TABLE 7 - uploaded by Shine Kochukunju Raju
Content may be subject to copyright.
Management of anticoagulant agents in the peri-bronchoscopic period 

Management of anticoagulant agents in the peri-bronchoscopic period 

Source publication
Article
Full-text available
Bleeding is one of the most feared complications of flexible bronchoscopy. Although infrequent, it can be catastrophic and result in fatal outcomes. Compared to other endoscopic procedures, the risk of morbidity and mortality from the bleeding is increased, as even a small amount of blood can fill the tracheobronchial tree and lead to respiratory f...

Citations

... The risk of post-procedure hemorrhagic complications was estimated as low in the case of thoracentesis, EBUS-TBNA and bronchoscopy without biopsy, and as intermediate for bronchoscopy with EEB (endobronchial biopsy), according to Abuqayyas et al. [9] and Ault et al. [10] Data were analyzed with STATISTICA 13.5 (Statsoft, Tulsa, USA). Continuous data are presented as the means with standard deviations (SD) or medians and interquartile range (IQR) as appropriate. ...
... TBB is a bronchoscopic diagnostic procedure that is frequently used in the diagnosis of lung tumors involving the lung periphery and parenchyma, as well as interstitial lung diseases (ILD), sarcoidosis and tuberculosis with extensive lung parenchymal involvement. TBB is accepted as a high-risk procedure among bronchoscopic procedures (9). Although there are a limited number of studies on the use of other bronchoscopic procedures in the elderly population in the literature, no studies have been reported on TBB application, which has a high complication rate, especially in elderly patients. ...
... For the evaluation of the pneumothorax, it is recommended to be checked by chest radiography after the procedure. Rarely, cardiac arrhythmia, desaturation, persistent cough, pneumomediastinum, and air embolism have been reported (7,(9)(10)(11)(12)(17)(18)(19). Complications were evaluated in detail in this study. ...
Article
Introduction: Among bronchoscopic procedures, transbronchial biopsy (TBB) is considered a high-risk procedure. In this study, we aimed to investigate the indications, diagnostic efficacy and complications of TBB in the elderly, which is accepted as a sensitive group. Materials and methods: The study was designed as a multicenter retrospective observational study. Data of 4226 patients who underwent diagnostic bronchoscopy were scanned for this study. 791 patients who underwent transbronchial biopsy were included in this study. All patients were evaluated in terms of lung regions, diagnosis, and complications. Result: A total of 791 patients, 329 (41.6%) female patients, who underwent TBB were included in the study. Mean age of the patients was 54.54 ± 14.94 years. The most common indications were ILD (45.6%), malignancy (24.0%) and sarcoidosis (9.9%). Mean age of the elderly patients (n= 263) was 69.89 ± 4.83 years, and mean age of the young patients (n= 528) was 46.90 ± 11.28 years (p<0.001). In both age groups, the most common indication was ILD. Complications developed during and after the procedure in 51 of the young patients (9.7%) and in 21 of the elderly (8.0%) (p= 0.441). The most common complication was pneumothorax with 4.6% in the elderly, and pneumothorax with 5.9% in the young (p= 0.441). The most common diagnosis was malignancy (12.2%) in the elderly, as the most common diagnosis was malignancy (7.2%) in the young (p = 0.020). While anthracosis, ILD and organized pneumonia were the other common diagnoses in the elderly, sarcoidosis, anthracosis and organized pneumonia were the other common diagnoses in the young. The diagnosis of sarcoidosis was achieved more frequently in the young (6.6%) than in the elderly (0.8%) (p<0.001). Conclusions: Transbronchial biopsy can be performed safely in elderly patients, with similar diagnostic success and complication rates to younger patients.
... In the case of flexible bronchoscopic procedures undergone by patients taking ATAs, bleeding risk and management of ATAs (when to withhold and restart or the need for bridging agents) before and after the procedures are well established [5][6][7]. For the flexible bronchoscopic procedures, such as endobronchial biopsy (EBB) or transbronchial lung biopsy (TBLB), the discontinuation of clopidogrel seven days prior to consideration of biopsy is recommended, and low-dose aspirin alone can be continued [7,8]. However, the management of ATAs before and after EBUS-TBNA has not yet been well understood. ...
