Download PDF
Semin Respir Crit Care Med 2004; 25(4): 413-423
DOI: 10.1055/s-2004-832714
Copyright © 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Role of Flexible Bronchoscopy in Lung Transplantation

Prashant N. Chhajed1 , 2 , 3 , Michael Tamm1 , 3 , Allan R. Glanville2
  • 1Division of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
  • 2The Lung Transplant Unit, St. Vincent’s Hospital, Sydney, Australia
  • 3Institute of Pulmonology, Medical Research and Development, Mumbai, India
Further Information

Publication History

Publication Date:
30 August 2004 (online)

    Permissions and Reprints

Flexible bronchoscopy with bronchoalveolar lavage and transbronchial biopsy has contributed significantly to the success of lung transplantation to detect rejection and infections (bacterial, fungal, viral, and protozoal). It permits the visualization of the airway anastomosis and also allows for the management of airway complications using interventional bronchoscopic techniques such as balloon dilatation, stent insertion, and laser. A new classification (TEGLA [thickness, extent of injury, granulation tissue, loose sutures, anastomotic complications]) for uniform reporting of airway ischemic injury is proposed. The common complications during flexible bronchoscopy include acute hypoxemia, bleeding, and pneumothorax. The management of these complications during flexible bronchoscopy and the value of surveillance and follow-up transbronchial biopsy and bronchoalveolar lavage is discussed. Bronchoalveolar lavage and transbronchial biopsy are also used for research purposes and might hopefully allow recognition of bronchiolitis obliterans at an earlier stage.

KEYWORDS

Flexible bronchoscopy - lung transplantation - transbronchial biopsy - bronchoalveolar lavage - stent

