European Geriatric Medicine https://doi.org/10.1007/s41999-017-0001-7
RESEARCH PAPER
Risk factors for bronchoscopic complications in patients over 75 years of age Sehnaz Olgun Yildizeli1 • Asli Tufan2 • Huseyin Arikan1
•
Caner Cinar1 • Derya Kocakaya1 • Emel Eryuksel1
Received: 20 August 2017 / Accepted: 27 September 2017 Ó European Geriatric Medicine Society 2017
Abstract Aim Bronchoscopy is a widely used, well-tolerated diagnostic and therapeutic intervention and has a low complication rate. The aim of this study was to describe the rates of bronchoscopic complications and risk factors in a group of patients 75 years’ old and above. Methods To investigate the rate of complications and risk factors in the older patients, we carried out a retrospective cohort study of 240 patients above 75 years of age who had bronchoscopy for various reasons. Results Complication rate was found to be 3.7% in the older patients group which was not different from the control group (1.2%, p [ 0.05). No significant relationship was found between age group and complication development (p [ 0.05). The type of procedures did not show any effect on complication development between age groups and individually. We found that anemia (OR 7.2, 95% CI 1.2–41.2), percutaneous gastrostomy (OR 9.9, 95% CI 1.6–58), immobility (OR 11.9, 95% CI 2.6–33.5) and procedures performed in the intensive care unit (OR 7.4, 95% CI 1.4–37.5) were significant risk factors for complication. Conclusions In the older patients group, bronchoscopy is a safe procedure regardless of the type of procedures performed and age. It has been shown that anemia, PEG presence, immobility and intensive care patients are associated with increased complication. Keywords Bronchoscopy Complication Older patients Risk factor
Introduction Fiberoptic bronchoscopy is widely used in the diagnosis and treatment of lung diseases and complication rates are low. In terms of complication development, in previous studies the general condition of the patient, the type of procedure performed, the equipment and experience of the operating team have been shown to be causative factors [1, 2]. Incidence varies between 0.3 and 30%, although the definition of complications changes. In the aging population, the incidence of malignancy risk increases, as well as the incidence of other pulmonary diseases. Bronchoscopy
can be used for diagnostic purposes in these patients [3]. While there are a limited number of studies that examine bronchoscopy tolerance and complication risks in the older patients, results indicate that age is not a risk factor alone [4–6]. But the number of older patients (C 75 years) is very low in these studies [7]. Existing studies have evaluated safety, diagnostic and therapeutic efficacy, but no study has evaluated the risk factors for complication development. The aim of this study is to identify risk factors for bronchoscopic complications that may develop in older patients.
& Sehnaz Olgun Yildizeli
[email protected]
Materials and methods
1
Department of Respiratory and Critical Care Medicine, Marmara University School of Medicine, Istanbul, Turkey
2
Division of Geriatrics, Department of Internal Medicine, Marmara University School of Medicine, Istanbul, Turkey
Between May 2009 and December 2016, 1683 cases of bronchoscopy performed by our hospital Chest Diseases Department were evaluated retrospectively. Both inpatients
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and outpatients as well as procedures performed in intensive care unit were included in the study. There were 268 cases over 75 years of age. Twenty-eight patients were not included in the study because of missing data. To compare the complication rates, 243 cases under the age of 75 were randomly matched by the computer using the patient ID number, so that the type of procedures would be similar. In older patients (C 75 years), age, gender body mass index (BMI), nursing home, need for individual care, dementia, cerebrovascular event, mobility, pressure sores, percutaneous endoscopic gastrostomy (PEG), hypoalbuminemia, presence of comorbid diseases [coronary artery disease (CAD), congestive heart failure (CHF), hypertension (HT), diabetes mellitus (DM), chronic renal failure (CRF), chronic obstructive pulmonary disease (COPD)], indications of procedure, location of procedure, complication status and complication type were evaluated. In the control group, parameters such as age, gender, indications of procedure, location of procedure, complication status and complication type were evaluated. Data of these patients were obtained from the computer records, the postbronchoscopic procedure report, and the nurse observation and information retrieval records prior to bronchoscopy. Anemia in older patients was defined as hemoglobin less than 11.5 g/dL. Hypoalbuminemia was defined as albumin level less than 3.5 g/dL. Polypharmacy was defined as patients using five or more medications. Dementia was defined as patients who were affected in their daily activities and had a score of less than 24 in the mini-mental state examination test or who were already receiving dementia medication. All fiberoptic bronchoscopy procedures were performed by a board-certified chest physician or by a resident with supervision by a senior. Procedures performed in the bronchoscopy unit or in the intensive care unit were evaluated. Oral and airway anesthesia was achieved with 2% lidocaine inhalation and direct application. Patients were sedated intravenously (iv) with midazolam. All patients were routinely monitored with threelead electrocardiogram (ECG) and pulse oximeter. Blood pressure was monitored non-invasively during the procedure. All patients also received oxygen support during the procedure. In patients under mechanical ventilatory support, oxygen treatment was provided as 100% during the procedure. Bronchoalveolar lavage (BAL) was performed with 3–4 doses of 40 ml of 0.9% saline and applied to specific areas detected by computerized thorax tomography. Transbronchial biopsies were performed under guidance of fluoroscopy. Routine chest radiography (X-ray) of the patient with transbronchial biopsy was performed. All patients were followed for at least 2 h after the procedure. The performing physician recorded adverse events during or shortly after procedure as complications. The types of
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complications were obtained from the procedure reports and the nurses’ observation reports after the procedure and were classified as bronchospasm, oxygen desaturation (hypoxemia), arrhythmia, hemorrhage, and pneumothorax. Analysis of other complications has not been evaluated. Desaturation was defined as a decrease in saturation more than 5% compared to baseline monitored by finger pulse oximetry during the procedure. Rhythm changes detected in the ECG from baseline and peak heart rate more than 140/min were defined as arrhythmia. Hemorrhage was defined as bleeding that occurred during the procedure and unstoppable with 2 mg adrenaline, 30 cc cold saline and compression by wedge position of bronchoscopy. Also, the detection of pneumothorax in the chest X-ray after the biopsies taken or in the presence of persistent hypoxemia during the procedure was defined as a complication of pneumothorax. Statistical Package for Social Sciences (SPSS) version 23 was used for statistical analysis. Normality was tested using the Shapiro–Wilk test and graphical methods. The data are presented as mean ± standard deviation or n (percent), where appropriate. The t test was used to test the differences between the two groups in terms of continuous variables, and the Chi-square test was used to test the categorical variables. p value \ 0.05 was accepted as a sign of statistical significance. Univariate logistic regression analysis was performed to identify which factors were associated with complication development. Multivariate logistic regression analyses with backward elimination procedure including all factors showing a p value B 0.20 in the univariate analysis were undertaken to obtain adjusted odds ratio (OR) along with 95% confidence interval (CI) and to define which variables were independently associated with complication development.
Results Study population and characteristics For the patients over 75 years old, 167 of 240 patients were male, mean age was 79 ± 3.8 years and mean BMI was 25.6 ± 4.5 years. Of the 243 patients under the age of 75 years, 141 were male. The mean age in this group was calculated as 44.7 ± 13.7 years (Table 1). For the older patients, it was found that 95 (39.6%) patients had COPD, 75 (31.3%) patients had CAD, 43 (17.9%) patients had CHF, 33 (13.8%) patients had CRF, 108 had HT, 73 (30.4%) patients had DM, and 40 (16.7%) patients had active malignancies.
European Geriatric Medicine Table 1 Demographic characteristics
\ 75 years old (n = 243)
C 75 years old (n = 240)
Gender (n) Male
141
167
44.7 ± 13.7
79 ± 3.8
Malignancy
69 (28.4)
113 (46.9)
Infectious
114 (46.9)
92 (38.5)
Others
60 (24.7)
35 (14.6)
BAL ? Brush
143 (58.8)
149 (61.9)
BAL ? Brush ? Biopsy
100 (41.2)
91 (38.1)
Age (mean ± SD) Indication (%)
Procedure type (%)
Procedure place (%) Bronchoscopy unit
238 (97.9)
225 (93.7)
Intensive care unit
5 (2.1)
15 (6.3)
Midazolam (mean ± SD), mg
3.8 ± 1.3
1.5 ± 1.3
BMI (mean ± SD), kg/m2 Comorbidities (%)
N/A
25.6 ± 4.5
COPD
37 (15.8)
95 (39.6)
CAD
19 (7.8)
75 (31.3)
CHF
9 (3.7)
43 (17.9)
CRF
6 (2.4)
33 (13.8)
HT
40 (16.4)
108 (45)
DM
36 (14.8)
73 (30.4)
Malignancy
14 (5.7)
40 (16.7)
SD standard deviation, BAL bronchoalveolar lavage, BMI body mass index, COPD chronic obstructive pulmonary disease, CAD coronary artery disease, CHF congestive heart failure, CRF chronic renal failure, HT hypertension, DM diabetes mellitus, N/A not available
Indications and procedures In the older patients group, the indications for bronchoscopy were found to be as malignancy suspicion 46% (n: 113), infectious causes 38.5% (n: 92), others 4 (n: 69), whereas in patients’ younger than 75 it has been found that malignancy suspicion was 28.4% (n: 69), infectious causes were 46.9% (n: 114) and others were 24.7% (n: 60). Evaluation of procedures performed showed that there was no difference between age groups regarding bronchoscopic procedure (p [ 0.05). In older patients, 149 (61.9%) BAL and Brush, 91 (38.1%) BAL, brush and biopsy were performed, whereas in patients younger than 75 years of age it was 143 (58.8%) for BAL and Brush, 100 (41.2%) for BAL, brush and biopsy. The mean midazolam dose used in sedation was 1.5 ± 1.3 mg in the older patients; in the group age \ 75 years old, it was 3.8 ± 1.3 mg. Compared to age group, 75 years of age and older received significantly lesser amounts of midazolam during bronchoscopy (p \ 0.001). Most of the procedures performed in the bronchoscopy unit in both age groups. But in the 75 years of age and over
group, procedures performed in the intensive care unit were significantly more (6.3 vs 2.1% respectively, p \ 0.05).
