patients and airway inspection in one. BAL was performed in 33 patients, bronchial washing in three and TBLB in five.

Diagnostic yield of bronchoscopy

In 17 of 37 patients (45.9%), bronchoscopy yielded clinically useful information (Table 2). An infectious organism was confirmed in 11 patients. The isolated pathogens were cytomegalovirus in two patients, Aspergillus spp. in two, Mycobacterium tuberculosis in two and Acinetobacter baumanii, Candida albicans, Staphylococcus aureus, Streptococcus viridans and Stenotrophomonas maltophilia in one patient each. Although C. albicans and S. viridans are not usually regarded as pathogens in immunocompetent hosts, they were isolated from immunocompromised patients and showed > [10.sup.4], colonies/ml on quantitative culture. In addition, bronchoscopy revealed alveolar haemorrhage as the cause of lung infiltration in six patients.

Based on the results of bronchoscopy, treatment was modified in 14 patients (37.8%). New antibiotics were started or added in seven patients, unnecessary antibiotics were discontinued in four and corticosteroid therapy was initiated in three. Nevertheless, therapeutic modification was not associated with survival (P=0.157).

Complications

ICU survival was 48.6% (18 of 37) and no differences were found between survivors (n=18) and non-survivors (n=19) in terms of age, gender, underlying diseases, baseline platelet count, international normalised ratio, activated partial thromboplastin time, fibrinogen, physiological parameters, SOFA score or SAPS II score. There were two procedure-associated deaths (5.4%). One was a patient with underlying leukaemia with pneumonia who had already been on vasopressors before bronchoscopy and died due to refractory septic shock. The other was an idiopathic myelofibrosis patient who was confirmed to have diffuse alveolar haemorrhage by bronchoscopy and died from progressive hypoxaemia due to uncontrolled haemorrhage.

No major bleeding requiring intervention occurred at sites other than the respiratory system. Tracheobronchial bleeding occurred in 12 patients (32.4%) after the procedure, but none required red cell transfusion, except for the previously mentioned patient who died of uncontrolled haemorrhage. The incidence of bleeding in 19 patients who had received pre-procedural platelet transfusion was not significantly different from 18 patients who had not (8/19 vs. 4/18, P=0.174). There were no statistically significant differences in baseline patient characteristics in patients who experienced bleeding and in those who did not (Table 3).

There were no episodes of pneumothorax or pulmonary infection attributable to the procedure. Three patients had transient tachyarrhythmia, but no patient experienced bradycardia. Transient hypotension and fever developed in two patients each.

Changes in physiological parameters and vital signs

Table 4 shows the changes in lung physiological parameters in patients who underwent bronchoscopy. Data on two patients who died within 24 hours of the procedure were omitted. For PIP and dynamic compliance, there was no significant difference among the three time points (Pre-2H, Post-2H, and Post-24H) (P >0.05, Table 4). However, the level of PEEP significantly differed based on one-way ANOVA (P=0.041). There was a trend of increased PEEP at Post-2H (9.1[+ or -]3.9 cm[H.sub.2]O) compared with Pre-2H (8.3[+ or -]3.9 cm[H.sub.2]O), but this difference did not reach statistical significance (P=0.035). There were no significant differences in heart rate, blood pressure or body temperature among the Pre-2H, Post-2H and Post-24H time points (P >0.05, Table 4).

Changes in oxygenation, SOFA score and SAPS II score

The Pa[O.sub.2]/Fi[O.sub.2] ratio at 24 hours after bronchoscopy was 205.4[+ or -]107.7, which was not significantly different from that of the pre-bronchoscopy period (P=0.791). In addition, there were no significant differences in SOFA score or SAPS II score between these two time points (P=0.373 and P=0.663, respectively) (Table 5).

DISCUSSION

In this study, flexible bronchoscopy in the ventilator-dependent patients with severe thrombocytopenia (platelet count <50,000 /[micro]l) did not cause serious complications or have a significant effect on lung physiological parameters and vital signs. Moreover, bronchoscopy yielded clinically useful information in 17 of 37 patients (45.9%) and treatment was modified in 14 patients (37.8%) based on the results of bronchoscopy.