REFERENCES

  • 1 Baldwin J C, Oyer P E, Stinson E B et al.. Comparison of cardiac rejection in heart and heart-lung transplantation.  J Heart Transplant. 1987;  6 352-356
    PubMedGoogle Scholar
  • 2 Rhenman B, Rhenman M J, Icenogle T B et al.. Heart-lung transplantation: the initial Arizona experience.  J Thorac Cardiovasc Surg. 1989;  98(5 Pt 2) 922-927
    PubMedGoogle Scholar
  • 3 Glanville A R, Imoto E, Baldwin J C et al.. The role of right ventricular endomyocardial biopsy in the long-term management of heart-lung transplant recipients.  J Heart Transplant. 1987;  6 357-361
    PubMedGoogle Scholar
  • 4 Higenbottam T, Hutter J A, Stewart S, Wallwork J. Transbronchial biopsy has eliminated the need for endomyocardial biopsy in heart-lung recipients.  J Heart Transplant. 1988;  7 435-439
    PubMedGoogle Scholar
  • 5 Husain A N, Siddiqui M T, Montoya A, Chandrasekhar A J, Garrity E R. Post-lung transplant biopsies: an 8-year Loyola experience.  Mod Pathol. 1996;  9 126-132
    PubMedGoogle Scholar
  • 6 Higenbottam T, Stewart S, Penketh A, Wallwork J. Transbronchial lung biopsy for the diagnosis of rejection in heart-lung transplant patients.  Transplantation. 1988;  46 532-539
    CrossrefPubMedGoogle Scholar
  • 7 Yousem S A, Berry G J, Cagle P T et al.. Revision of the 1990 working formulation for the classification of pulmonary allograft rejection: Lung Rejection Study Group.  J Heart Lung Transplant. 1996;  15(1 Pt 1) 1-15
    PubMedGoogle Scholar
  • 8 Trulock E P, Ettinger N A, Brunt E M et al.. The role of transbronchial lung biopsy in the treatment of lung transplant recipients: an analysis of 200 consecutive procedures.  Chest. 1992;  102 1049-1054
    CrossrefPubMedGoogle Scholar
  • 9 Sibley R K, Berry G J, Tazelaar H D et al.. The role of transbronchial biopsies in the management of lung transplant recipients.  J Heart Lung Transplant. 1993;  12 308-324
    PubMedGoogle Scholar
  • 10 Hopkins P M, Aboyoun C L, Chhajed P N et al.. Prospective analysis of 1,235 transbronchial lung biopsies in lung transplant recipients.  J Heart Lung Transplant. 2002;  21 1062-1067
    CrossrefPubMedGoogle Scholar
  • 11 British Thoracic Society guidelines on diagnostic flexible bronchoscopy.  Thorax. 2001;  56(Suppl 1) i1-21
    CrossrefPubMedGoogle Scholar
  • 12 Pearce S J. Fibreoptic bronchoscopy: is sedation necessary?.  BMJ. 1980;  281 779-780
    PubMedGoogle Scholar
  • 13 Colt H G, Morris J F. Fiberoptic bronchoscopy without premedication: a retrospective study.  Chest. 1990;  98 1327-1330
    PubMedGoogle Scholar
  • 14 Simpson F G, Arnold A G, Purvis A et al.. Postal survey of bronchoscopic practice by physicians in the United Kingdom.  Thorax. 1986;  41 311-317
    CrossrefPubMedGoogle Scholar
  • 15 Prakash U B, Offord K P, Stubbs S E. Bronchoscopy in North America: the ACCP survey.  Chest. 1991;  100 1668-1675
    CrossrefPubMedGoogle Scholar
  • 16 Reed A P. Preparation of the patient for awake flexible fiberoptic bronchoscopy.  Chest. 1992;  101 244-253
    PubMedGoogle Scholar
  • 17 Rees P J, Hay J G, Webb J R. Premedication for fibreoptic bronchoscopy.  Thorax. 1983;  38 624-627
    PubMedGoogle Scholar
  • 18 Macfarlane J T, Storr A, Wart M J, Smith W H. Safety, usefulness and acceptability of fibreoptic bronchoscopy in the elderly.  Age Ageing. 1981;  10 127-131
    PubMedGoogle Scholar
  • 19 Williams T J, Nicoulet I, Coleman E, McAlaney C. Safety and patient acceptability of intravenous midazolam for fibre optic bronchoscopy.  Respir Med. 1994;  88 305-307
    PubMedGoogle Scholar
