Effectiveness Not Established

Therapeutic Bronchoscopy

for Dyspnea

Bronchoscopy is a technique of directly visualizing the inside of the airways in the lung for diagnostic or therapeutic purposes. A bronchoscope is inserted into the airways through the nose, mouth, or tracheostomy. Therapeutic use includes a number of procedures for acute or chronic situations for the treatment of tumors, air leaks, drug application, removal of foreign bodies, and removal of sputum.

Research Evidence Summaries

Ost, D.E., Ernst, A., Grosu, H.B., Lei, X., Diaz-Mendoza, J., Slade, M., . . . AQuIRE Bronchoscopy Registry. (2015). Therapeutic bronchoscopy for malignant central airway obstruction: Success rates and impact on dyspnea and quality of life. Chest, 147, 1282–1298. 

Study Purpose

To measure the technical success of therapeutic bronchoscopy and its impact in improving dyspnea and quality of life among patients with malignant central airway obstruction

Intervention Characteristics/Basic Study Process

Data from the AQuIRE (American College of Chest Physicians Quality Improvement Registry) for 1,115 procedures on 947 patients undergoing therapeutic bronchoscopy from January 2009–February 2013 were used for this study. Primary outcome data were defined as greater than a 50% opening of airway lumen. A smaller subset (N = 187) of centers collected pre- and postprocedure (30 days) secondary outcome data looking at dyspnea improvement after bronchoscopy as measured via Borg scores and health-related quality of life (HRQOL) measured via the SF-6D.

Sample Characteristics

  • N = 947   
  • AGE = 62.8 years
  • MALES: 55.6%, FEMALES: 44.4%
  • CURRENT TREATMENT: Other
  • KEY DISEASE CHARACTERISTICS: Of all participants, 71.7% had primary lung cancer.
  • OTHER KEY SAMPLE CHARACTERISTICS: The sample size for clinical outcome data was 187.

Setting

  • SITE: Multi-site   
  • SETTING TYPE: Multiple settings    
  • LOCATION: Cleveland Clinic Foundation, Cleveland, OH; the Penn State Cancer Institute, Hershey, PA; the University of Illinois Hospital and Health Sciences Center, Chicago, IL; the Department of Pulmonary and Critical Care Medicine, Boston University, Boston, MA; the Department of Interventional Pulmonology, Chicago Chest Center, Chicago, IL; the Department of Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX; the Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC; the Department of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD; the Department of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH; and the Department of Pulmonary and Critical Care Medicine, University of Calgary, Calgary, AB, Canada

Phase of Care and Clinical Applications

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Elder care, palliative care

Study Design

  • Retrospective data analysis for technical outcomes
  • Prospective trial to evaluate clinical outcomes

Measurement Instruments/Methods

  • SF-6D
  • Borg Rating of Perceived Exertion Scale score 
  • Technical success was based on anatomic criteria defined as a brochoscopically reopening of the airway lumen to greater than 50% of the normal diameter, and the airway had to connect to a viable area of distal lung. All clinical outcomes were assessed by the attending physician using standardized definitions from a code book developed by the American College of Chest Physicians Quality Improvement Registry, Evaluation and Education (AQuIRE) program, to evaluate therapeutic bronchoscopy for malignant central airway obstruction.

Results

The technical success rate of the therapeutic bronchoscopies was 90%–98%. Participants with an American Society of Anesthesiology score greater than 3 with renal failure, primary lung cancer, left mainstem disease, and tracheoesophageal fistula were linked with failure. In addition, participants who were heavy smokers and who had multiple cancers and lobar obstruction showed a smaller improvement than the other participants. A 3.9% complication rate was observed, 0.5% of the patients died postprocedure, and the 30-day mortality rate was 15%. Secondary outcome data post-procedure showed that 48% of the patients had a clinically significant improvement in dyspnea, dyspnea stayed the same in 43% of patients, and 9% had worse dyspnea. HRQOL improved postprocedure for 42% of patients. Those that had worse baseline dyspnea scores tended to have the greatest improvement. Those with lobular obstructions had smaller measures of improvement in HRQOL.

Conclusions

The use of therapeutic bronchoscopy for the treatment of malignant central airway obstruction had a high technical success rate. More importantly, patients showed significant improvement in their subjective rating of dyspnea and in HRQOL. Having clinical outcome data assists in the process of weighing potential risks versus benefits of this procedure. Given that some of the patients with the worst dyspnea at baseline ultimately had the greatest benefit, these patients should be considered for therapeutic bronchoscopy and not assumed to be too sick to benefit.

Limitations

  • Small sample (< 100)
  • Risk of bias (no control group)
  • Risk of bias (no random assignment)
  • Key sample group differences that could influence results
  • Findings not generalizable
  • No standard method of patient selection or standardization of procedure, as all clinical decisions were at the discretion of the individual performing the therapeutic bronchoscopy
  • Significant variations in practice patterns existed in different centers and locations of care.
  • Technical success rates were determined by the individual performing the procedure, and bias may have existed.

Nursing Implications

To educate and advocate for patients undergoing therapeutic bronchoscopies, nurses must be knowledgeable about the different types, purpose, indications, and potential risks and benefits of each. The technical success of the procedure is not sufficient enough in measuring the overall benefit to the patient; quality of life and palliation of dyspnea outcomes must also be considered.

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