Indications and Outcome of Flexible Bronchoscopy at Muhimbili National Hospital in Dar es Salaam: Tanzania

doi:10.21203/rs.3.rs-2565560/v1

Download PDF

Research Article

Indications and Outcome of Flexible Bronchoscopy at Muhimbili National Hospital in Dar es Salaam: Tanzania

https://doi.org/10.21203/rs.3.rs-2565560/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background:A flexible bronchoscopy is an essential tool that is globally used for the diagnosis and treatment of Broncho-pulmonary diseases. However the indication and outcome of flexible bronchoscopy has not been widely documented in majority of low resource settings.

Objective:To determine the indications and outcome of flexible bronchoscopy (FB) at Muhimbili National Hospital (MNH).

Methodology: A cross sectional analytical study was conducted for a period of 12months. Details involving indications and outcome of flexible bronchoscopy includes; bronchoscopy findings, therapeutic value, diagnostic yield, and early procedural related complications together with their demographic data were documented after each procedure followed by analysis using SPSS version 25.

Results:Among 151 patients underwent flexible bronchoscopy 76(50.3%) were male and 75(49.7%) were female. The median age of 58 years with IQR (43, 65). Among the indications of flexible bronchoscopy, Cough and hemoptysis were the leading by 82.1% and 25.2% respectively. On the other hand hyperemic mucosa (31.1%) and endobronchial mass (21.2%) constituted the majority of the bronchoscopy findings. The overall diagnostic yield was 34.3% and procedural related complications was 18.54%. Among the indications for flexible bronchoscopy, the hemoptysis was associated with procedure related complications by 31.6% (p-value<0.020, OR 2.779). Among sampling technique of flexible bronchoscopy, the endobronchial biopsy and BAL sampling technique were associated with procedure related complications by 39.5 %( p-value<0.001, OR 4.393) and 14.7 %( p-value<0.005, OR 1.870) respectively

Conclusion: We have demonstrated that flexible bronchoscopy is a safe and reliable procedure in diagnosis of respiratory maladies including MTB at Muhimbili National Hospital.

Flexible bronchoscopy (FB)

Indications

Bronchoscopic Outcomes

Bronchoscopy is an endoscopic technique that allows visualization of the airway of a patient with respiratory maladies(1). In Tanzania bronchoscopy started in 1991 at Muhimbili National Hospital in Dar es Salaam though it was done on small scale. Over the past five years, there is a three-fold increase in bronchoscopy at Muhimbili National Hospital. (2)Despite this increase, there are few documented indications and outcomes of bronchoscopy in Tanzania.

There are two types of bronchoscopes which are rigid and flexible. The flexible bronchoscope is an endoscopic instrument of choice for visualizing the tracheobronchial mucosa, down to the bronchioles.(3) This study focused only on flexible bronchoscopy as it is a new emerging endoscopic technique of choice globally for visualizing the airway down to the bronchioles levels. Flexible bronchoscopy is usually performed under local anesthesia.(4)

Flexible bronchoscopy is useful both for diagnostic and therapeutic purposes.(3) The therapeutic values include endobronchial laser ablation, electrocautery, foreign body removal, tumor debulking, balloon dilatation, photodynamic therapy, and stent placement.(5) The diagnostic values include; transbronchial biopsy, bronchial washing or brushing, bronchi alveolar lavage (BAL) sampling, and transbronchial needle aspiration.(6, 7) The indications for flexible bronchoscopy include symptoms or radiological anomalies that cannot be explained by non-invasive methods or to obtain samples from the lower airways.(8)

The outcome of flexible bronchoscopy includes; findings, diagnosis yield from samples, therapeutics, and complications.(8)

The flexible bronchoscopy is a very effective and safe procedure, the safety and effectiveness depend on the accuracy of the patient's selection and the experience of the bronchoscopist.(8)

A prospective cross sectional analytical study was conducted in bronchoscopy unit at Muhimbili National Hospital. We studied 159 patients who underwent flexible bronchoscopy from March 2021 to February 2022 by non-probability convenient sampling, patients with age above 12years were included while those who were repeating bronchoscopy were excluded from the study.