Complications and risk factors for complication development Nine (3.7%) of the patients in the older patients group had complications. Pneumothorax in 1 case, bleeding in 1 case, and desaturation in 7 cases were detected. There was no mortality among complicated patients. The mean age of complicated patients was 79.1 years, and the mean age of patients who did not develop any complication was 78.9 years within this age group. There was no significant difference between the two groups (p [ 0.005). Three (1.2%) patients developed complications in the age \ 75 years’ group; 1 case of pneumothorax, 1 case of hemorrhage, and 1 case of desaturation were detected. No significant relationship was found between age group and complication development (p [ 0.05). Type of procedures did not show any effect on complication development between age groups and individually. Also, there was no correlation between complication development and midazolam doses (p [ 0.05).
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Patients were divided into three groups as single comorbid condition, two comorbid conditions and C 3 comorbid conditions. There was no significant difference between the groups in terms of complication development (p [ 0.05). In the analysis performed, the presence of anemia, presence of PEG, immobility and procedures performed in the ICU were defined as independent risk factors (Table 2).
Discussion In this retrospective study, risk factors for complication development in older patients were evaluated. There are studies in the literature that investigate the incidence of bronchoscopy complications in older patients, but there are no studies that have done risk factor analysis in the older patients group in terms of complication development. In this study, there were 240 cases in the patient group we examined, and a control group of 243 patients was included in the evaluation. The older patients group was randomly matched by the computer to the \ 75 years’ age group according to the procedures performed. When all the patients included in the study were evaluated, the complication rate of bronchoscopy was found as 2.4% in general, and it is comparable to results in the literature [8]. The incidence of complication was found as 3.7% in the older patients group, whereas it was found as 1.2% in the \ 75 years’ old group, but it was not statistically significant between the groups (p [ 0.05). A thorough literature search has shown that there are very limited publications in the C 75 age group, with differences in the definition of advanced age group. The British Thoracic Society reports in 2013 ‘‘Diagnostic flexible bronchoscopy in adults’’ guideline that age is not a contraindication for flexible bronchoscopy alone [9]. Allan and colleagues reported that in 120 cases of patients above the age of 80, the incidence of complications was 3.3% and did not differ between their control and study groups. They have not reported any mortality [10]. In our study, the incidence of complications was 3.7% in patients over 75 years of age and there were no mortal cases. However,
Table 2 Significant risk factors for complication development Variables
Odds ratio (95% CI)
p
Anemia
7.2 (1.2–41.2)
0.027
PEG
9.9 (1.6–58)
0.036
Immobility Procedures performed in ICU
11.9 (2.7–33.5)
0.001
7.4 (1.4–37.5)
0.046
CI confidence interval, PEG percutaneous gastrostomy, ICU intensive care unit
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in a prospective cohort study by Hehn et al., which evaluated age and bronchoscopy tolerance, reported positive correlation between age and complication frequency. They have suggested that transbronchial biopsy may result in more complications in older patients than in the younger, but they have not found any difference in hemorrhage, bronchospasm, hypoxemia, and non-respiratory complications. They could not show a significant risk factor in subgroup analysis for increased risk of pneumothorax with transbronchial biopsy [6]. Similarly, Rokach et al. reported a complication rate of 11.5% in patients aged 80 years and above, and it was argued that older age is a risk factor for developing bronchoscopic complications [7]. When the complications were evaluated, it was found that the risk of hypoxemia was higher in the older age group. This increased risk of complication, which is contradictory to previous studies, relates the risk to the fact that most of the cases included were intensive care patients and that two of the three mortal cases reported in the study were patients receiving mechanical ventilation support in the intensive care unit. In the results of our study there was a statistically significant difference between the advanced age group and the control group when the types of complications were evaluated. However, in terms of complication development, bronchoscopy performed in intensive care unit was found to be a risk factor, which is consistent with the hypothesis suggested by Rokach et al. In the same study, it was suggested that the underlying comorbidities may increase the risk of complications in older patients. Although there is evidence that the presence of comorbid disease decreases the safety of the procedure in older patients [11], our study did not identify a risk factor for subgroup analysis according to the underlying comorbidities (DM, CAD, COPD, CHF, CRF) of older patients. We found that midazolam was used significantly less in the older age group than in the age group of \ 75 years (1.5 ± 1.3 vs 3.8 ± 1.3 mg, p \ 0,001). While flexible bronchoscopy can be done without sedation, it is known that patient comfort and tolerance are better in the procedures performed under sedation [12]. However, sedative agents used in adults have been reported to cause respiratory depression during the procedure [13]. The most common agent used for sedation in flexible bronchoscopy in recent years is benzodiazepines, which are preferred because of the rapid onset of action and the relatively shorter duration of action [14]. In a flexible bronchoscopy study, it was shown that the sedation dose required for procedures in older ages was lower and patients older than eighty had a higher risk of sedation-related complications compared to the age of under eighty [10]. Also, Hehn et al. reported that the dose required for sedation was lower in older patients than in younger patients [6]. Like these results, the dose used in our study was significantly lower