  • 20 Chhajed P N, Aboyoun C L, Malouf M A et al.. Progressive increase in sedative drug requirements for flexible bronchoscopy in lung transplant recipients.  Am J Respir Crit Care Med. 2003;  167 A529
    PubMedGoogle Scholar
  • 21 Chhajed P N, Cooper P. Pediatric flexible bronchoscopy.  Indian Pediatr. 2001;  38 1382-1392
    PubMedGoogle Scholar
  • 22 Chhajed P N, Aboyoun C, Malouf M A et al.. Management of acute hypoxemia during flexible bronchoscopy with insertion of a nasopharyngeal tube in lung transplant recipients.  Chest. 2002;  121 1350-1354
    CrossrefPubMedGoogle Scholar
  • 23 Chhajed P N, Tamm M, Malouf M A, Glanville A R. Lung transplantation: management and complications.  Indian J Chest Dis Allied Sci. 2002;  44 31-43
    PubMedGoogle Scholar
  • 24 Snell G I, Ward C, Wilson J W et al.. Immunopathological changes in the airways of stable lung transplant recipients.  Thorax. 1997;  52 322-328
    PubMedGoogle Scholar
  • 25 Heurlin N, Markling L, Barkholt L et al.. Rapid detection of cytomegalovirus antigen on alveolar cells in bronchoalveolar fluid from transplant patients with cytomegalovirus pneumonia.  Clin Transplant. 1994;  8 466-473
    PubMedGoogle Scholar
  • 26 Tiroke A H, Bewig B, Haverich A. Bronchoalveolar lavage in lung transplantation: state of the art.  Clin Transplant. 1999;  13 131-157
    CrossrefPubMedGoogle Scholar
  • 27 Zavala D C. Pulmonary hemorrhage in fiberoptic transbronchial biopsy.  Chest. 1976;  70 584-588
    CrossrefPubMedGoogle Scholar
  • 28 Chhajed P N, Aboyoun C, Malouf M A et al.. Risk factors and management of bleeding associated with transbronchial lung biopsy in lung transplant recipients.  J Heart Lung Transplant. 2003;  22 195-197
    CrossrefPubMedGoogle Scholar
  • 29 Scott J P, Fradet G, Smyth R L et al.. Prospective study of transbronchial biopsies in the management of heart-lung and single lung transplant patients. J Heart Lung Transplant. 1991 10(5 Pt 1): 626-636 discussion 636-627
    Google Scholar
  • 30 Chhajed P N, Malouf M A, Glanville A R. Bronchoscopic dilatation in the management of benign (non-transplant) tracheobronchial stenosis.  Intern Med J. 2001;  31 512-516
    Google Scholar
  • 31 Sheski F D, Mathur P N. Long-term results of fiberoptic bronchoscopic balloon dilation in the management of benign tracheobronchial stenosis.  Chest. 1998;  114 796-800
    CrossrefPubMedGoogle Scholar
  • 32 Davies D G, Parsek M R, Pearson J P et al.. The involvement of cell-to-cell signals in the development of a bacterial biofilm.  Science. 1998;  280 295-298
    CrossrefPubMedGoogle Scholar
  • 33 Kolter R, Losick R. One for all and all for one.  Science. 1998;  280 226-227
    CrossrefPubMedGoogle Scholar
  • 34 Seballos R J, Mehta A C. Care and maintenence of the flexible bronchoscope. In: Wang KMA Flexible Bronchoscopy Boston, MA; Blackwell 1995: 81-92
    Google Scholar
  • 35 Culver D A, Gordon S M, Mehta A C. Infection control in the bronchoscopy suite: a review of outbreaks and guidelines for prevention.  Am J Respir Crit Care Med. 2003;  167 1050-1056
    CrossrefPubMedGoogle Scholar
  • 36 Rutala W A, Gergen M F, Weber D J. Comparative evaluation of the sporicidal activity of new low-temperature sterilization technologies: ethylene oxide, 2 plasma sterilization systems, and liquid peracetic acid.  Am J Infect Control. 1998;  26 393-398
    PubMedGoogle Scholar
  • 37 Muscarella L F. Deja vu … all over again? The importance of instrument drying.  Infect Control Hosp Epidemiol. 2000;  21 628-629
    PubMedGoogle Scholar
  • 38 Kirschke D L, Jones T F, Craig A S et al.. Pseudomonas aeruginosa and Serratia marcescens contamination associated with a manufacturing defect in bronchoscopes.  N Engl J Med. 2003;  348 214-220
