Contraindications

I do not think there is any one absolute contraindication for a bronchoscopy. However, there are many situations where special precautions must be taken. I will list some commonly encountered high risk situations.

• Uncooperative Patient:
• 
  Uncooperative or mentally deranged patients are not suitable candidates for fiberoptic bronchoscopy under local anesthesia. A bronchoscopy must be performed under general anesthesia. This is not a contraindication for a bronchoscopy. However, it is an issue regarding the type of anesthesia used.
• Acute Myocardial Infarction:
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  Recent myocardial infarction, unstable angina and serious dysarrhythmias are relative contraindications for a bronchoscopy.
• C02 Retention:
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  C02 retention is a concern. If there is a strong indication for a bronchoscopy in a chronic C02 retainer, a bronchoscopy can be performed without premedication or valium. The Watch the patient closely and intubate if the need arises. The alternative is to intubate the patient and perform the bronchoscopy under a controlled situation on a ventilator.
• Low PO2:
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  The inability to raise the pre-bronchoscopy P02 to 65 mm with supplemental oxygen is a contraindication. This scenario can occur with patients on a ventilator who have ARDS like a picture.
• Coagulation Defect:
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  There is no contraindication for a bronchoscopy in patients with uremia or patients with a known coagulation defect. Of course, there is a contraindication for brushing or biopsy. Bronchoalveolar lavage can be done safely in these patients.
• Tracheal Stenosis:
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  You should be aware of the concept of "open" and "closed" bronchoscopy. Fiberoptic bronchoscope is a closed bronchoscope, while the rigid bronchoscope is an open scope. In patients with tracheal stenosis, be aware that if you go beyond the stenosis with a fiberoptic bronchoscope, you could be completely occluding the airway.
• Foreign Body:
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  If you are sure of the prescience of a foreign body, it is best to do a rigid bronchoscopy under general anesthesia. If there is some doubt, you can use the bronchoscopy as a screening procedure.
• Asthma:
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  Asthmatics can develop severe laryngospasm and bronchospasm during a bronchoscope. With proper preparation, using steroids and bronchodilators, the procedure can be carried out safely. I routinely give 200 mg of hydrocortisone the night before and immediately prior to the procedure. The preprocedural administration of bronchodilating agents is an important step in the prevention of complications.

  References:

  1. Summary and recommendations of a workshop on the investigative use of fiberoptic bronchoscopy and bronchoalveolar lavage in individuals with asthma. J Allergy Clin Immunol 76:145-7, 1985.
  2. Sahn, SA, et al. Fiberoptic bronchoscopy in bronchial asthma. A word of caution. Chest 69:39-42, 1976.
  3. Nakhostemm, JA. Bronchofiberoscopy in asthmatics: A method for minimizing complications. Respiration 36:112-6, 1978.
• SVC Syndrome:
• 
  Superior vena caval syndrome used to be considered a contraindication for a bronchoscopy. The concerns are:
  • Bleeding with the biopsy
  • Tolerance of the supine position by the patient. I usually perform the bronchoscopy in a sitting positions in patients with SVC. Patients seem to tolerate the bronchoscopy in the sitting position quite well. I have not found bleeding to be a problem.