title: Diffuse bleeding from the bronchial mucosa on flexible bronchoscopy in lung transplanted patients: 'the hemorrhagic bronchial mucosa syndrome'.
abstract: BACKGROUND
  Flexible bronchoscopy (FFB) with bronchoalveolar lavage and transbronchial lung biopsy is a frequently performed procedure after lung transplantation (LTx). During 2002-2006, we performed 1,800 FFBs on LTx patients at our center.
  
  
  OBJECTIVE
  To describe the occurrence of bronchial mucosal bleeding during FFB in 5 patients.
  
  
  METHODS
  FFB was performed under sedation with propofol and after intubation with a laryngeal mask. All 5 patients had normal chest X-rays and no clinical signs of lower respiratory tract infection. They were normotensive, had normal lung function, normal platelet counts and prothrombin times and no clinical evidence of other coagulopathies. Immunosuppression consisted of cyclosporin A, azathioprine and prednisolone.
  
  
  RESULTS
  In these 5 patients, we observed diffuse bleeding from the bronchial mucosa in both the transplanted and native lung. Bleeding was preceded by coughing and the development of diffuse mucosal hyperemia followed by mucosal petechiae, which subsequently coalesced into mucosal hemorrhage and overt intrabronchial bleeding. In 1 case, the bleeding caused impairment of lung function and hypoxemia.
  
  
  CONCLUSIONS
  Bronchial mucosal bleeding is probably caused by increased intrathoracic pressure induced by coughing in a closed airway system, which in turn induces a high pressure in the intrathoracic vessels that is transferred to the bronchial vascular system. Vulnerability of the mucosal capillaries due to immunosuppression probably also contributes to what we have termed 'the hemorrhagic bronchial mucosa syndrome'. The hemorrhagic bronchial mucosa syndrome with intrabronchial bleeding is a rare complication of bronchoscopy, predominantly occurring in LTx patients. From a prophylactic point of view, it seems essential to avoid coughing during bronchoscopy in intubated patients.
authors.affiliation: Heart Center, Division of Lung Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. nils.milman@webspeed.dk
authors.forename: Nils
authors.initials: N
authors.lastname: Milman
mesh_terms: D000328:Adult; D000368:Aged; D001999:Bronchoscopy / Q000009:adverse effects*; D006470:Hemorrhage / Q000209:etiology* / Q000473:pathology; D006801:Humans; D016040:Lung Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D020545:Respiratory Mucosa / Q000473:pathology*