Since its introduction by Ikeda in 1968, flexible bronchoscopy has been used increasingly more often for the diagnosis and therapy of respiratory disease S14. Critically ill patients are no exception, especially because they are often too unstable to be moved for other diagnostic procedures (15-19). Flexible bronchosopy is generally regarded as safe, contributes valuable diagnostic information and is useful for therapeutic purposes in patients who are undergoing mechanical ventilation (3).

However, performing bronchoscopy in ventilator-dependent patients has potential for serious complications such as barotrauma, haemodynamic compromise and major bleeding (3). These complications may be especially detrimental to patients with severe thrombocytopenia and may limit the role of bronchoscopy in this population (20). Complications such as barotrauma necessitate the placement of tubes which may precipitate major bleeding and may adversely affect the clinical course of patients. Moreover, significant mucosal bleeding induced by the procedure may worsen already disrupted gas exchange and there is always the fear of major haemorrhage elsewhere.

This study suggests that flexible bronchoscopy, with or without BAL or TBLB, is useful clinically and can be performed relatively safely even in ventilator-dependent patients with severe thrombocytopenia (platelet count <50,000 /[micro]l). Although the risk of spontaneous bleeding does not increase until the platelet count falls below 10,000 /[micro]l, bronchoscopic manipulations may precipitate bleeding and many of our patients had concomitant coagulation deficiencies and/or fever, which put these patients at increased risk of bleeding (21). The relatively low incidence of bleeding seen in this study might be related to the aggressive pre- and post-procedural transfusion of platelets and coagulation factors.

Two patients died within 24 hours of the procedure. One was a 34-year-old male acute leukaemia patient with diffuse consolidation on chest radiography. Before bronchoscopy, he was already on dopamine and noradrenaline to maintain his arterial pressure. His [P.sub.a][O.sub.a]/Fi[O.sub.2] ratio was 96.7 and his SOFA score was 20. He underwent bronchoscopy at the request of his attending physician. He died due to multi-organ failure, despite the use of antimicrobials and inotropic agents. The other patient was a 51-year-old female patient with idiopathic myelofibrosis and sepsis, with a SOFA score of 16 and [P.sub.a][O.sub.a]/Fi[O.sub.2] ratio of 87.7. She was confirmed to have diffuse alveolar haemorrhage and although transfusion increased her platelet count from 9000 to 31,000 /[micro]l at two hours post-bronchoscopy, progressive bleeding aggravated hypoxia and resulted in her death. There is the possibility that bronchoscopic interventions may have adversely affected the clinical course in these two patients, resulting in their premature deaths. However, given that these patients had underlying severe haematologic diseases with multi-organ failure and were rapidly deteriorating at the time of the procedure, it is more likely that their deaths were attributable to progression of their underlying diseases. Nonetheless, when deciding to perform a procedure with inherent risks, such as bronchoscopy, the risks and benefits of the procedure should be carefully contemplated, especially in patients with a high probability of death.

Excluding the two patients who died, the patients in this study did not experience significant worsening of oxygenation parameters, although the majority of patients (89.1%) underwent BAL. However, the slight increase in PEEP at Post-2H may have been an indication of transient worsening of oxygenation. These results are compatible with previous studies demonstrating that BAL is associated with a transient reduction in [P.sub.a][O.sub.2], generally lasting for less than two hours(22,23). There was no significant decrease in lung mechanics and haemodynamic parameters, which suggests that there were no long-lasting adverse effects of the procedure. Similarly, there were no significant changes in organ failure or severity scores.

The fact that the result of the bronchoscopy was helpful in 17 (47.2%) patients is encouraging. It is intriguing that, despite the presence of thrombocytopenia, TBLB was aggressively performed in five patients, yielding positive results in two (invasive aspergillosis and cytomegalovirus infection, respectively). The safety and utility of TBLB in this population should be further studied. Moreover, the findings of bronchoscopy resulted in therapeutic modifications in 14 (37.8%) patients, although our study did not have the power to make conclusions on the therapeutic implications of bronchoscopy.

There are several limitations to this study. First, this study included only a limited number of patients from a single centre and thus the presence of selection bias is possible. Second, as this was a retrospective study, the effect of the procedure may have been under- or overestimated. For example, we defined major bleeding as a condition that required intervention for control; this may have underestimated the risk of bleeding after the procedure.