... Since the recommended period for how long ATAs should be discontinued prior to the EBUS procedure in patients receiving ATAs is not clear, we defined the "insufficient discontinuation group" for ATAs when each drug was continuously used or discontinued for less than the following periods according to the criteria of the recommended guidelines in the field of flexible bronchoscopy [8]: (1) if clopidogrel (an irreversible P2Y 12 receptor blocker; antiplatelet drug) was discontinued for less than 5 days; (2) if cilostazol (phosphodiesterase-3 inhibitor; reversible antiplatelet drug) was discontinued for less than 2 days; (3) if warfarin (inhibits production of vitamin K-dependent clotting; oral anticoagulant) was discontinued for less than 5 days; (4) if a low-molecular-weight heparin (LMWH; antithrombin inhibitor), such as enoxaparin and dalteparin, was discontinued for less than 24 hr; or (5) if direct oral anticoagulants (DOACs; factor Xa inhibitors), such as rivaroxaban, edoxaban, and apixaban were discontinued for less than 2 days. Due to the fact that aspirin (irreversible cyclooxygenase inhibitor; antiplatelet drug) is not recommended to be stopped before the EBB and/or TBLB, even if aspirin was continuously used before the procedure, the case was not classified as belonging to the insufficient discontinuation group. ...
... Therefore, as operators would have actively discontinued ATAs or simplified the procedure as much as possible for patients who were expected to have a high risk of bleeding, caution should be taken in interpreting the results of this study. Finally, for warfarin, as suggested in the previous guidelines [8], we determined whether patients should be included in the insufficient discontinuation group based on discontinuation five days before the procedure day. However, in real clinical practice, coagulation tests will be more important. ...
Article
Full-text available
Background and Objectives: The application of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been markedly increased over the past decade. EBUS-TBNA is known to be a very safe and accurate procedure; however, the incidence of bleeding complications in patients who are taking antithrombotic agents (ATAs) is not well established. Materials and Methods: We conducted a retrospective analysis of a prospectively registered EBUS-TBNA cohort in a single tertiary hospital from May 2009 to December 2016. The patients were divided into two groups: an insufficient discontinuation group, defined as having a prescription for ATAs on the procedure day or only interrupting them for a short period of time, and a sufficient discontinuation group, defined as having prescription for ATAs during 30 days prior to the procedure and interrupting them for a sufficient period of time. Results: During the study period, a total of 4271 patients, after excluding 3773 patients who did not take ATAs at all, 498 patients were classified into the insufficient discontinuation group (n = 102) and the sufficient discontinuation group (n = 396). The baseline characteristics of patients and examined lesions between two groups were not significantly different, except insufficient discontinuation group had longer prothrombin times than the sufficient discontinuation group. In the insufficient discontinuation group, the most common reasons for prescriptions of ATAs were ischemic heart disease (48.0%) and cerebral vascular disease (28.4%), and half of the patients were taking two or more ATAs. Eventually, only one bleeding complication in the insufficient discontinuation group (1/102, 1.0%) and one event in the sufficient discontinuation group (1/396, 0.3%) occurred (p = 0.368). Conclusions: EBUS-TBNA is considered a safe procedure in terms of bleeding complications, even in patients with insufficient stopping of ATAs.
... To minimize the risk of procedurerelated bleeding, it is important to discuss with their pulmonologist regarding duration of holding AC pre-and postprocedure and need for any bridging AC for the procedure. 76 Prompt medication history and recent PT/international normalized ratio (INR) and aPTTresult review can help identify the cause. Commonly, medications such as digoxin can interact with warfarin metabolism and increase therapeutic levels. ...
Article
Life-threatening hemoptysis (LTH) is any amount of hemoptysis that causes significant hemodynamic decompensation or respiratory distress which may lead to death if left untreated. While the amount of hemoptysis that qualifies as massive hemoptysis has continued to be debated, any amount between 100 to 1,000 mL/day is considered significant. Up to 15% cases of hemoptysis are LTH and need urgent life-saving intervention. Understanding of pulmonary vascular anatomy is of paramount importance to manage LTH. The goal of treatment lies in airway protection, appropriate oxygenation, and prevention of exsanguination. Once the airway is stabilized, a quick diagnosis and control of bleeding site is targeted. This chapter highlights current practices and approach to LTH including medical management, bronchoscopic approach, and advanced therapies such as bronchial artery embolization and surgical resection. We review situations, such as bronchiectasis, vascular malformation, diffuse alveolar hemorrhage, and tracheostomy bleed and specific approach to management of these conditions in a systematic and evidence-based manner.
