A low ratio of pulse pressure (PP) to diastolic pressure (DP) is associated with an increased risk of hemorrhage in lung cancer patients who experience endobronchial biopsy (EBB)-induced hemorrhage during bronchoscopy, according to findings of a study published in BMC Pulmonary Medicine.

Hemorrhage is the most common and most problematic complication occurring during endobronchial biopsy, resulting in potentially life-threatening intraoperative hypoxemia from excessive blood loss. Severe hypertension (defined as systolic pressure [SP] >200 mm Hg and/or DP >110 mm Hg) is already considered a contraindication for bronchoscopy, but the authors sought to clarify whether blood pressure (BP) actually affects biopsy-induced hemorrhage.

In a retrospective cohort study, the researchers analyzed data from 643 adult patients who underwent EBB and were diagnosed with lung cancer over a 4-year period from 2014 to 2018 at the Jinhua Municipal Central Hospital in Jinhua, China. The study included patients with endobronchial local exophytic lesions who received forceps biopsies and those diagnosed with a primary lung cancer. Patients were divided into 2 groups: those who received hemostatic maneuvers during EBB (hemorrhage group, n=243, 37.8%) and those who did not experience hemorrhage or did not require hemostatic maneuvers (nonhemorrhage group, n=400). No study participants experienced severe hemorrhage, defined as a single amount of biopsy-induced blood loss of 100 ml or more. Exclusion criteria included: immunosuppression, continuous anticoagulant or antiplatelet therapy, severe liver and kidney disease, and active bleeding.


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An independent association was shown between PP/PD and EBB-induced hemorrhage risk (per 1 standard deviation [SD; 0.24 PP/DP]; adjusted odds ratio, 0.788; 95% CI, 0.653-0.951). Multivariate regression analysis performed using quartiles of PP/DP indicated that a lower PP/DP ratio correlated to a higher risk of EBB-induced hemorrhage (P for trend <.05). For every 1 SD increase of PP/DP, the odds of hemorrhage fell by about 19.0%. The strength of this association remained significant after adjustment for potential confounders, such as age, gender, BMI, smoking, lesion location, cancer histological type and stage, prothrombin time, activated partial thromboplastin time, triglyceride level, high-density lipoprotein cholesterol level, white blood cell count, platelet count, and C-reactive protein level. No link was detected between EBB-induced hemorrhage and SP, DP, mean arterial pressure, or PP. All EBBs were performed using general anesthesia and laryngeal mask.

The strengths of the study are in its use of experienced bronchoscopists to conduct the EBB procedure, inclusion of consecutive patients, use of a single biopsy method (EBB), the comparatively fixed number of biopsies studied, and use of a consistent method of BP measurement. A limitation is the retrospective nature of the study, which meant that some potential confounders might not have been considered and some complications could have been underestimated.

“Since few studies focused on the association between different BP components and risk of EBB-induced hemorrhage, our findings are novel and might indicate that BP is a modifiable factor to reduce EBB-induced hemorrhage,” the authors state. “Thus, PP/PD ratio has the potential to be used for risk assessment and risk modification prior to bronchoscopy.”

Wang S, Ye Q. Association between blood pressure and the risk of biopsy-induced endobronchial hemorrhage during bronchoscopy. BMC Pulm Med. 2022;22(1):25. doi:10.1186/s12890-022-01822-5