In conclusion, bronchoscopy is clinically useful and can be performed with acceptable risk in the majority of ventilator-dependent patients with severe thrombocytopenia. Severe thrombocytopenia itself should not preclude bronchoscopy, even in patients undergoing mechanical ventilation.

Accepted for publication on February 6, 2008.

REFERENCES

(1.) Raoof S, Mehrishi S, Prakash UB. Role of bronchoscopy in modern medical intensive care unit. Clin Chest Med 2001; 22:241-261.

(2.) Lindholm CE, Ollman B, Snyder J, Millen E, Grenvik A. Flexible fiberoptic bronchoscopy in critical care medicine. Diagnosis, therapy and complications. Crit Care Med 1974; 2:250-261.

(3.) Turner JS, Willcox PA, Hayhurst MD, Potgieter PD. Fiberoptic bronchoscopy in the intensive care unit--a prospective study of 147 procedures in 107 patients. Crit Care Med 1994; 22:259-264.

(4.) O'Brien JD, Ettinger NA, Shevlin D, Kollef MH. Safety and yield of transbronchial biopsy in mechanically ventilated patients. Crit Care Med 1997; 25:440-446.

(5.) Hertz MI, Woodward ME, Gross CR, Swart M, Marcy TW, Bitterman PB. Safety of bronchoalveolar lavage in the critically ill, mechanically ventilated patient. Crit Care Med 1991; 19:1526-1532.

(6.) Bulpa PA, Dive AM, Mertens L, Delos MA, Jamart J, Evrard PA et al. Combined bronchoalveolar lavage and transbronchial lung biopsy: safety and yield in ventilated patients. Eur Respir J 2003; 21:489-494.

(7.) Lim do H, Lee J, Lee HG, Park BB, Peck KR, Oh WS et al. Pulmonary complications after hematopoietic stem cell transplantation. J Korean Med Sci 2006; 21:406-411.

(8.) Afessa B, Peters SG. Major complications following hematopoietic stem cell transplantation. Semin Respir Crit Care Med 2006;27:297-309.

(9.) Levine DS, Navarro OM, Chaudry G, Doyle JJ, Blaser SL Imaging the complications of bone marrow transplantation in children. Radiographics 2007; 27:307-324.

(10.) Camus P, Costabel U. Drug-induced respiratory disease in patients with hematological diseases. Semin Respir Crit Care Med 2005; 26:458-481.

(11.) Lehne G, Lote K. Pulmonary toxicity of cytotoxic and immunosuppressive agents. A review. Acta Oncol 1990; 29:113-124.

(12.) Snyder LS, Hertz MI. Cytotoxic drug-induced lung injury. Semin Respir Infect 1988; 3:217-228.

(13.) Weiss SM, Hert RC, Gianola FJ, Clark JG, Crawford SW Complications of fiberoptic bronchoscopy in thrombocytopenic patients. Chest 1993; 104:1025-1028.

(14.) Sackner MA. Bronchofiberscopy. Am Rev Respir Dis 1975; 111:62-68.

(15.) Milledge JS. Therapeutic fibreoptic bronchoscopy in intensive care. Br Med J 1976; 2:1427-1429.

(16.) Barrett CR Jr. Flexible fiberoptic bronchoscopy in the critically ill patient. Methodology and indications. Chest 1978; 73:746-749.

(17.) Stevens RP, Lillington GA, Parsons GH. Fiberoptic bronchoscopy in the intensive care unit. Heart Lung 1981; 10:10371045.

(18.) Jolliet P, Chevrolet JC. Bronchoscopy in the intensive care unit. Intensive Care Med 1992; 18:160-169.

(19.) Olopade CO, Prakash UB. Bronchoscopy in the critical-care unit. Mayo Clin Proc 1989; 64:1255-1263.

(20.) Papin TA, Lynch JP 3rd, Weg JG. Transbronchial biopsy in the thrombocytopenic patient. Chest 1985; 88:549-552.

(21.) Drews RE, Weinberger SE. Thrombocytopenic disorders in critically ill patients. Am J Respir Crit Care Med 2000; 162:347-351.

