title: Bronchoscopic lung biopsy using noninvasive ventilatory support: case series and review of literature of NIV-assisted bronchoscopy.
abstract: BACKGROUND
  Fiberoptic bronchoscopy and lung biopsy are important diagnostic tools in patients with diffuse pulmonary infiltrates. However, these patients often have hypoxemic respiratory failure that makes this procedure hazardous. Noninvasive ventilation (NIV) has been shown to improve  oxygenation in hypoxemic patients.
  
  
  OBJECTIVE
  To report the efficacy and safety of an innovative technique of NIV-assisted bronchoscopic lung biopsy in a small case-series of hypoxemic subjects with diffuse parenchymal infiltrates; also to systematically review the literature on NIV-assisted  bronchoscopy.
  
  
  METHODS
  Subjects with bilateral diffuse parenchymal infiltrates and P(aO(2))/F(IO(2)) < 200 mm Hg underwent bronchoscopic lung biopsy under NIV support. NIV was initiated 10 min before the procedure and continued for 30 min after the procedure.  The primary outcomes were performance of successful procedure and episodes of decline in S(pO(2)) < 90%. Secondary end points were the change in the respiratory and hemodynamic parameters during the procedure and occurrence of complications such as pneumothorax, hemorrhage,  and endotracheal intubation.
  
  
  RESULTS
  Six subjects, with a mean ± SD age of 44.5 ± 11.6 years, were included in the study. The median (interquartile range [IQR]) P(aO(2))/F(IO(2)) prior to lung biopsy was 164.5 mm Hg (146.3-176.3 mm  Hg), and the median (IQR) inspiratory and expiratory positive airway pressures were 14 cm H(2)O (12-15 cm H(2)O) and 5 cm H(2)O. Fiberoptic bronchoscopy was well tolerated and all subjects maintained S(pO(2)) > 92% during the procedure.  One subject required endotracheal intubation due to hemoptysis. A definite diagnosis was obtained in 5 of the 6 subjects. A repeat procedure was performed in one subject, which again yielded no diagnosis. No other periprocedural complications were encountered.
  
  
  CONCLUSIONS
  NIV-assisted bronchoscopic  lung biopsy is a novel method for obtaining diagnosis in hypoxemic patients with diffuse lung infiltrates. However, this approach should be reserved for centers with extensive experience in NIV. More studies are required to define the utility of this approach.
authors.affiliation: Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India. riteshpgi@gmail.com
authors.forename: Ritesh
authors.initials: R
authors.lastname: Agarwal
authors.forename: Ajmal
authors.initials: A
authors.lastname: Khan
authors.forename: Ashutosh N
authors.initials: AN
authors.lastname: Aggarwal
authors.forename: Dheeraj
authors.initials: D
authors.lastname: Gupta
mesh_terms: D000328:Adult; D001706:Biopsy / Q000379:methods*; D001999:Bronchoscopy / Q000379:methods*; D005260:Female; D005336:Fiber Optic Technology; D006801:Humans; D008171:Lung Diseases / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D063087:Noninvasive Ventilation