The data were collected and recorded on structured checklist. The checklist was administered to the bronchoscopist soon after performing flexible bronchoscopy. The laboratory result for the sample collected during the procedure were followed up in the laboratory after 2weeks.The date were entered into SPSS version 25 and analyzed.

A total of 151 patients underwent flexible bronchoscopy: There were 76 male patients representing 50.3% and 75 female patients representing 49.7%.The median age of the study participant was 58 years with interquartile rage (IQR) of (43-65). The age range was between 16 to 96 years. Majority of participant their ages were above sixty years (37.1%). Overall 143(94.7%) of the procedures were for diagnostic purposes, and 8(5.3%) of the procedures was for therapeutic purposes, where by the foreign body removal was 1(12.5%) and mucous clearance was 7(87.5%). None of the procedure were aborted due to complications. Table 1 shows the demographic characteristics of the participants.

Table 1: Demographic characteristics of the patients who underwent flexible bronchoscopy at MNH.

Variable

Frequency (n)

Percentage (%)

Age group (years)

≤ 35

36 - 45

46 - 60

>60

Median age in years (IQR)

Sex

Male

Female

TOTAL

58 (43,65)

151

13.9

15.2

33.8

37.1

50.3

49.7

100%

The most leading indication for flexible bronchoscopy was cough in 82.1% of cases, followed by hemoptysis in 25.2% of the cases. Lung mass cases were 11.9%, dyspnea cases were 9.9%, and lung collapse 1.3% and 0.7% were for cases with other indications such as foreign body, wheezing, post PTB squeal, cancer of the esophagus and nodule from the chest X-ray film. Figure 1 summarizes the indications for bronchoscopy.

The most frequent bronchoscopy findings was hyperemic mucosa by 31.1% followed by endobronchial mass by 21.2%,and in 20.5% of the bronchoscopies there was no abnormality found, the rest of the findings the frequency was less than 8%. The therapeutic value of flexible bronchoscopy was mucous clearance 7(87.5%) and foreign body removal 1(12.5%), however stenting and tumor debulking were not performed at all. The most diagnostic yield was nonspecific inflammatory 102(67.5%), carcinoma and MTB were reported by 42(27.8%) and 7(4.7%) respectively. The most frequent histological type for carcinoma was adenocarcinoma by 30(71.43%) followed by squamous cell carcinoma by 11(26.19%) and lymphoma by 1(2.38%). The overall procedural related complications was 28/151(18.54%), the most frequent complication was desaturation by 14(9.3%) followed by hemorrhage by 12(7.9%) and pneumothorax and bronchospasm both occurred by 1(0.6). Table 2 summarizes the flexible bronchoscopy outcomes at MNH.

Among the indications for flexible bronchoscopy, the hemoptysis was associated with procedure related complications by 31.6% (p-value<0.020, OR 2.779). There was no significant association between procedures related complications and other indications. The endobronchial biopsy and BAL sampling technique were associated with procedure related complications by 39.5 %( p-value<0.001, OR 4.393) and 14.7 %( p-value<0.005, OR 1.870) respectively while the bronchial brushing and transbronchial biopsy were not associated with procedure related complications. Expertise level of education was not associated with procedure related complications, p-value >0.220 across all levels Table 3.

Flexible bronchoscopy is the gold standard procedure in pulmonary medicine used to assist in diagnosis, staging and treatment of lung cancer, management of variety of pulmonary diseases. It provides a visual access to air passage and take biopsy of tissue or fluid if necessary. Flexible bronchoscopy is performed under local anesthesia or sedation. This study was conducted to state the indications and outcome of flexible bronchoscopy at bronchoscopy unit, Muhimbili National Hospital in the period of March 2021 and February 2022. Flexible bronchoscopy procedure related complication being the primary outcome.

In the present study, there was no significant difference in sex with male to female ratio 1:1, 76(50.3%) and 75(49.7%) respectively. The median age of patients was 58 years with interquartile range of 43–65. The majority of the patients were presented in the fifth decade of life, which reflect the higher morbidity in the elderly age group. This study found that the most flexible bronchoscopy was done for diagnostic purpose by 94.7% and the therapeutic purpose was only 5.3%. The two common indication for flexible bronchoscopy were cough and hemoptysis by 82.1% and 25.2% respectively. These data were accordance with studies done in Egypt, Saudi Arabia, Greece USA and Tanzania (3, 8, 9)

In this study it was found that the most two common finding during the flexible bronchoscopy were hyperemic mucosa and endobronchial mass by 31.1% and 21.2% respectively. This data partially match the study done in Egypt and Nigeria (8). This variation could be attributed by a large sample size included in this study compare to the previous studies.