(22.) Karetzky MS, Garvey JW, Brandstetter RD. Effect of fiberoptic bronchoscopy on arterial oxygen tension. N Y State J Med 1974; 74:62-63.

(23.) Albertini RE, Harrell JH 2nd, Kurihara N, Moser KM. Arterial hypoxemia induced by fiberoptic bronchoscopy. JAMA 1974; 230:1666-1667.

Y. H. KIM *, G. Y. SUH ([dagger]), M. H. KIM ([double dagger]), H. Y. PARK([section]), E. H. KANG**, W.-J. KOH([dagger][dagger]), M. P. CHUNG([dagger]), H. KIM([double dagger][double dagger]), O. J. KWON([double dagger][double dagger]), K. KIM([section][section]) Divisions of Pulmonary and Critical Care Medicine and Haematology/Oncology, Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea

* M.D., Clinical Professor, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, East-West Neo Medical Centre, Kyung Hee University.

([dagger]) M.D., Ph.D., Associate Professor, Division of Pulmonary and Critical Care Medicine.

([double dagger]) M.D., Fellow, Division of Pulmonary and Critical Care Medicine.

([section]) M.D., Resident, Division of Pulmonary and Critical Care Medicine.

** M.D., Ph.D., Clinical Professor, Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Korea University.

([dagger][dagger]) M.D., Ph.D., Assistant Professor, Division of Pulmonary and Critical Care Medicine.

([double dagger][double dagger]) M.D., Ph.D., Professor, Division of Pulmonary and Critical Care Medicine.

([section][section]) M.D., Ph.D., Assistant Professor, Division of Haematology/Oncology.

Address for reprints: A/Prof Gee Young Sub, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Republic of Korea.
TABLE 1
Baseline characteristics of patients (n=37)

Characteristics

Mean age (y) 46.9[+ or -]15.2
Gender, M/F 20: 17
Underlying disease (n, %)
haematologic disease 21 (56.7)
infection 5 (13.6)
post-liver transplantation 4 (10.8)
autoimmune disease 4 (10.8)
cirrhosis 2 (5.4)
idiopathic pulmonary fibrosis 1 (2.7)
SOFA score 11.4[+ or -]2.8
SAPS II score 46.9[+ or -]14.2
Laboratory data
white cell (/[mu]l) 4300[+ or -]5090
platelet (/[mu]l) 27,000[+ or -]12,500
haemoglobin (g/dl) 9.5[+ or -]1.7
APTT (s) 51.1[+ or -]10.6
INR 1.42[+ or -]0.3
fibrinogen (mg/dl) 327.5[+ or -]160.0
Vital signs
blood pressure (mmHg) 82.4[+ or -]12.1
heart rate (beats/min) 115.8[+ or -]26.3
body temperature ([degrees]) 37.2[+ or -]1.1
Lung physiology
PEEP (cm[H.sub.2]O) 8.7[+ or -]4.2
PIP (cm[H.sub.2]O) 20.3[+ or -]7.5
compliance (ml/cm[H.sub.2]O) 42.0[+ or -]27.1
Gas exchange
[P.sub.a][O.sub.2]/Fi[O.sub.2] 187.1[+ or -]96.4

SOFA=sequential organ failure assessment score, SAPS
II=simplified acute physiologic score II, APTT=activated
partial thromboplastin time, INR=international normalised ratio,
PEEP=positive end-expiratory pressure, PIP=peak inspiratory
pressure.

TABLE 2
Diagnostic yield of bronchoscopy

 BAL Bronchial TBLB
 (n=33) washing (n=5)
 (n=3)

Alvaeolar haemorrhage 6
Cytomegalovirus 1 1
Aspeigillus spp. 1 1
M. tuberculosis 2
C. albicans 1
A. baumanii 1
S. aureus 1
S. viridans 1
S. maltophilia 1
Total 14 1 2

M. tuberculosis =Mycobacterium tuberculosis, C. albicans=Candida
albicans, A. baumanii=Acinetobacter baumanii, S.
aureus=Staphylococcus aureus, S. viridans=Streptococcus viridans,
S. maltophilia=Stenotrophomonas maltophilia.

