Contraindications for Bronchoscopy

Absolute and Relative Contraindications

• The British Thoracic Society recommends that bronchoscopy should be avoided within 6 weeks of a myocardial infarction, and is relatively contraindicated in patients with severe hypoxemia, raised pre-procedure arterial CO₂, unstable cervical spine, severe maxillofacial trauma, or obstructing oral/laryngeal disease 1, 2
• The European Respiratory Society suggests that recent myocardial infarction is a relative contraindication to bronchoscopy, and the procedure should be avoided if possible within 6 weeks of MI due to increased risk of arrhythmias and cardiac complications 1, 3, 4, 5, 6, 7, 8
• The British Thoracic Society indicates that severe cardiac disease is not an absolute contraindication, but patients with severe cardiovascular disease require careful consideration and ECG monitoring during the procedure 9
• The European Respiratory Society recommends that bronchoscopy is relatively contraindicated in patients with severe hypoxemia (SaO₂ <93%), though it may be performed with appropriate precautions including oxygen supplementation and close monitoring 1
• The British Thoracic Society advises that sedation should be avoided when pre-bronchoscopy arterial CO₂ is elevated, as both sedation and oxygen supplementation can further increase CO₂ levels 1, 3, 4, 5, 6, 7, 8
• The European Respiratory Society suggests that patients with severe COPD require arterial blood gas measurement before bronchoscopy, and sedation should be avoided if CO₂ is raised 1, 5, 6, 7, 8
• The British Thoracic Society recommends that if biopsy is anticipated, oral anticoagulants should be stopped at least 3 days before bronchoscopy or reversed with low-dose vitamin K 1, 3, 4, 5, 6, 7, 8
• The European Respiratory Society indicates that if anticoagulation must continue, INR should be reduced to <2.5 1, 3, 4, 5, 6, 7, 8

Anatomical Contraindications

• The European Respiratory Society states that unstable cervical spine is an absolute contraindication to rigid bronchoscopy due to neck extension requirements 10, 2
• The British Thoracic Society advises that severe maxillofacial trauma or deformity prevents safe passage of rigid bronchoscope 10, 2
• The European Respiratory Society recommends that obstructing oral or laryngeal disease blocks access for rigid bronchoscope insertion 10, 2

Important Clinical Considerations

• The British Thoracic Society suggests that oxygen supplementation should achieve SaO₂ ≥90% to reduce arrhythmia risk 1, 3, 4, 5, 6, 7, 9, 8
• The European Respiratory Society recommends that continuous oximetry monitoring is mandatory 1, 3, 4, 5, 6, 7, 8
• The British Thoracic Society advises that ECG monitoring should be considered in patients with severe cardiac disease or hypoxia despite oxygen supplementation 1, 9, 8
• The European Respiratory Society indicates that resuscitation equipment must be readily available 1, 9, 8
• The British Thoracic Society recommends that intravenous access should be established before bronchoscopy and maintained through recovery 1, 3, 4, 5, 6, 7, 9, 8
• The European Respiratory Society suggests that do not sedate patients with elevated baseline CO₂, as this can precipitate respiratory failure 1, 3, 4, 5, 6, 7, 8
• The British Thoracic Society advises that do not proceed without checking coagulation parameters in patients with liver disease, uraemia, immunosuppression, or pulmonary hypertension when biopsy is planned 9
• The European Respiratory Society recommends that do not forget prophylactic antibiotics in asplenic patients, those with heart valve prostheses, or previous endocarditis 1, 3, 4, 5, 6, 7, 8

Management of Antiplatelet Agents Before Bronchoscopy

Oral Anticoagulant Management

• 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 11
• The short-term risk of thromboembolism in patients with mechanical heart valves when not anticoagulated is very small 12, 13, 14

Risk Stratification for Bleeding

• Patients at increased risk of bleeding include those with uraemia, immunosuppression, pulmonary hypertension, liver disease, coagulation disorders, or thrombocytopenia 12, 13, 14, 15, 16
• In high-risk patients, check platelet count, prothrombin time (PT), and activated partial thromboplastin time (APTT) before bronchoscopy 12, 13, 14
• Routine preoperative coagulation screening is unjustified in those with no risk factors undergoing routine bronchoscopy 12, 13, 14

Procedure-Specific Considerations

• Significant hemorrhage (>50 ml) occurred in 1.6-4.4% of patients undergoing transbronchial biopsy for diffuse lung disease 12, 15, 16
• Profuse bleeding was more likely after transbronchial than endobronchial biopsies 15, 16
• The risk of bleeding during transbronchial biopsies is unrelated to forceps size but slightly higher in mechanically ventilated patients 12, 13, 14