    CrossrefPubMedGoogle Scholar
  • 39 Pereira Jr W, Kovnat D M, Snider G L. A prospective cooperative study of complications following flexible fiberoptic bronchoscopy.  Chest. 1978;  73 813-816
    CrossrefPubMedGoogle Scholar
  • 40 Credle Jr W F, Smiddy J F, Elliott R C. Complications of fiberoptic bronchoscopy.  Am Rev Respir Dis. 1974;  109 67-72
    PubMedGoogle Scholar
  • 41 Langmack E L, Martin R J, Pak J, Kraft M. Serum lidocaine concentrations in asthmatics undergoing research bronchoscopy.  Chest. 2000;  117 1055-1060
    CrossrefPubMedGoogle Scholar
  • 42 Chhajed P N, Aboyoun C L, Malouf M A et al.. Prophylactic nasopharyngeal tube insertion prevents acute hypoxemia due to upper airway obstruction during flexible bronchoscopy. Intern Med J.  2003;  33(7) 317-318
    CrossrefPubMedGoogle Scholar
  • 43 Chhajed P N, Glanville A R. Management of hypoxemia during flexible bronchoscopy.  Clin Chest Med. 2003;  24 511-516
    CrossrefPubMedGoogle Scholar
  • 44 Diette G B, Wiener C M, White Jr P. The higher risk of bleeding in lung transplant recipients from bronchoscopy is independent of traditional bleeding risks: results of a prospective cohort study.  Chest. 1999;  115 397-402
    CrossrefPubMedGoogle Scholar
  • 45 Cordasco Jr E M, Mehta A C, Ahmad M. Bronchoscopically induced bleeding: a summary of nine years’ Cleveland clinic experience and review of the literature.  Chest. 1991;  100 1141-1147
    PubMedGoogle Scholar
  • 46 Prakash U B, Utz J P. Bronchoscopic lung biopsy. In: Wang KP, Mehta AC Flexible Bronchoscopy London; Blackwell 1995: 119-135
    Google Scholar
  • 47 Breuer H W, Charchut S, Worth H, Trampisch H J, Glanzer K. Endobronchial versus intravenous application of the vasopressin derivative glypressin during diagnostic bronchoscopy.  Eur Respir J. 1989;  2 225-228
    PubMedGoogle Scholar
  • 48 Barman S A, Ardell J L, Parker J C, Perry M L, Taylor A E. Pulmonary and systemic blood flow contributions to upper airways in canine lung.  Am J Physiol. 1988;  255(5 Pt 2) H1130-H1135
    PubMedGoogle Scholar
  • 49 Magno M. Comparative anatomy of the tracheobronchial circulation.  Eur Respir J Suppl. 1990;  12 557s-562s , discussion 562s-563s
    PubMedGoogle Scholar
  • 50 Shennib H, Massard G. Airway complications in lung transplantation.  Ann Thorac Surg. 1994;  57 506-511
    CrossrefPubMedGoogle Scholar
  • 51 Couraud L, Nashef S AM, Nicolini P, Jougon J. Classification of airway anastomotic healing.  Eur J Cardiothorac Surg. 1992;  6 496-497
    CrossrefPubMedGoogle Scholar
  • 52 Malouf M A, Glanville A R. The spectrum of mycobacterial infection after lung transplantation.  Am J Respir Crit Care Med. 1999;  160(5 Pt 1) 1611-1616
    CrossrefPubMedGoogle Scholar
  • 53 Tamm M, Malouf M, Glanville A. Pulmonary Scedosporium infection following lung transplantation.  Transpl Infect Dis. 2001;  3 189-194
    CrossrefPubMedGoogle Scholar
  • 54 Yousem S A. Graft eosinophilia in lung transplantation.  Hum Pathol. 1992;  23 1172-1177
    CrossrefPubMedGoogle Scholar
  • 55 Nunley D R, Grgurich W, Iacono A T et al.. Allograft colonization and infections with Pseudomonas in cystic fibrosis lung transplant recipients.  Chest. 1998;  113 1235-1243
    CrossrefPubMedGoogle Scholar
  • 56 Kramer M R, Stoehr C, Lewiston N J, Starnes V A, Theodore J. Trimethoprim-sulfamethoxazole prophylaxis for Pneumocystis carinii infections in heart-lung and lung transplantation: how effective and for how long?.  Transplantation. 1992;  53 586-589
    PubMedGoogle Scholar