... Minor bleeding into the airway can have significant hemodynamic consequences, therefore, no invasive pulmonary procedures (with the exception of thoracentesis) are considered as having no clinically important bleeding risk by the ACC. Nevertheless, bronchoscopic airway inspection, lavage, or brushing and endobronchial ultrasound with transbronchial needle aspiration are classified as low bleeding risk by the ACC given multiple studies showing bleeding rates to be less than 0.2% [12,17,18]. Other diagnostic or therapeutic interventions such as rigid bronchoscopy, transbronchial biopsy, and tracheostomy portend a higher bleeding risk [17,18]. ...
... Nevertheless, bronchoscopic airway inspection, lavage, or brushing and endobronchial ultrasound with transbronchial needle aspiration are classified as low bleeding risk by the ACC given multiple studies showing bleeding rates to be less than 0.2% [12,17,18]. Other diagnostic or therapeutic interventions such as rigid bronchoscopy, transbronchial biopsy, and tracheostomy portend a higher bleeding risk [17,18]. ...
Article
Purpose of review: As the prevalence of patients on antithrombotics is increasing, anesthesiologists must have a firm understanding of these medications and considerations for their periprocedural management. This review details up-to-date periprocedural management of direct oral anticoagulants (DOACs). Recent findings: DOACs have favorable pharmacokinetics including quick onset of action and short half-lives. Periprocedural management of DOACs relies heavily on drug half-life as well as procedural risk of bleeding. Other than a few exceptions, the American College of Cardiologists generally recommends complete clearance of oral anticoagulants prior to high-risk bleeding procedures and partial clearance prior to low-risk bleeding procedures. Procedures with little to no clinical risk of bleeding can be performed without any drug interruption or during trough levels. Exceptions to periprocedural DOAC management pertain to electrophysiology procedures. Summary: With the exception of no clinically relevant bleeding risk or certain electrophysiology procedures, DOACs should be discontinued periprocedurally in accordance with bleeding risks and drug's half-life. Bridging is generally not recommended for DOACs.
... The discontinuation of direct-oral anticoagulants (DOAC) is mostly based on expert opinion. [19,20] Information about the timeframe of discontinuation of antithrombotic drugs before thoracentesis is summarized in Table 3. [21][22][23][24] In conclusion, in cases without a need for urgent thoracentesis (complicated parapneumonic effusion and hemothorax), the procedure should be performed under ideal conditions (INR <1.5, platelet count >50,000/µl, and creatinine <6 mg/dl). Particular caution should be taken when creatinine >3 mg/dl. ...
... Considering the patients' comorbidities, anticoagulants should be discontinued for a specified timeframe before the procedure and should be restarted within 24-48 h after an uneventful procedure. [21][22][23][24] The management of anti-platelet and anticoagulant therapy before pleural procedures is summarized in Figures 2 and 3, respectively. ...
... Among patients receiving warfarin, if the risk of thrombosis is low (>3 months after venous thromboembolism, atrial fibrillation without valve disease, and thrombophilia), current evidence does not recommend bridging, warfarin should be discontinued 5 days before the procedure and INR should be <1.5. [24] Warfarin can be restarted at the same dose the day after the procedure. In patients with a high risk of thrombosis (atrial fibrillation with valve disease, mitral stenosis, mitral valve prosthesis, <3 months after venous thromboembolism, or severe thrombophilia), warfarin should be discontinued 5 days before the procedure, for bridging LMWH should be started 2 days after warfarin is discontinued. ...
Article
Full-text available
Pleural effusion is a common clinical entity. Pleural procedures performed for the diagnosis and management of pleural effusions may increase the risk of bleeding, especially in patients with coagulopathies and comorbidities and those in need for antithrombotic drugs. Current literature provides sparse, low level of evidence, which is insufficient for safe implementation of pleural procedures among these patients. Thoracentesis, pleural biopsy (closed or percutaneous), catheter or chest tube drainage, and thoracoscopy are the main pleural procedures performed in these patients. Considering the bleeding risk associated with a specific pleural procedure, the risk is low for thoracentesis, moderate for insertion or removal of the chest tube or tunneled catheter, and moderate high for pleural biopsies and thoracoscopy. The current statement is prepared mainly for the pulmonologists and intended to provide recommendations to reduce the risk of bleeding following pleural procedures. The management of bleeding complication is out of the scope of this statement.
... Usually, the procedure has been proven to be safe; however, significant hemorrhage or refractory bleeding is frequently encountered by bronchoscopists. Moreover, massive biopsy-related endobronchial hemorrhage in the airway remains most difficult-tomanage complication and could be life-threatening due to difficult hemostasis following EBB [2,3]. ...
