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The Lung Transplant Unit, St. Vincent’s Hospital, Sydney, Australia
Correspondence: Prashant N. Chhajed, MD, DNB, FCCP, The Lung Transplant Unit, St. Vincent’s Hospital, Xavier Building, Level 4, Victoria St, Darlinghurst, NSW 2010, Sydney, Australia; e-mail: chhajed{at}hotmail.com
To the Editor:
We read with interest the prospective report of Herth et al (October 2002),1 which examined the role of aspirin as a risk factor for bleeding associated with transbronchial lung biopsy (TBBX). Two hundred eighty-five of the 1,217 study subjects had consumed aspirin within 24 h of undergoing the procedure. No bleeding was defined as traces of blood after finishing the biopsies without the need for continued suctioning. Mild bleeding was defined as the need for continued suctioning of blood from the airways after the procedure, moderate bleeding was defined as a requirement for intubation of the biopsied segment with the flexible bronchoscope into the wedge position, and severe bleeding was defined as the need for an additional intervention, such as placement of a temporary bronchus blocker, the application of a fibrin sealant, admission to a critical care unit, or the need for blood products.
There are several unanswered questions regarding the methodology used in this article. TBBX may be performed with or without wedging the bronchoscope.2 3 Was the bronchoscope wedged to obtain the TBBX? If it was, then when was the wedge position removed? With the wedge technique, the bronchoscope is reinserted or rewedged if there is evidence of bleeding postbiopsy and suctioning is discouraged. If the TBBX was performed without wedging the bronchoscope, then at what stage was suctioning stopped and the bleeding segment wedged with the bronchoscope? Furthermore, this appears to be a collaborative work from two centers. Was the same technique used to obtain TBBX in both centers? What criteria were used to ensure that the need for clinical intervention to judge the amount of bleeding associated with TBBX was uniform in both the centers?
Some bronchoscopists may not wedge the bronchoscope at all and may continue suctioning with the "back-and-forth technique" until bleeding stops spontaneously.3 Were further TBBXs abandoned because of the severity of bleeding?
As none of the patients in the study required intubation, admission to critical care areas, or blood transfusion, the article highlights the fact that TBBX may be undertaken with controllable bleeding complications in patients who have received aspirin within 24 h of the procedure. Bleeding during TBBX is usually recorded as the volume of mixed blood and lavage fluid that is collected through the suction system of the bronchoscope at the end of the procedure.3 4 5 However, this study does not clearly assess the role of aspirin in the risk of bleeding associated with TBBX, as the quantity of bleeding was not recorded, irrespective of whether it was controlled with bronchoscopic methods and despite the prospective nature of the study. The identification of the severity of bleeding following TBBX in patients who have taken aspirin within 24 h of the procedure and its management in this large series remains elusive.
References
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