Impact of Operator and Anesthesia Choice on Bronchoscopic Biopsy Yield and Complications

Flexible bronchoscopy with bronchoalveolar lavage and transbronchial biopsy is the gold standard for the diagnosis of infection, acute rejection, and airway complications in lung transplant recipients. In the hands of an experienced operator, bronchoscopy carries minimal risk. The outcome of all bronchoscopies performed in the first year following lung transplantation at the Hospital of the University of Pennsylvania was recorded retrospectively. Records were included if lung transplantation was performed from January 2011 to December 2013. A total of 549 bronchoscopies were performed on 132 patients. Three hundred bronchoscopies were done on bilateral lung transplants and 249 on single lung transplants. Intravenous conscious sedation managed by the pulmonologist was used in 459 cases and 90 were done under general anesthesia. The bronchoscopy was performed during a rotation with a novice fellow in 168 of the 549 cases. The mean number of samples sent for analysis was 9.09±3.5 pieces, with a mean number of samples with alveolated tissue of 7.08±3.2. With novice fellows, the mean number sent was 8.82 with 6.97 pieces of alveolated tissue. These numbers were 9.10 and 7.12 versus 9.17 and 6.67 under conscious sedation and general anesthesia, respectively. There were complications in 82 (14.9%) of the bronchoscopies. We purposely had a sensitive definition of to be able to capture all unexpected events that were described in the report. These included: Bleeding controlled with suctioning, bleeding requiring the use of iced saline or epinephrine, bleeding requiring an endotracheal tube or bronchial blocker, pneumothorax without need for tube thoracostomy, pneumothorax requiring tube thoracostomy, hypoxemia requiring intervention during the procedure, hypoxemia requiring admission, sepsis linked to the procedure, and death. There was no significant difference in complications based on trainee level. There were more complications when procedures were performed under intravenous conscious sedation, with complications noted in 77 cases (16.8%) versus in 5 cases (5.6%) performed under general anesthesia. Bronchoscopy can be performed safely with no change in procedural yield or complications when novice trainees participate. While it does not affect yield, complications can potentially be reduced by the use of general anesthesia.