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Flexible BronchoscopyFlexible BronchoscopyPart 4C: Transbronchial lung biopsy VOLUME 3Part 4C: Transbronchial lung biopsy VOLUME 3

Prepared ByPrepared ByBronchoscopy InternationalBronchoscopy International

Contact us at BI@bronchoscopy.orgContact us at BI@bronchoscopy.org

Transbronchial lung Transbronchial lung biopsy (TBLB)biopsy (TBLB)

Prepared and distributed by Prepared and distributed by

Bronchoscopy InternationalBronchoscopy International

More about biopsy techniques and prevention of procedure-related

complications

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Manipulating the bronchoscope during Manipulating the bronchoscope during TBLBTBLB

Video of TBLB

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Techniques of TBLB without Techniques of TBLB without FluoroscopyFluoroscopy

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Advance the forceps until gentle resistance is Advance the forceps until gentle resistance is met. Then pull back. Patient may have pain if met. Then pull back. Patient may have pain if

forceps is out to farforceps is out to far

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Advance the open forceps again until gentle Advance the open forceps again until gentle resistance is met. After closing the forceps, pull back resistance is met. After closing the forceps, pull back

immediately without entering the bronchoscope. Keep immediately without entering the bronchoscope. Keep the scope wedged.the scope wedged.

Exhalation

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Anchor Forceps at Bifurcation of Respiratory Bronchioles

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Similar technique is used Similar technique is used under fluoroscopic guidanceunder fluoroscopic guidance Usually 4-5 specimens Usually 4-5 specimens

are obtained are obtained Lung parenchyma is Lung parenchyma is

obtained by tearing the obtained by tearing the respiratory bronchiolesrespiratory bronchioles

Forceps to distal may Forceps to distal may cause pneumothoraxcause pneumothorax

Forceps too proximal Forceps too proximal may cause bleedingmay cause bleeding

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Left lower lobe fluoroscopic Left lower lobe fluoroscopic guidanceguidance

Anterobasal LB 8Anterobasal LB 8 Lateral basal LB 9Lateral basal LB 9 Posterior basal LB 10Posterior basal LB 10 Superior segment LB 6Superior segment LB 6

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Left upper lobe fluoroscopic Left upper lobe fluoroscopic guidanceguidance

Apical posterior LB Apical posterior LB 1+21+2

Anterior segment LB Anterior segment LB 33

Lingula LB 4+5Lingula LB 4+5

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Right lower lobe fluoroscopic Right lower lobe fluoroscopic guidanceguidance

Anterior basal RB 8Anterior basal RB 8 Lateral basal RB 9Lateral basal RB 9

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Fluoroscopy is especially Fluoroscopy is especially useful in case of focal useful in case of focal

diseasedisease

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Fluoroscopy can be performed Fluoroscopy can be performed using C-arm with patient supine or using C-arm with patient supine or

sittingsitting

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Indications for fluoroscopyIndications for fluoroscopy

To localize abnormalitiesTo localize abnormalities TO help prevent pneumothoraxTO help prevent pneumothorax TO extract foreign bodiesTO extract foreign bodies TO perform biopsy or brushing of TO perform biopsy or brushing of

solitary pulmonary nodulessolitary pulmonary nodules To improve diagnostic yieldTo improve diagnostic yield To detect pneumothoraxTo detect pneumothorax

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If necessary, forceps can be advanced If necessary, forceps can be advanced into various segments. Position is into various segments. Position is verified using fluoroscopy before verified using fluoroscopy before

biopsies are obtainedbiopsies are obtained

Video of forceps probing basal segments

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However, TBLB is “safe” without However, TBLB is “safe” without fluoroscopyfluoroscopy

Andres G et al, Chest 1988;94:557Andres G et al, Chest 1988;94:557 TBLB: 122 with & 135 without FluoroscopyTBLB: 122 with & 135 without Fluoroscopy

Diagnostic yield higher for focal diseases with Diagnostic yield higher for focal diseases with Fluoro (pre-CT era), complication rate same Fluoro (pre-CT era), complication rate same

Mulligan S et al, ARRD 1988; 137:486Mulligan S et al, ARRD 1988; 137:486 N=168, Retrospective, AIDS & PCP, yield and N=168, Retrospective, AIDS & PCP, yield and

complications samecomplications same Puar HS, Chest 1985: 87:303Puar HS, Chest 1985: 87:303

N=68, Sarcoidosis, Yield 76%, 1 PneumoN=68, Sarcoidosis, Yield 76%, 1 Pneumo

Computed tomography scans can help Computed tomography scans can help avoids need for double image avoids need for double image fluoroscopyfluoroscopy

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Complications after TBLBComplications after TBLB

Review of 22 prospective studies of BLB (1974-1991)*

Fluoroscopy employed in 19 studies BLB PTX Bleed Death Total (n) 4,252 167 89 5 Percent 4.0 2.1 0.1

* Courtesy: Villeneuve and Kvale in: Textbook of Bronchoscopy Editors: Feinsilver and Fein, Williams & Wilkins, 1995, page 64

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Preventing bleeds during and after Preventing bleeds during and after TBLBTBLB

Avoid biopsy in bleeding diatheses.

Maintain wedge position after biopsy.

Avoid excessive suction after biopsy. Instead, use gentle brief suction to assess degree of bleeding.

If bleeding is excessive: gently instill 5-10 ml iced-saline through FFB, wait for 30 sec, then suction gently.

