To the Editor:
Flexible bronchoscopy is one of the most commonly performed procedures by the chest physicians. Although rarely reported, bleeding is one of the most feared complications of flexible bronchoscopy.1 Bleeding rates vary with the type of bronchoscopic procedure performed; with an overall rate of 0.83% and 1.9% if either brushing or biopsy is performed. The risk of bleeding with bronchoalveolar lavage and endobronchial ultrasound-guided transbronchial (TBBx) biopsy are low, intermediate with TBBx and endobronchial forceps biopsies and high with TBBx cryobiopsy and therapeutic bronchoscopy.2–4
Oral antiplatelet therapy with drugs such as aspirin and clopidogrel is widely used to prevent arterial thrombosis. Balancing the risk of bleeding during bronchoscopy to the risk of thrombosis while withholding these agents is clinically challenging; especially in the periprocedural period. Current evidence does not suggest any increased risk of bleeding following TBBx with a singular use of aspirin.3 The study conducted by Ernst et al5 showed high bleeding rate of 89% in the clopidogrel only group and 100% bleeding rate in the group receiving combination of clopidogrel and aspirin. Several studies suggest stopping clopidogrel 5 to 7 days before the TBBx to prevent bleeding during bronchoscopic procedures.1–3
We report a case of an 81-year-old woman who underwent TBBx for a 9×14 mm in size right lower lobe nodule with irregular margins. The patient was on a dual antiplatelet therapy with aspirin and clopidogrel for a stent placed for an abdominal aortic aneurysm. The patient stopped taking clopidogrel 7 days before the procedure. TBBx was performed and the histopathology result revealed a blood clot and a single fragment of alveolated lung with no specific pathologic changes. She resumed the medications 24 hours after the procedure.
The patient suffered with a constant cough, low-grade fever, and small amount of hemoptysis for a month following the procedure. At a follow-up visit computed tomographic scan of the chest revealed a new 29×30 mm well-circumscribed nodular density with a smooth border in the right lower lobe adjacent to the initial nodule. The lesion was suggestive of postbiopsy hemorrhage and a hematoma (Fig. 1).
Currently, there are no specific data regarding the optimal time for resuming antiplatelet therapy with clopidogrel after bronchoscopy.2 Recent studies suggest resuming clopidogrel after 4 to 12 and 24 hours of bronchoscopy, respectively. Our patient discontinued clopidogrel 7 days in advance and resumed it 24 hours after the bronchoscopic procedure but still developed a large hematoma in the region of the TBBx biopsy. Besides she continued to have scant amount of hemoptysis even after a month of the procedure. This case report raises a concern and highlights the lack of specific clinical data and related guidelines regarding the optimal time at which the antiplatelet therapy with clopidogrel should be resumed to decrease the risk associated with the bronchoscopic procedures. Larger studies are needed to identify patients at an increased risk of bleeding during the peribronchoscopic period. Accurate knowledge of safe cutoff values for the optimal time for discontinuation and resumption of antiplatelet agents in these patients would help in curtailing the risk of bleeding associated with various bronchscopic procedures.
Parth R. Shah, MBBS
Atul C. Mehta, MD
Department of Pulmonary Medicine Cleveland Clinic Respiratory Institute Cleveland Clinic, Cleveland, OH
1. Bernasconi M, Koegelenberg CFN, Koutsokera A, et al. Iatrogenic bleeding during flexible bronchoscopy: risk factors, prophylactic measures and management. ERJ Open Res. 2017;3:00084–02016.
2. Youness HA, Keddissi J, Berim I, et al. Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy. J Thorac Dis. 2017;9(suppl 10):S1022–S1033.
3. Abuqayyas S, Raju S, Bartholomew JR, et al. Management of antithrombotic agents in patients undergoing flexible bronchoscopy. Eur Respir Rev. 2017;26:pii:170001.
4. Vaidya PJ, Munavvar M, Leuppi JD, et al. Endobronchial ultrasound-guided transbronchial needle aspiration: risks and repairs, respirology. 2017. Doi: org/10.1111/resp.13096.
5. Ernst A, Eberhardt R, Wahidi M, et al. Effect of routine clopidogrel use on bleeding complications after transbronchial biopsy in humans. Chest. 2006;129:734–737.