In present study it was found that the most indication for flexible bronchoscopy was mainly to diagnose respiratory malignancy. The overall diagnostic yield was 34.8%, with the highest yield in patients with endobronchial mass. The respiratory infection, MTB was diagnosed by 4.7% while the non-specific inflammatory was reported by 67.5%. In contrast, the above mentioned results did not agree with those of Qanash at al.(10)^, who found that the most common indication was to diagnose respiratory infections, mainly the MTB. The overall diagnostic yield was 46% with highest yield in HIV patients with pulmonary infiltrates. This disagreement might be attributed by difference in sample size of each study, as well as the efficiency of the bronchoscopic specimen handling, such as use of appropriate transport media and efficiency of cytological and microbiological evaluation. In our study 30 cases were diagnosed to have adenocarcinoma by 71.43% followed by 11 cases of squamous cell carcinoma by 26.19% and 1 case of lymphoma by 2.38%. The predominance of adenocarcinoma in this study is similar to previous studies, such as Ndilanha et al, Alamoudi et all, and Eman et al (11).

Regarding the therapeutic value of flexible bronchoscopy we found that overall therapeutic value was 8(5.3%), the most patients underwent mucous clearance 7(4.6%) and 1(12.5%) underwent foreign body removal, whereby the procedure such as stenting and tumor debulking were not performed at all. This data differs with the study done in Egypt where it was found that 50% of cases underwent foreign body remove and interventional procedure such as stent placement, debulking by shaft of bronchoscope were performed by 1% and 5% respectively. This mismatch might be attributed by the lack of proper infrastructure to perform such an interventional flexible bronchoscopy.

In the present study, there were no mortality or procedure aborted due to complications. The complication of flexible bronchoscopy were uncommon, the study found that 81.5% of cases had no procedure related complications. 14(9.3%) case suffered desaturation during the procedure, though were not hypoxic before the beginning of the procedure and 12(7.9%) cases had hemorrhage during biopsy, which was controlled by local hemostatic measures. This result resembles to the study by Alamoudi et al(9, 11) who found that 74% of the cases had no complications during the procedure. Similarly, Qanash et al(10), in their study had found minimal complications and concluded that the flexible bronchoscopy is the safe procedure. This results also is similar to those of Mona et al(8), who found that 85% of cases had no complications, and the complications were as follows; bleeding was 4%, desaturation was 8% and surgical emphysema was 1%. In this study we found among the indications of bronchoscopy, the hemoptysis was associated with procedure related complications. Patients presenting with hemoptysis had four times higher risk of developing complications during flexible bronchoscopy. We also found that among the sampling technique, the endobronchial biopsy and BAL were associated with procedure related complications while expertise level of education was not associated with procedure related complications.

The flexible bronchoscopy is a very effective and safe procedure associated with low rate of complications and factors associated with complications are hemoptysis as indication of bronchoscopy, endobronchial biopsy and BAL sampling techniques, However safety and effectiveness depend on the accuracy of selection of patients for the procedure, the experience of the bronchoscopist and the availability of the other supporting infrastructures. This study has described that the most indication for flexible bronchoscopy was cough and the most bronchoscopy finding was hyperemic mucosa. The most prevalent diagnostic yield was carcinoma, however MTB also was diagnosed from the specimen obtained during flexible bronchoscopy. We have therefore demonstrated that the flexible bronchoscopy is a safe and useful diagnostic tool and the proper use of diagnostic technique provides a high degree of success.

Ethical Approval and Consent to participate

Ethical approval was obtained from IRB of Muhimbili University of Health and Allied Science REF.DA.282/298/01.C/MUHAS-REC-06-2021-685.

All methods were performed according to the provisions of relevant guideline and regulations.

The participants signed to consent for their participation in this study and declared their approval for their information to be used for the purpose of this research only

Informed consent was obtained from all participants .