... EBB-induced hemorrhage is the most frequent and difficult-to-manage complication encountered during bronchoscopy, particularly when performing biopsies in patients with lung cancer. Conceivably, endobronchial refractory bleeding or massive hemorrhage in the airway may be life-threatening [2,3]. Several factors have been associated with the risk of bleeding during bronchoscopy, including immunosuppressive status, thrombocytopenia (platelet count < 50 × 10 9 /L), uncontrolled hypertension or pulmonary arterial hypertension, lung transplant, anticoagulant and/or antiplatelet drug use, severe liver and/or kidney disease, and bleeding tendencies [6,[13][14][15][16]. ...
Article
Full-text available
Background: Lipoprotein concentrations have been associated with the major risk of bleeding events. However, whether plasma levels of LDL-C are associated with the risk of biopsy-related endobronchial hemorrhage remain elusive. Therefore, the present study was initiated to investigate the explicit association of low-density lipoprotein cholesterol (LDL-C) with endobronchial biopsy (EBB)-induced refractory hemorrhage in patients with lung cancer. Methods: This retrospective study included a total of 659 consecutive patients with lung cancer who had undergone EBB at a tertiary hospital between January 2014 and April 2018. Using multiple regression analysis, the association between LDL-C and the risk of EBB-induced refractory hemorrhage was assessed after adjusting for potential confounding factors. Results: A significant proportion (13.8%, 91/659) of the patients experienced refractory hemorrhage following EBB. In multivariate regression analysis, higher plasma LDL-C concentrations were associated with increased risk of EBB-induced refractory hemorrhage in patients with lung cancer after adjusting for potential confounders (P < 0.05). Using the lowest quartile of plasma LDL-C as the reference group, the odds ratio (95% confidence interval) of Q2, Q3, and Q4 were 2.32 (1.07, 5.03), 2.37 (0.94, 5.95), and 3.65 (1.16, 11.51), respectively (P for trend < 0.05). Moreover, this association was noticeably more pronounced in male patients with lung cancer in the subgroup analysis (P < 0.05). Conclusions: Plasma LDL-C was positively correlated with the increased risk of EBB-induced refractory hemorrhage in patients with lung cancer; predominantly, the associated risk was more pronounced in male patients with lung cancer.
... For patients undergoing low-(but not minimal) and highrisk bleeding procedures, oral anticoagulation will need to be temporarily discontinued to allow for normalization of coagulation status 36,39,66 (Table 2). Specific management of warfarin and DOACs are discussed below. ...
Non-operating room anesthesia presents unique challenges for anesthesiologists. Limited preprocedural optimization and unfamiliarity with the location and procedure itself add to the difficulties in delivering safe care for these patients. Management of chronic oral anticoagulation can prove especially problematic since risks of bleeding for non-operating room procedures vary widely and differ from traditional surgeries. In addition, many physicians may not be familiar with the growing number of newly approved oral anticoagulants and their periprocedural management. This review will examine common non-operating procedures, their risks of bleeding, as well as pharmacokinetics of oral anticoagulants available on the market and periprocedural management options.
... With regard to optimal duration for stopping newer anticoagulants, the half-life of drugs was taken into consideration; the half-life of NOACs (apixaban, rivaroxaban, edoxaban, and dabigatran) ranges from 9 to 15 h, and stopping these drugs 1-2 days before the procedure can minimize bleeding risk. [54,55] The evidence was also reviewed for initiating bridge therapy with heparin in patients at high risk of thrombosis if anticoagulation is stopped before bronchoscopy. Data from cardiovascular studies showed that warfarin interruption in atrial fibrillation increases the risk of thromboembolic events, and bridging therapy does not prevent such events; in fact, low molecular-weight heparin (LMWH) increases the risk of major perioperative bleeding. ...
Article
Full-text available
Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national‐level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.
... [15,39,40] Subjects who are on antiplatelet or anticoagulation therapy should stop the drugs as per the standard guidelines [ Table 4]. [41,42] ...
Article
Full-text available
Background: Bronchoscopic lung cryobiopsy (BLC) is a novel technique for obtaining lung tissue for the diagnosis of diffuse parenchymal lung diseases. The procedure is performed using several different variations of technique, resulting in an inconsistent diagnostic yield and a variable risk of complications. There is an unmet need for standardization of the technical aspects of BLC. Methodology: This is a position statement framed by a group comprising experts from the fields of pulmonary medicine, thoracic surgery, pathology, and radiology under the aegis of the Indian Association for Bronchology. Sixteen questions on