J Varon, R Fromm, Jr.
complications, fiberoptic bronchoscopy, training
J Varon, R Fromm, Jr.. Fiberoptic Bronchoscopy: Complications Among Physicians-In-Training. The Internet Journal of Emergency and Intensive Care Medicine. 1997 Volume 2 Number 1.
Fiberoptic bronchoscopy (FOB) has been in clinical use in since 1968. This technique has evolved over the last two decades and its applications have greatly increased. The indications for this procedure have expanded in recent years due to several factors. Among them, the acquired immunodeficiency syndrome (AIDS) epidemic, the increasing number of organ transplants, and the widespread use of chemotherapeutic agents.
To become proficient, performance of 50 to 100 FOBs has been suggested. In addition, a recent survey indicated that at least 25 bronchoscopic procedures per year were necessary to maintain competence in the procedure. The morbidity associated with FOB among practicing bronchoscopists has been reported to be very low in retrospective studies. Moreover, very few studies have described the complication rates associated with learning of this technique. The purpose of this study was to examine the frequency and types of complications of bronchoscopy occurring in a large teaching program.
Materials and Methods
FOBs performed at the Veterans Affairs Medical Center in Houston, Texas, were identified from the bronchoscopy log during a 97 month study period (September 1985 to October 1993). All these FOBs are performed in the bronchoscopy suite by first and second year pulmonary/critical care fellows under Baylor College of Medicine faculty guidance. The patients undergoing FOB are hospitalized for this procedure 24 hours prior to the FOB or they have been inpatients. No outpatient bronchoscopies are performed at this institution. The nasal route is used in the majority of the patients.
The bronchoscopy log book record includes patient age, name, social security number, indications for the procedure, radiographic appearance, type of procedures performed (i.e., brushings, bronchoalveolar lavage, etc), coagulation studies, oxygen saturation prior to the procedure, premedication utilized, complications experienced, and the final diagnosis and outcome for each procedure. The indications for FOB were divided into atelectasis, cavitary lesions, hemoptysis, infiltrates, mass lesions and brachytherapy. Each one of the complications was reviewed in detail in a separate complication log book.
Bronchoscopies totaled 3572 during the study period. Transbronchial biopsies (TBBx) were performed in 1408, endobronchial biopsies (EnBx) in 926, bronchoalveolar lavage (BAL) in 962 and Wang-needle biopsies in 376.
Complications occurred in 1.58% (56) of the procedures. The average age of patients experiences complications during FOB was 53.6 ± 13.1 years. The indications for FOB that led to complications are depicted in Table 1. These complications included 6 deaths, 18 hemorrhages, 26 pneumothoraces, and 6 others. Bleeding was the cause of death in 3, cardiac dysrhythmia in 2, and severe bronchospasm in one patient. TBBx was the procedure most commonly associated with complications (n=41). This was followed by brushings (n=38), BAL (n=26), EnBx (n=12) and Wang-needle biopsy (n=9).
Fiberoptic bronchoscopy has become a useful tool in the diagnosis of many thoracic diseases. It has revolutionized the diagnostic approach to airway and parenchymal pulmonary disease. The student of FOB needs a long apprenticeship to become familiar with the instrument as well as with the anatomical differences that exist among individuals. In addition, learning to perform FOB necessarily involves repetition of the procedure in sufficient numbers to develop proficiency.
Our study demonstrates a low incidence of complications among patients undergoing FOB. This is particularly interesting as these procedures were performed by physicians-in-training. We conclude that FOB is a safe procedure even when physicians-in-training are performing them.