  • 57 Miller R F, Le Noury J, Corbett E L, Felton J M, De Cock K M. Pneumocystis carinii infection: current treatment and prevention.  J Antimicrob Chemother. 1996;  37(suppl B) 33-53
    CrossrefPubMedGoogle Scholar
  • 58 Cahill B C, Hibbs J R, Savik K et al.. Aspergillus airway colonization and invasive disease after lung transplantation.  Chest. 1997;  112 1160-1164
    CrossrefPubMedGoogle Scholar
  • 59 Nunley D R, Ohori P, Grgurich W F et al.. Pulmonary aspergillosis in cystic fibrosis lung transplant recipients.  Chest. 1998;  114 1321-1329
    CrossrefPubMedGoogle Scholar
  • 60 Helmi M, Love R B, Welter D, Cornwell R D, Meyer K C. Aspergillus infection in lung transplant recipients with cystic fibrosis: risk factors and outcomes comparison to other types of transplant recipients.  Chest. 2003;  123 800-808
    CrossrefPubMedGoogle Scholar
  • 61 Stephan F, Bernaudin J F, Cesari D et al.. Blood and alveolar lymphocyte subsets in pulmonary cytomegalovirus infection after lung transplantation.  BMC Infect Dis. 2001;  1 15
    CrossrefPubMedGoogle Scholar
  • 62 Riise G C, Kjellstrom C, Ryd W et al.. Inflammatory cells and activation markers in BAL during acute rejection and infection in lung transplant recipients: a prospective, longitudinal study.  Eur Respir J. 1997;  10 1742-1746
    CrossrefPubMedGoogle Scholar
  • 63 Bewig B, Haacke T C, Tiroke A et al.. Detection of CMV pneumonitis after lung transplantation using PCR of DNA from bronchoalveolar lavage cells.  Respiration. 2000;  67 166-172
    CrossrefPubMedGoogle Scholar
  • 64 Boehler A, Vogt P, Zollinger A, Weder W, Speich R. Prospective study of the value of transbronchial lung biopsy after lung transplantation.  Eur Respir J. 1996;  9 658-662
    CrossrefPubMedGoogle Scholar
  • 65 Kesten S, Chamberlain D, Maurer J. Yield of surveillance transbronchial biopsies performed beyond two years after lung transplantation.  J Heart Lung Transplant. 1996;  15 384-388
    PubMedGoogle Scholar
  • 66 Valentine V G, Taylor D E, Dhillon G S et al.. Success of lung transplantation without surveillance bronchoscopy.  J Heart Lung Transplant. 2002;  21 319-326
    CrossrefPubMedGoogle Scholar
  • 67 Tamm M, Sharples L D, Higenbottam T W, Stewart S, Wallwork J. Bronchiolitis obliterans syndrome in heart-lung transplantation: surveillance biopsies.  Am J Respir Crit Care Med. 1997;  155 1705-1710
    CrossrefPubMedGoogle Scholar
  • 68 Baz M A, Layish D T, Govert J A et al.. Diagnostic yield of bronchoscopies after isolated lung transplantation.  Chest. 1996;  110 84-88
    CrossrefPubMedGoogle Scholar
  • 69 Aboyoun C L, Tamm M, Chhajed P N et al.. Diagnostic value of follow-up transbronchial lung biopsy after lung rejection.  Am J Respir Crit Care Med. 2001;  164 460-463
    CrossrefPubMedGoogle Scholar
  • 70 Pomerance A, Madden B, Burke M M, Yacoub M H. Transbronchial biopsy in heart and lung transplantation: clinicopathologic correlations.  J Heart Lung Transplant. 1995;  14 761-773
    PubMedGoogle Scholar
  • 71 Chamberlain D, Maurer J, Chaparro C, Idolor L. Evaluation of transbronchial lung biopsy specimens in the diagnosis of bronchiolitis obliterans after lung transplantation.  J Heart Lung Transplant. 1994;  13 963-971
    PubMedGoogle Scholar
  • 72 Collins J, Hartman M J, Warner T F et al.. Frequency and CT findings of recurrent disease after lung transplantation.  Radiology. 2001;  219 503-509
    CrossrefPubMedGoogle Scholar
  • 73 Gabbay E, Dark J H, Ashcroft T et al.. Recurrence of Langerhans' cell granulomatosis following lung transplantation.  Thorax. 1998;  53 326-327
    CrossrefPubMedGoogle Scholar