TABLE 3
Comparison of patient characteristics with respect to occurrence
of bleeding after bronchoscopy

 Tracheal No tracheal P value
 bleeding bleeding
 (n= 12) (n=25)

Mean age (y) 52.2[+ or -]12.3 46.0[+ or -]17.1 0.271

Male (n) 7 13 0.498

Platelet
(/[mu]l) 24,420[+ or -]12,120 28,800[+ or -]12,640 0.705

INR 1.44[+ or -]0.36 1.42[+ or -]0.33 0.263

APTT (sec) 50.3[+ or -]9.0 51.9[+ or -]11.5 0.090

Fibrinogen
(mg/dl) 349.0[+ or -]123.1 317.0[+ or -]176.4. 0.521

Haematologic
malignancy (n) 8 13 0.399

Infection (n) 1 4 0.523

Post-liver
transplantation
(n) 1 3 0.737

Cirrhosis (n) 1 1 0.585

TBLB (n) 3 2 0.182

SOFA score 12.1[+ or -]3.0 11.0[+ or -]2.8 0.306

SAPS 11 score 49.3[+ or -]18.6 46.0[+ or -]12.9 0.597

Number of
patients
transfused
before
bronchoscopy
(n)

Platelet 7 12 0.556

FFP 3 5 0.729

INR=international normalised ratio, APTT=activated partial
thromboplastin time, TBLB=transbronchial lung biopsy,
SOFA=sequential organ failure assessment score, SAPS II=simplified
acute physiologic score II, FFP=fresh frozen plasma.

TABLE 4
The changes of gas exchange and lung physiologic parameters
in patients surviving more than 24 hours after bronchoscopy (n=35)

 Pre-2H Post-2H

Compliance (ml/
cm[H.sub2.]O) 42.8[+ or-]27.7 39.5[+ or-]31.6

PIP (cm[H.sub2.]O) 20.0[+ or-]7.6 21.7+7.2

PEEP (cm[H.sub2.]O) 8.3[+ or-]3.9 9.1[+ or-]3.9

HR (beats/min) 116.9[+ or-]26.9 113.4[+ or-]27.3

BP (mmHg) 82.6[+ or-]12.9 81.5[+ or-]12.0

BT ([degrees]) 37.5[+ or-]1.1 37.2[+ or-]1.2

 Post- 24H P

Compliance (ml/
cm[H.sub2.]O) 42.7[+ or-]30.4 0.710

PIP (cm[H.sub2.]O) 21.6[+ or-]7.9 0.078

PEEP (cm[H.sub2.]O) 9.3[+ or-]4.1 0.041

HR (beats/min) 114.4[+ or-] 26.1 0.253

BP (mmHg) 83.6[+ or-]12.1 0.618

BT ([degrees]) 37.5[+ or-]1.1 0.165

PIP=peak inspiratory pressure, PEEP=positive end-expiratory
pressure, HR=heart rate, BP =blood pressure, BT=body temperature.

TABLE 5
The changes of oxygenation, SOFA score and SAPS II score in
patients surviving more than 24 hours after bronchoscopy (n=35)

 Prior to 24 hours after P
 bronchoscopy bronchoscopy
[P.sub.a][O.sub.2]
/Fi[O.sub.2] 209.0[+ or -]87.4 205.4[+ or -]107.7 0.791

SOFA score 12.3[+ or -]3.0 12.0[+ or -]3.4 0.373

SAPS 11 score 47.0[+ or -]15.0 47.8[+ or -]14.6 0.663

SOFA=sequential organ failure assessment score, SAPS
11= simplified acute physiologic score 11.
COPYRIGHT 2008 Australian Society of Anaesthetists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2008 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Kim, Y.H.; Suh, G.Y.; Kim, M.H.; Park, H.Y.; Kang, E.H.; Koh, W.-J.; Chung, M.P.; Kim, H.; Kwon, O.J
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Geographic Code:9SOUT
Date:May 1, 2008
Words:4777
Previous Article:Comparison of the laryngeal mask (LMA[TM]) and laryngeal tube (LT[R]) with the perilaryngeal airway (CobraPLA[R]) in brief paediatric surgical...
Next Article:Risk factors for treatment failure in patients with severe acute cardiogenic pulmonary oedema.
Topics:

Terms of use | Privacy policy | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters