Safety of Therapeutic Rigid Bronchoscopy in People Aged 80 and Older: A Retrospective Cohort Analysis

To the Editor: Because the prevalence of malignancies increases with age, people aged 65 and older account for 70% of newly diagnosed lung cancers.1,2 Although this population will double in the United States by 2032, and the population aged 85 and older grows even faster,1 elderly people are less likely to receive curative surgery or palliative chemo-radiation therapy.3 Therapeutic interventional bronchoscopy, including rigid bronchoscopy, laser resection, and stent placement, are indicated for palliation of malignant disease and relief of benign central airway obstruction and are shown to improve survival, quality of life, and pulmonary function while providing symptom relief.4,5 Comparisons of diagnostic flexible bronchoscopy in people aged 80 and older and those younger than 80 found no significant increase in complications, yet there are no data suggesting safety of therapeutic rigid bronchoscopy in this population.6,7 A retrospective cohort analysis was performed using comprehensive chart review (with institutional review board approval) of 18 such procedures performed in octogenarians (mean age ±standard deviation, 84.4±2.6, range 80–88) over a 39-month period at a tertiary academic center. Rigid bronchoscopies were performed under general anesthesia with spontaneous assisted ventilation using the EFER-Dumon bronchoscope (Bryan Corp., Woburn, MA); an Nd:YAG laser and silicone stents were used if necessary. Midazolam pre-medication, followed by propofol rapid-sequence induction were used; remifentanil and fentanyl were the opioids of choice. Lactated Ringer's solution and normal saline were used as crystalloids, and phenylephrine was used to treat intraoperative hypotension. Of 18 procedures, four patients were American Society of Anesthesiologists (ASA) Class IV, 11 were Class III, and three were Class II. Preoperative comorbidities included hypertension (n=8), arrhythmia (n=4), hypothyroidism (n=3), recurrent pneumonia (n=2), chronic obstructive pulmonary disorder (n=2), recent coronary artery bypass graft with congestive heart failure (n=1), and severe anemia (n=1). All procedures were therapeutic, the most common indication being dyspnea from malignant airway obstruction; only two patients had benign strictures. The majority of obstructing lesions (70%) were located in the trachea and mainstem bronchi. Nd:YAG laser was used in 11 or 18 procedures, and three involved silicone stent insertion. Five patients underwent rigid bronchoscopic dilatation, and three had balloon dilatation. Repeat procedures were necessary in one patient with benign strictures and one with malignant disease. Mean anesthesia time was 56±15 minutes, mean procedure time was 37±15 minutes, and mean recovery room stay was 84±33 minutes (Table 1). Intraoperative hypotension requiring phenylephrine was seen on seven occasions (39%). One study8 reported that, in a different age bracket (mean age 48), hypotension was not a significant complication. This discrepancy underscores the need for vigilant hemodynamic monitoring in people aged 80 and older. Procedure-related bleeding requiring local instillation of epinephrine (1:20,000) occurred on two occasions, both at the site of rigid bronchoscopic dilatation. One patient had intraoperative hypoxemia (<80% for >1 minute) requiring aggressive suctioning and increased oxygen supplementation. Because the anesthesiologist and bronchoscopist share the airway, depending on the extent of obstruction, need for laser resection, ability to oxygenate and ventilate, and severity of underlying comorbidities, priorities must be given to oxygenation and bronchoscopic intervention. Postoperative supplemental oxygenation up to 90 minutes to maintain oxygen saturation of greater than 90% was required in 11 cases. One patient required bronchodilator therapy for bronchospasm. Three patients had excessive somnolence (although not requiring reversal of anesthesia or reintubation) at the time of recovery room discharge. These results are consistent with findings from studies of flexible bronchoscopy using midazolam and fentanyl in people aged 80 and older.6,7 Decisions regarding discharge or admission was based on the postanesthesia scoring system. On 16 of 18 occasions, patients were discharged home within 24 hours (same day in 9/18). Longer admissions (4 and 10 days) were required for the remaining two cases. All patients stated subjective relief from dyspnea. There was no perioperative mortality, and no patients required postoperative intubation or mechanical ventilation. The anesthesia literature suggests that postoperative mortality correlates with ASA class (3.5% for ASA class III, 18.3% with ASA class IV9). Despite the observed absence of postoperative mortality, one cannot infer zero mortality; based on the principle elaborated previously,10 the hypothetical upper limit of the 95% confidence interval of mortality in this small series of 18 is 15%. This number can be diminished if larger series with zero mortality are reported. This retrospective analysis of people aged 80 and older with multiple comorbidities and advanced ASA class suggests that these patients can safely undergo therapeutic rigid bronchoscopy by an experienced interventional team and that age should not be used as a sole exclusionary criterion. Although no patients suffered major complications, reversible hypotension and hypoxemia were common. Additional studies are warranted to assess the effect of interventional airway procedures on long-term survival and quality of life of people aged 80 and older. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this manuscript. MD and HGC are salaried employees of University of California at Irvine (UCI, a nonprofit state university with no financial interest). SS is a volunteer medical observer working at UCI. Author Contributions: MD: study design, institutional review board acquisition, data analysis, manuscript co-authorship and review. SS: data collection, data analysis, manuscript co-authorship. HGC: initial idea, study design, manuscript co-authorship and review, mentorship. Sponsor's Role: This study was not sponsored by any financial institution.