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in the older patients group. The subgroup analysis showed no relationship between midazolam dose used and the type of procedure (p [ 0.05). When complicated cases were evaluated, there was no correlation between complication development and the amount of midazolam used in both groups (p [ 0.05). However, it was not possible to assess patient compliance and tolerance because of the retrospective design of our study. In the older patients, minimal stress causes sudden health change, which is defined as ‘frailty’ because of the general depression caused by age-related physiological system impairment [15]. Frailty can be seen in approximately four quarters of the cases over the age of 85 years, and in these patients, conditions known as low risk such as minimal infection, minimal surgery can lead to immobility or need of extra care [15]. While many models and definitions are generated for frailty, sarcopenia-associated general malaise, muscle weakness and related inadequate exercise capacity for daily activities, decrease in cognitive functions, weight loss or obesity, presence of osteoporosis, anemia, and decrease in VO2max comorbidities are thought to make older patients frail [16]. Although multicenter studies have shown that the underlying comorbid diseases are a risk factor for frail older patients, it can be identified without them. It is also stated that chronological age alone does not prevent invasive procedures and does not lead to development of complications [15]. It is emphasized that the main importance of this definition is the necessity of making good profit and loss account in the interventional procedures in this group of patients. In our study, patients were assessed to determine risk factors for possible frail older patients using data regarding age, gender body mass index, nursing home, need for individual care, presence of dementia, cerebrovascular event, mobility, pressure sores, percutaneous endoscopic gastrostomy, hypoalbuminemia, anemia, presence of comorbid diseases (coronary artery disease, congestive heart failure, hypertension, diabetes, chronic renal failure, chronic obstructive pulmonary disease), malignancy, falling history, fracture history and polypharmacy. The results showed that presence of anemia (p \ 0.027), presence of PEG (p \ 0.036), immobilization (p \ 0.001) and procedures performed in intensive care unit (p \ 0.046) were found to be risk factors for complication development in bronchoscopic procedures. There was no correlation between type of complication and risk factors (p [ 0.05). While immobility is a risk factor for frail older patients, PEG presence has also been associated with limited functional capacity in general. It is thought that the presence of anemia is primarily related to chronic diseases and comorbidities. Our study has some limitations. First, its retrospective design does not allow to objectively evaluate sarcopenia,
cognitive function and nutritional status of patients who are thought to be frail and older. Secondly, bronchoscopic procedures were performed by different operators. Third and last, patients who were scheduled to undergo bronchoscopy were firstly evaluated in the outpatient clinic, which may have caused biases related to patient selection. In conclusion, this study found that the complication rate associated with flexible bronchoscopy in patients aged 75 years and above was not different from other age groups. It has been shown that there is no chronological age effect for complication development but anemia, PEG presence, immobility and intensive care patients are associated with increased risk. The definition of frailty is evolving, as this terminology is still under discussion among experts in geriatrics. The general perception is that frailty is a state of vulnerability and non-resilience with limited reserve capacity in major organ systems. This leads to reduced capability to withstand stress such as trauma or disease. Frailty is a risk factor for dependence and disability. Seen as in our patients anemia, PEG presence, immobility and intensive care patients are risk factors. These risk factors also coincide with the definition of frail older patients. In this age group, objective assessment of frail older patients before all interventional procedures, not only flexible bronchoscopy, would be beneficial in terms of predicting the risk of complications. Multicenter prospective studies with more patient numbers are needed to support the results and assess the type of complications that may develop and risk factors.
Compliance with ethical standards Conflict of interest The authors declare no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent For this type of study formal consent is not required.
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