Epinephrine, 1:10,000 (1-3 ml) via FFB is usually not useful if bleeding is distal

Iced saline via scope Iced saline via scope wedged into segmental wedged into segmental

bronchusbronchus

Iced saline via scope Iced saline via scope wedged into segmental wedged into segmental

bronchusbronchus

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True or False: A chest radiograph True or False: A chest radiograph should always be performed after TBLBshould always be performed after TBLB

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FalseFalse. Chest radiographs are not . Chest radiographs are not always necessary after TBLBalways necessary after TBLB

Fluoroscopy can reveal lung collapseFluoroscopy can reveal lung collapse Pneumothorax occurs in < 3 % of patients.Pneumothorax occurs in < 3 % of patients. Chest 2006;129:1561-1564Chest 2006;129:1561-1564

Among 350 consecutive biopsies, chest Among 350 consecutive biopsies, chest radiograph within 2 hours after procedure radiograph within 2 hours after procedure revealed pneumothorax in 10 patients, 7 of revealed pneumothorax in 10 patients, 7 of whom were symptomaticwhom were symptomatic

Chest radiographs are probably indicated Chest radiographs are probably indicated only in symptomatic patients.only in symptomatic patients.

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TBLB in special TBLB in special circumstancescircumstances

Pulmonary arterial Pulmonary arterial hypertensionhypertension

Renal failureRenal failure Antiplatelet agentsAntiplatelet agents

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TBLB in Pulmonary arterial TBLB in Pulmonary arterial hypertensionhypertension

TBLB is not a primary diagnostic test for TBLB is not a primary diagnostic test for PAH.PAH.

Bleeding following TBBX is from Bleeding following TBBX is from bronchial artery circulation which carry bronchial artery circulation which carry systemic pressures.systemic pressures.

In patients with supra-systemic PAH, In patients with supra-systemic PAH, bronchoscopy itself is high risk because bronchoscopy itself is high risk because of severe hypoxemia.of severe hypoxemia.

As of 2007, a single animal study has As of 2007, a single animal study has shown safety of TBLB when MPA shown safety of TBLB when MPA pressure were high (33 mm Hg).pressure were high (33 mm Hg).

Morris M, JOB 1996;3:11-Morris M, JOB 1996;3:11-1616

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TBLB in Renal FailureTBLB in Renal Failure

Check INR & platelet countCheck INR & platelet countBleeding time can be misleadingBleeding time can be misleadingDialysis within 24 hrs prior to procedure with TBLBDialysis within 24 hrs prior to procedure with TBLBCorrect INR and platelet count if necessary (<1.5, Correct INR and platelet count if necessary (<1.5,

>50,000)>50,000)Desmopressin (DDAVP) 3Desmopressin (DDAVP) 3µg/kg, IV 30 min prior to µg/kg, IV 30 min prior to

the procedure costs $ 1000, potential use of the procedure costs $ 1000, potential use of DDAVP analogues, estrogen, Cryoprecipitate)DDAVP analogues, estrogen, Cryoprecipitate)

Risk of bleeding is about 8%Risk of bleeding is about 8%

Mehta N, JOB, 2005; 12(2): 81-83Mehta N, JOB, 2005; 12(2): 81-83Mannucci, NEJM 1983;308:3Mannucci, NEJM 1983;308:3

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N=604 patients, N=604 patients, Clopidogrel = 18Clopidogrel = 18 Clopidogrel + aspirin = 12Clopidogrel + aspirin = 12 Control = 574Control = 574

Bleeding frequency: Bleeding frequency: Clopidogrel = 16/18 (89%)Clopidogrel = 16/18 (89%) Clopidogrel + aspirin = 12/12 Clopidogrel + aspirin = 12/12

(100%) (100%) Control group = 20/574 (3.4%) Control group = 20/574 (3.4%)

Ernst A, et al. Chest 2006

Clopidogrel should be discontinued at least 5 days before TBLB

Aspirin itself need not be stopped before TBLB

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Other antiplatelet agents and Other antiplatelet agents and AnticoagulantsAnticoagulants

Aspirin Aspirin (1)(1) , Ticlopidine need not be , Ticlopidine need not be discontinueddiscontinued

Warfarin (Coumadin) should be Warfarin (Coumadin) should be discontinued until INR <1.5discontinued until INR <1.5(or INR corrected using Fresh Frozen Plasma or Vitamin K)(or INR corrected using Fresh Frozen Plasma or Vitamin K)

I.V. Heparin should be stopped 2-6 hrs I.V. Heparin should be stopped 2-6 hrs prior to biopsy. Check PTT.prior to biopsy. Check PTT.

Low molecular weight heparin should be Low molecular weight heparin should be held 12 hrs (hold previous dose).held 12 hrs (hold previous dose).

S.Q. Heparin is safe and can be S.Q. Heparin is safe and can be continued.continued.

Follow recommendations for all other Follow recommendations for all other newer anti-coagulants and other agents.newer anti-coagulants and other agents.

(1) Herth F, Chest 2002;122;1461(1) Herth F, Chest 2002;122;1461

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Prepared with the exert assistance of Udaya Prepared with the exert assistance of Udaya Prakash M.D. (Mayo Clinic, USA), and Atul Mehta Prakash M.D. (Mayo Clinic, USA), and Atul Mehta

M.D. (Cleveland Clinic, USA), and John Conforti M.D. M.D. (Cleveland Clinic, USA), and John Conforti M.D. (Wake Forrest, USA)(Wake Forrest, USA)

Udaya Prakash

Atul Mehta

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This presentation is part of a This presentation is part of a comprehensive curriculum for comprehensive curriculum for

Flexible Bronchoscopy. Our Flexible Bronchoscopy. Our goals are to help health care goals are to help health care

workers become better at what workers become better at what they do, and to decrease the they do, and to decrease the burden of procedure-related burden of procedure-related

training on patients.training on patients.

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