Bronchoscopic Lung Biopsy Using Noninvasive Ventilatory Support: Case Series and Review of Literature of NIV-Assisted Bronchoscopy

BACKGROUND: Fiberoptic bronchoscopy and lung biopsy are important diagnostic tools in patients with diffuse pulmonary infiltrates. However, these patients often have hypoxemic respiratory failure that makes this procedure hazardous. Noninvasive ventilation (NIV) has been shown to improve oxygenation in hypoxemic patients. OBJECTIVE: To report the efficacy and safety of an innovative technique of NIV-assisted bronchoscopic lung biopsy in a small case-series of hypoxemic subjects with diffuse parenchymal infiltrates; also to systematically review the literature on NIV-assisted bronchoscopy. METHODS: Subjects with bilateral diffuse parenchymal infiltrates and P-aO2/F-IO2 < 200 mm Hg underwent bronchoscopic lung biopsy under NIV support. NIV was initiated 10 min before the procedure and continued for 30 min after the procedure. The primary outcomes were performance of successful procedure and episodes of decline in S-pO2 < 90%. Secondary end points were the change in the respiratory and hemodynamic parameters during the procedure and occurrence of complications such as pneumothorax, hemorrhage, and endotracheal intubation. RESULTS: Six subjects, with a mean +/- SD age of 44.5 +/- 11.6 years, were included in the study. The median (interquartile range [IQR]) P-aO2/F-IO2 prior to lung biopsy was 164.5 mm Hg (146.3-176.3 mm Hg), and the median (IQR) inspiratory and expiratory positive airway pressures were 14 cm H2O (12-15 cm H2O) and 5 cm H2O. Fiberoptic bronchoscopy was well tolerated and all subjects maintained S-pO2 > 92% during the procedure. One subject required endotracheal intubation due to hemoptysis. A definite diagnosis was obtained in 5 of the 6 subjects. A repeat procedure was performed in one subject, which again yielded no diagnosis. No other periprocedural complications were encountered. CONCLUSIONS: NIV-assisted bronchoscopic lung biopsy is a novel method for obtaining diagnosis in hypoxemic patients with diffuse lung infiltrates. However, this approach should be reserved for centers with extensive experience in NIV. More studies are required to define the utility of this approach.