Fiberoptic Bronchoscopy in Bronchial Asthma*

Fiberoptic Bronchoscopy in BronchialAsthma*A Word of CautionSteoen A. Sahn, M.D., F.C.C.P.; and Churles Scoggin, M.D.**Three instances of intense laryngospasm and bronchospasmoccurred as a result of fiberoptic bronchoscopicexamination in three patients with quiescent bronchialasthma. The indications for the procedure were hemoptysisin one patient and lobar collapse in two. It is likelythat vagally mediated reflex laryngospasm and bronchoconstrictionoccur when irritant receptora are mechani-cally stimulated by the bronchoscope. Therefore, in theasthmatic population with its increased airway reactivity,indications for fiberoptic bronchoscopy should be absolute,and the procedure sbould be performed under optimalcondition& A retionale for minimizing the risk of thisprocedure in patients with bronchial asthma is discussed.ince the description of the flexible fiberopticbronchoscope for the early diagnosis of peripherallylocated endobronchial lesions by Ikeda et allin 1968, the diagnostic and therapeutic potential ofthis instrument has been widely expanded. Due toits relative technical simplicity and minimal patientdiscomfort, this instrument has been used for bronchialbrush biopsies, - transbronchial-pulmonary biopsies,evaluation of hemoptysis, treatment ofatelectasis, and in patients with respiratory failure.*Major complications and mortality from fiberopticbronchoscopic examination have been reported tobe quite low. However, patients with bronchialasthma may be at increased risk during this procedure.During a four-month period, we encounteredthree episodes of severe laryngospasm and bronchospasm,one leading to death, in three consecutivefiberoptic bronchoscopic examinations in asthmaticsubjects. The purpose of this report is to stress thepotential risk involved in bronchoscopic examinationof asthmatic patients and to discuss the possiblemechanisms involved in the production of laryngc~spasm and bronchospasm. Measures to minimizerisk in these patients will also be reviewed.A 54year-old man entered Colorado General Hospital,Denver, for evaluation of hemoptysis. The patient had had'From the Division of Pulmona Medicine, Department ofMedicine, University of Coloraro Medical Center, Denver.''Teaching and Research Scholar, American College ofPhysicians.Manuscript received June 20; revision accepted July 25.Reprint requests: Dr. Scoggin, 4200 East Ninth Avenue,Denuer 80220bronchial asthma since childhood with numerous hospitalizationsfor status asthmaticus. He had been treated withtheophylline preparations and occasional courses of corticesteroidtherapy. Three months prior to admission, the patientnoted blood-streaked sputum. Fever, weight loss, and chestpain were not present. The patient's asthma was under goodcontrol with oral administration of theophylline. Findingsfrom physical examination were normal. Laboratory examinationrevealed a leukocyte count of 9,70O/cu mm, with 12percent eosinophils. Arterial blood gas analysis with the patientbreathing ambient air showed a pH of 7.42, an arterialcarbon dioldde tension (PaC02) of 33 mm Hg, and anarterial oxygen pressure ( Pa02 ) of 85 mm Hg ( normal forDenver, PaC02 of 35 2 2 mm Hg and Pa02 of 70 f 5 mmHg). A chest roentgenogram was normal. After the administrationof 30 mg of codeine and 0.4 mg of atropine intramuscularly,the 6beroptic bronchoscope was passed transnasallywithout difficulty. Adequate local anesthesia to thevocal cords and bronchial mucosa was effected with a 1percent solution of lidocaine ( Xylocaine ) . Inspection of thevocal cords and the lobar, segmental, and subsegmentalbronchi required approximately five minutes and revealed noabnormalities. Upon withdrawal of the bronchascope, thepatient developed intense laryngospasm and bronchospasm.Stridor, use of the accessory respiratory muscles, and intercostalretraction were noted. While the patient was breathing4 L of oxygen per minute by nasal cannula, arterial blood gasanalysis showed a pH of 7.48, a PaCOz of 28 mm Hg, and aPa02 of 60 mm Hg. The patient was given 0.5 ml ofterbutaline subcutaneously, inhaled epinephrine, and an intravenousdrip infusion of aminophylline at 1 mg/kg of bodyweight per hour. Thirty minutes after initiation of therapy,the patient's respiratory status had improved. No furthersequelae of the bronchoscopic examination were noted, andno cause for the patient's hemoptysis was found.A 48-year-old woman was transferred to Colorado GeneralHospital for evaluation of bronchial asthma with persistentleft lower lobe atelectasis and fever. Physical examinationdisclosed dullness to percussion, decreased fremitus, anddecreased breath sounds at the left pulmonary base. Auscul-CHEST, 69: 1, JANUARY, 1976 FIBEROPTIC BRONCHOSCOPY IN BRONCHIAL ASTHMA 39Downloaded From: http://publications.chestnet.org/ on 03/29/2014