  • 74 Habib S B, Congleton J, Carr D et al.. Recurrence of recipient Langerhans’ cell histiocytosis following bilateral lung transplantation.  Thorax. 1998;  53 323-325
    CrossrefPubMedGoogle Scholar
  • 75 Chhajed P N, Malouf M A, Tamm M, Spratt P, Glanville A R. Interventional bronchoscopy for the management of airway complications following lung transplantation.  Chest. 2001;  120 1894-1899
    CrossrefPubMedGoogle Scholar
  • 76 Griffith B P, Hardesty R L, Armitage J M et al.. A decade of lung transplantation.  Ann Surg. 1993;  218 310-318 , discussion 318-320
    PubMedGoogle Scholar
  • 77 Schafers H J, Haydock D A, Cooper J D. The prevalence and management of bronchial anastomotic complications in lung transplantation.  J Thorac Cardiovasc Surg. 1991;  101 1044-1052
    PubMedGoogle Scholar
  • 78 Schmid R A, Boehler A, Speich R et al.. Bronchial anastomotic complications following lung transplantation: still a major cause of morbidity.  Eur Respir J. 1997;  10 2872-2875
    CrossrefPubMedGoogle Scholar
  • 79 Carre P, Rousseau H, Lombart L et al.. Balloon dilatation and self-expanding metal Wallstent insertion: for management of bronchostenosis following lung transplantation. The Toulouse Lung Transplantation Group.  Chest. 1994;  105 343-348
    CrossrefPubMedGoogle Scholar
  • 80 Kshettry V R, Kroshus T J, Hertz M I et al.. Early and late airway complications after lung transplantation: incidence and management.  Ann Thorac Surg. 1997;  63 1576-1583
    CrossrefPubMedGoogle Scholar
  • 81 Brichon P Y, Blanc-Jouvan F, Rousseau H et al.. Endovascular stents for bronchial stenosis after lung transplantation.  Transplant Proc. 1992;  24 2656-2659
    PubMedGoogle Scholar
  • 82 Vinograd I, Klin B, Brosh T et al.. A new intratracheal stent made from nitinol, an alloy with “shape memory effect”.  J Thorac Cardiovasc Surg. 1994;  107 1255-1261
    PubMedGoogle Scholar
  • 83 Williams D F. Titanium as a metal for implantation, II: Biological properties and clinical applications.  J Med Eng Technol. 1977;  1 266-270
    PubMedGoogle Scholar
  • 84 Chhajed P N, Malouf M A, Tamm M, Glanville A R. Ultraflex stents for the management of airway complications in lung transplant recipients.  Respirology. 2003;  8 59-64
    CrossrefPubMedGoogle Scholar
  • 85 Tamm M, Roth M, Malouf M et al.. Primary fibroblast cell cultures from transbronchial biopsies of lung transplant recipients.  Transplantation. 2001;  71 337-339
    PubMedGoogle Scholar
  • 86 Azzola A, Havryk A, Chhajed P N et al.. Everolimus and mycophenolate mofetil are potent inhibitors of fibroblast proliferation after lung transplantation.  Transplantation. 2004;  77 275-280
    CrossrefPubMedGoogle Scholar
  • 87 Bergmann M, Tiroke A, Schafer H, Barth J, Haverich A. Gene expression of profibrotic mediators in bronchiolitis obliterans syndrome after lung transplantation.  Scand Cardiovasc J. 1998;  32 97-103
    CrossrefPubMedGoogle Scholar
  • 88 Scholma J, Slebos D J, Boezen H M et al.. Eosinophilic granulocytes and interleukin-6 level in bronchoalveolar lavage fluid are associated with the development of obliterative bronchiolitis after lung transplantation.  Am J Respir Crit Care Med. 2000;  162 2221-2225
    CrossrefPubMedGoogle Scholar
  • 89 Havryk A, Azzola A, Chhajed P N et al.. Matrix metalloproteinase profile in bronchoalveolar lavage fluid in posttransplant obliterative bronchiolitis.  Am J Respir Crit Care Med. 2002;  165 A396
    PubMedGoogle Scholar

Prashant N ChhajedM.D. 

Division of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel

Petersgraben 4, CH-4031, Basel, Switzerland

Email: chhajed@hotmail.com

      >