Consent for publication

Not applicable

Availability of data and materials

All materials pertinent to this research are available and shall be provided by the corresponding Author upon reasonable request.

Competing interest

The authors declare no competing interest

Funding

No funding

Authors’ contribution

The principal investigator prepared the full text article of this article and all other authors reviewed and contributed their expert opinions.

Tito Lyimo had access to entire data in this study, he took full accountability for data integrity and ensured the accuracy of data analysis.

Concept and Design : Tito Lyimo and Moses Byomuganyizi

Acquisition , analysis and interpretation of data : Tito Lyimo, Victor Meza Kyaruzi , Moses Byomuganyizi and Ramadhani Hassan Khamisi

Drafting of Manuscript : Tito Lyimo and Victor Meza Kyaruzi

Critical revision of the manuscript for intellectual content: Tito Lyimo , Victor Meza Kyaruzi , Moses Byomuganyizi , Ramadhani Hassan Khamisi

Statistical Analysis: Tito Lyimo and Victor Meza Kyaruzi

Administrative , technical or material support: Tito Lyimo , Moses Byomuganyizi

Supervision : Moses Byomuganyizi , Ramadhani Hassan Khamisi

Acknowledgement

Not applicable

Author’s Information

Not applicable

Stahl D, Richard K, Papadimos T. Complications of bronchoscopy: A concise synopsis. Int J Crit Illn Inj Sci. 2015;5(3):189.
Delage A, Marquette C. Airway foreign bodies : Clinical presentation , diagnosis and treatment Airway foreign bodies : clinical presentation , diagnosis and treatment. 2015;(June 2010).
Ndilanha DA, Shayo GA, Hassan R, Byomuganyizi M, Lema LEK. Diagnoses from lung specimen collected through flexible bronchoscopy from patients in a tertiary hospital in Dar es Salaam Tanzania: a retrospective cross-sectional study. BMC Pulm Med. 2019;19(1):1–7.
Rand IA Du, Blaikley J, Booton R, Chaudhuri N, Gupta V, Khalid S, et al. British Thoracic Society guideline for diagnostic fl exible bronchoscopy in adults. 2013;
Ganga S, Hospital R, Nagar R, Delhi N, Ganga S, Hospital R, et al. Flexible Fiberoptic Bronchoscopy in Pediatric Practice. 2019;
Adeoti AO, Desalu OO, Fadare JO, Alaofin W, Onyedum CC. Bronchoscopy in Nigerian Clinical Practice: A Survey of Medical Doctors’ Perception, Use and Associated Challenges. Ethiop J Health Sci. 2017;27(4):331–8.
Hamouda S, Oueslati A, Belhadj I, Khalsi F, Tinsa F, Boussetta K. Flexible bronchoscopy contribution in the approach of diagnosis and treatment of children’s respiratory diseases: The experience of a unique pediatric unit in Tunisia. Afr Health Sci. 2016;16(1):51–60.
Ahmad MM, Abdelfattah EB, Mohamed RGM. Indications and outcome of bronchoscopy in Bronchoscopy Unit , Chest Department , Ain Shams University Hospital : a 6-month report. 2018;136–45.
Adewole OO, Onakpoya UU, Ogunrombi AB, Komolafe A, Odeyemi AD, Adeniran S, et al. Flexible fiberoptic bronchoscopy in respiratory care : Diagnostic yield , complications , and challenges in a Nigerian Tertiary Center. 2017;77–81.
Qanash S, Hakami OA, Al-Husayni F, Gari AG. Flexible Fiberoptic Bronchoscopy: Indications, Diagnostic Yield and Complications. Cureus. 2020;12(10):5–11.
Alamoudi OS. Lung cancer at a university hospital in Saudi Arabia: A four-year prospective study of clinical, pathological, radiological, bronchoscopic, and biochemical parameters. Ann Thorac Med. 2010;5(1):30–6.

Table 2 and 3 are available in the Supplementary Files section.

No competing interests reported.

Table23.docx

Download PDF

Version 1

posted

You are reading this latest preprint version

Indications and Outcome of Flexible Bronchoscopy at Muhimbili National Hospital in Dar es Salaam: Tanzania

Status:

Version 1

Abstract

Figures

Introduction

Methodology

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1