sult of a combination of factors: compromised airwayby the bronchoscope, underlying respiratorydisease, respiratory depression secondary to premedication,adverse effects of topical anesthesiaand suctioning, and possibly subepithelial receptor-mediated reflexes causing bronchoconstrictionand ventilation-perfusion disturbances. Karetzkyet a120 have shown that si@cant hypoxernia occurredwhen the bronchoscopic tip was at the levelof the canna, an area known to have a high concentrationof subepithelial receptor sites.Patient 1 underwent bronchoscopic examinationfor evaluation of hemoptysis at a time when hisasthma was in remission. Despite a modest dose ofatropine, adequate local anesthesia to preventcough, and supplemental oxygen, laryngospasm andbronchospasm developed. The second patient, whounderwent bronchoscopic examination for persistentleft lower l~be atelectasis and fever, was also inremission. Premedication and local anesthesia didnot prevent a severe upper and lower airway reactionto instrumentation, leading to irreversible hypoxicbrain damage. Patient 3 underwent bronchoscopicexamination on two occasions, one withthe fiberoptic instrument and the other under generalanesthesia with the rigid bronchoscope, forpersistent left upper lobe illapse in the face ofintensive medical and physical therapy. Bronchospasmoccurred with both the fiberoptic and rigidbronchoscope, which suggests that mechanical imtationwas the initiating factor; however, respiratoryfailure after the straight bronchoscopic examinationmay have been due to the additive adverseeffects of halothane. This anesthetic has been shownto depress hypercapnic ventilatory drives, increasethe level of alveolar carbon dioxide tension atwhich respiration begins,22 and require a prolongedrecovery tirneaZsIn all patients, modest doses of atropine weregiven as premedication, adequate local anesthesiawas provided with lidocaine, and supplemental oxygenwas provided to maintain normal values ofPaO2. We hypothesize that in certain patients withbronchial asthma, intense laryngospasm and bronchospasmare triggered by the mechanical manipulationof the fiberoptic bronchoscope against thelarynx and bronchial mucosa and is reflexly mediated,at least partially, by vagal pathways. Possiblylarger doses of atropine (1 to 2 mg) administeredparenterally or by inhalation might ameliorate oreven obliterate these reflex responses. Atropine reducesthe occurrence of laryngospasm during generalanesthesia. This appears to be due to the reductionof respiratory-tract secretions that can causereflex laryngospasm and not to blockade of laryngealskeletal m~scle.~The decision to perform fiberoptic bronchoscopicprocedures in patients with bronchial asthma shouldbe based on absolute indications, and the procedureshould be undertaken with great caution. These patientsare in an extremely high-risk group for thedevelopment of laryngospasm and bronchospasm.Unless there are compelling factors, the procedureshould be performed only when the patient's asthmais quiescent and he is in a state of maximum bronchodilation.Large doses of atropine should be givenas premedication, the vocal cords should be carefullyand fully anesthetized, and supplemental oxygenshould be administered, so that the risk of majorcomplications in this group of patients will be minimized.ACKNOWLEDGMENTS: We wish to thank Drs. T. L.Petty, J. H. Ellis, Jr., and M. D. Iseman for their helpful suggestions,and Ms. S. L. Jones for expert technical assistance inpreparation of the manuscript.1 Ikeda S, Yanai N, Ishikawa S: Flexible bronchofiberscope.Keio J Med 17:l-16, 19682 Zavala DC, Richardson RH, Mukerjee PK, et al: Use ofthe bronchofiberscope for bronchial brush biopsy. Chest63:889-892, 19733 Levin DC, Wicks AB, Ellis JH Jr: Transbronchial lungbiopsy via the fiberoptic bronchoscope. Am Rev RespirDis 110:4-12, 19744 Smiddy JF, Elliott RC: The evaluation of hemoptysis withfiberoptic bronchoscopy. Chest 64: 158-162, 19735 Wanner A, Landa JF, Nieman RE Jr, et al: Bedsidebronchofiberscopy for atelectasis and lung abscess. JAMA244: 1281-1283, 19736 Matsumoto T, DeLaurentis D: Tracheal aspiration andfiberoptic bronchoscopy. JAMA 221: 1163, 19727 Renz LE, Smiddy JF, Rausher CR, et al: Bronchoscopy inrespiratory failure. JAMA 219:619, 19728 Tahir AH: Bronchoscopy in respiratory failure. JAMA220:725, 19729 DuBois AB, Dautrebande L: Acute effects of breathinginert dust particles and of carbachol aerosol on themechanical characteristics of the lungs in man: Changesin response after inhaling syrnpathomimetic aerosols. JClin Invest 37: 174-1755. 