In this episode, I’ll discuss endobronchial instillation of epinephrine, cold saline, and saline to prevent bleeding in patients undergoing endobronchial biopsy.
Severe bleeding as a result of an endobronchial biopsy has the potential for serious and even fatal patient outcomes. Providers routinely administer medications through the channel of the bronchoscope and into the lungs in an attempt to prevent severe bleeding complications, despite there being limited high-quality data to support this practice.
A group of authors published in the journal Chest a multi-center randomized controlled trial of nearly 500 patients that underwent endobronchial biopsy with various prophylactic hemostatic agents to determine the safety and efficacy of this practice. Patients were randomized in a 1:1:1 fashion to receive endobronchial instillation of either epinephrine or ice cold saline as prophylactic hemostatic agents or saline as control.
The primary efficacy outcomes were defined as the Bleeding Severity Scale and the Visual Analogue Scale in the termination of the biopsy.
In the primary analysis, none of the hemostatic agents had a statistically significant improvement in either of the primary outcome measures. The authors did note however in the subgroup of patients that were under 65 years of age, the incidence of bleeding in the ice cold saline group had a relative risk of 0.9 with a 95% confidence interval of 0.82 to 0.99.
The authors concluded:
In this study, we did not observe any improvement in biopsy-related iatrogenic bleeding with the prophylactic haemostasis. However, we observed a trend toward reduced bleeding with prophylactic haemostasis in the subgroup of patients aged <65 years, which merits further study. While this study did not identify an effective hemostatic strategy, it certainly does affirm the safety of administering epinephrine or ice cold saline during endobronchial biopsy with no difference in adverse events vs placebo for either hemostatic agent. Expect providers to want to continue to administer epinephrine or ice cold saline prophylactically, and epinephrine or tranexamic acid in the event that bleeding has occurred and cannot be controlled with ice cold saline.
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