Severe bleeding from endobronchial or transbronchial lung biopsy is a known potential complication of bronchoscopic procedures.1 Benjamin Franklin reminds us, “An ounce of prevention is worth a pound of cure.” Anticipating the risk of excessive bleeding and taking precautions to prevent it can reduce its occurrence. Some of these measures include: wedging the bronchoscope in the subsegmental bronchus while performing transbronchial lung biopsy; using a needle to initially sample a vascular endobronchial mass; or pretreating a vascular endobronchial mass with a vasoconstrictor. All bronchoscopy suites must be equipped with the tools that may be needed to manage complications that arise from bronchoscopy, including, but not limited to, excessive bleeding. These tools include endotracheal tubes, bronchial blockers, and a vasoconstrictive agent.
The primary vasoconstrictive agents that have been traditionally used in the bronchoscopy suite are epinephrine, norepinephrine, and ice-cooled saline.2–4 In a recent bronchoscopy training course a group of expert faculty members, with over 100 collective years of experience, were asked whether they used epinephrine/norepinephrine as vasoconstrictive agents in the airway. None of these experts supported the use of vasoactive drugs and referred the audience to a recent letter to the editor from Steinfort and colleagues reporting 2 near-fatal arrhythmias as supportive evidence.5
The experts present at the bronchoscopy training course agreed that the citation by Steinfort and colleagues may be the tip of the iceberg. The discussions highlighted that using epinephrine or norepinephrine has potential to cause coronary spasm, myocardial ischemia, and related consequences, especially in the elderly and those with a history of coronary heart disease. Despite close monitoring, these complications may go unrecognized or may be confused with those arising from hypoxemia.6–8 The hypothesis of Steinfort and colleagues adds yet another wrinkle to this dilemma. The audience was then asked the same question, and nearly a third of those in attendance still supported the use of epinephrine in managing potential or active bleeding during bronchoscopy.
Who is correct? The practice of medicine has traditionally used an apprentice-based educational model. The apprentice model of education advocates that we adopt the practices of our mentors, often without question. Practice changes require the acquisition of new evidence that supports the need for a change. Physicians are trained to be cautious of change and to critically evaluate the evidence that is being used to support a change. This was the case in the use of radical mastectomies for breast cancer in the second half of the 20th century.9 Despite the plea from many experts that this approach did not control the disease and that women were being harmed by the surgery, it took a lengthy and controversial randomized trial to convince many physicians that radical mastectomy was no longer appropriate for most cases.
I am not suggesting that the use of epinephrine during bronchoscopy-induced bleeding is as big a problem as radical mastectomy and breast cancer management; I only use it as an example to cite those instances in which many experts had warned of the harm a practice was causing, yet change did not follow.
We seem reluctant to heed the call of experts without evidence of randomized controlled trials. I would ask us to consider this question: What kind of evidence is needed for this community of physicians to decide that vasoactive drugs should be avoided in the airway: a randomized controlled trial, a consensus statement from our professional societies, or a report of a known life-threatening complication?
Considering all of the above, I would suggest that it is time to remove epinephrine and other vasoactive drugs from the armamentarium for the management of airway bleeding. Iced saline is an effective alternative, and there are no reports of untoward outcomes. It is contrary to logic that we would require a comparative study or even a professional society consensus statement to make this change in our bronchoscopy practices. The recent letter by Steinfort and the opinion of experts, such as those at a recent bronchoscopy course, should be enough for all of us to recognize the fact that the use of these vasoactive drugs is outdated and dangerous.
Eric S. Edell, MD
Mayo Clinic, Rochester, MN
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