195810 Nadel JA, Widdicombe JG: Reflex effects of upper airwayinitation on total lung resistance and blood pressure. JAppl Physiol 17:861-865, 196211 Sirnonsson BG, Jacobs FM, Nadel JA: Role of autonomicnervous system and the cough reflex in the increasedresponsiveness of airways in patients with obstructiveairway disease. J Clin Invest 46: 1812-1818, 196712 Widdicombe JG, Kent DC, Nadel JA: Mechanism ofbronchoconstriction during inhalation of dust. J ApplPhysiol 17:613-616, 196213 Curry JJ: The action of histamine on the respiratory tractin normal and asthmatic subjects. J Clin Invest 25:785-791, 194614 Tiffeneau R: Pharmacodynamic du poumon asthmatique.Path01 Biol Semaine Hop 6:421-447, 195815 Credle WF Jr, Smiddy JF, Elliott RC: Complications ofCHEST, 69: 1, JANUARY, 1976 FIBEROPTIC BRONCHOSCOPY IN BRONCHIAL ASTHMA 41Downloaded From: http://publications.chestnet.org/ on 03/29/2014

fiberoptic bronchoscopy. Am Rev Respir Dis 109:67-72,1974.16 JafTe JH: Narcotic analgesics. In The Pharmacologic Basisof Therapeutics (3rd ed) (Goodman LS, Gillman A,eds ) . Toronto, Macmillan Co, 1965, pp 257-26017 Adriani J: The clinical pharmacology of local anesthetics.Clin Pharmacol Ther 1 :645-673, 196018 Albertini RE, Hamell JH, Moser KM: Arterial hypoxemiainduced by fiberoptic bronchoscopy. Chest 65:117, 197419 Dubrawsky C, Awe RJ, Jenkins DE: The effect of bronchofiberscopicexamination on oxygenation status. Chest67: 137-140, 197520 Karetzky MS, Garvey JW, Brandstetter RD: Effect offiberoptic bronchoscopy on arterial oxygen tension. NYState J Med 74:62-63, 197421 Kleinholz EJ, Fussell J, McBrayer R: Arterial blood gasstudies during fiberoptic bronchoscopy. Am Rev RespirDis 108:1014, 197322 Fink BR, Ngai SH, Hanks EC: The central regulation ofrespiration during halothane anesthesia. Anesthesiology23 :200-206, 196223 Price HL, Dripps RD: General anesthetics. In The PharmacologicBasis of Therapeutics ( 3rd ed) ( Goodman LS,Gilman A, eds). Toronto, Macmillan Co, 1965, pp 90-9324 Innes IR, Nickerson M: Drugs inhibiting the action ofacetylcholine on structures innervated by postganglionicparasympathetic nerves. In The Pharmacologic Basis ofTherapeutics (3rd ed) (Goodman LS, Gilman A, eds).Toronto, Macmillan Co, 1965, pp 522-532Tenderness in DestructionThe Volcano Vesuvius on August 24th A.D. 79The hail of pumice and ashes which overwhelmedPompeii did not come Herculaneum's way. But whatdescended instead was mud. For, in addition to the rainof solid projectiles, the mountain also belched forth atorrent of steam escaping at a heat of 2000°F. Condensingand mingling with seawater spray, this stream producedscorching local downpours, which churned up thelava surface of the mountain into a boiling mass. The"mud lava" formed a tomd, treacly river which poureddown the deep ravines and obliterated Herculaneum.Then gradually the mass cooled and solidified to theconsistency of rock. The hot mud moved on Herculaneumwith a curious mixture of irresistible violenceand gentle delicacy. The buildings of the town werebulldozed into ruin and yet the mud preserved manythings. In its slow but inexorable procession, the tonidooze filled rooms without disturbing the position of acradle in the nursery, or the pots on the kitchen stove.Cooling, it scorched cloth and papyrus; but it did notdestroy them. Nor did it pulverize wood. It only carbonizedit. And so beams, stairs, furniture, a woodenclothes press, a cupboard, a little household shrine withgods still inside, all were saved. Indeed, even egg-shellsremained intact-in the same carbonized condition, withina kitchen cupboard, and again on a dining-room tablewhere they were found with the rest of the lunch-bread,salad, cakes and fruit-that was being served when thecatastrophe struck.Grant, M: Cities of Vesuvius: Pompei andHerculaneum, New York, Macmillan, 197142 SAHN, SC0661N CHEST, 69: 1, JANUARY, 1976Downloaded From: http://publications.chestnet.org/ on 03/29/2014