bi1 part 3b: endobronchial brushing volume 1 bronchoscopy international strategy and planning...

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Part 3B: Endobronchial BrushingPart 3B: Endobronchial Brushingvolume 1volume 1

Bronchoscopy InternationalBronchoscopy International

Strategy and Planning

Execution

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When to perform endobronchial When to perform endobronchial brushingbrushing

Visible airway mucosal abnormalitiesVisible airway mucosal abnormalities Visible airway nodules or massesVisible airway nodules or masses In case of suspected sarcoidosis (even if In case of suspected sarcoidosis (even if

airway mucosa appears normal)airway mucosa appears normal) In case of abnormal autofluorescence to In case of abnormal autofluorescence to

diagnose intraepithelial lesions (dysplasia, diagnose intraepithelial lesions (dysplasia, metaplasia, carcinoma in-situ)metaplasia, carcinoma in-situ)

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Training is essential in order toTraining is essential in order to

Learn proper techniques and indicationsLearn proper techniques and indications Avoid procedure-related complications.Avoid procedure-related complications. Learn to protect the equipment and the Learn to protect the equipment and the

patientpatient To obtain adequate tissue for diagnosisTo obtain adequate tissue for diagnosis To avoid damaging the working channelTo avoid damaging the working channel To avoid excess patient discomfort (cough, To avoid excess patient discomfort (cough,

anxiety, shortness of breath).anxiety, shortness of breath). To avoid bleeding, that might also prompt To avoid bleeding, that might also prompt

cough and patient agitation.cough and patient agitation.

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Q1: Optimal endobronchial brushing Q1: Optimal endobronchial brushing samples requires correct processingsamples requires correct processing

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Q8: Optimal endobronchial brushing Q8: Optimal endobronchial brushing samples requires correct processingsamples requires correct processing

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TRUETRUE. Brushing samples must be processed . Brushing samples must be processed correctly and according to the needs and correctly and according to the needs and preferences of your institution’s cytology preferences of your institution’s cytology

and microbiology laboratories.and microbiology laboratories.

Other ways to potentially increase Other ways to potentially increase diagnostic yield includediagnostic yield include Using brushes with longer bristlesUsing brushes with longer bristles Brushing vigorously and for a longer period of Brushing vigorously and for a longer period of

time.time. Making sure that all parts of the brush are in Making sure that all parts of the brush are in

contact with the mucosal abnormality.contact with the mucosal abnormality. Using the pirouette technique (rotation) in Using the pirouette technique (rotation) in

combination with long-axis motion.combination with long-axis motion.

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Bronchial brushing:Bronchial brushing:

Originally done under fluoroscopy without Originally done under fluoroscopy without bronchoscopybronchoscopy

Common indications:Common indications: Visible endobronchial tumors or mucosal abnormalityVisible endobronchial tumors or mucosal abnormality Peripheral tumors (+/- fluoroscopy)Peripheral tumors (+/- fluoroscopy) Peripheral infection – pneumonia, abscess, cavityPeripheral infection – pneumonia, abscess, cavity

Brush samples larger surface area of lesionBrush samples larger surface area of lesion

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Bronchial brushing:Bronchial brushing: Different size brushesDifferent size brushes

Standard 3 mm cytology Standard 3 mm cytology 7 mm brush (rarely used)7 mm brush (rarely used)

No sheathNo sheath For visible lesions onlyFor visible lesions only Cannot be retracted into scopeCannot be retracted into scope Collects more cells but yield Collects more cells but yield

and bleeding equivalent to 3 and bleeding equivalent to 3 mmmm11

Protected specimen brushProtected specimen brush Avoid upper airway Avoid upper airway

contaminationcontamination For diagnosis of infection/ For diagnosis of infection/

quantitative culturesquantitative cultures

1Cleve Clin J Med 1987;54:195-203

From Flexible Bronchoscopy Wang and Mehta

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Technique:Technique: Advance catheter into desired segment Advance catheter into desired segment

– then extend brush (up to 5 cm)– then extend brush (up to 5 cm) Make sure brush extension doesn’t push Make sure brush extension doesn’t push

back the scope or catheterback the scope or catheter Move back and forth over the visible Move back and forth over the visible

lesion or blindly in distal airway (5-10 lesion or blindly in distal airway (5-10 times) +/- rotationtimes) +/- rotation

Cells collected in brush bristlesCells collected in brush bristles

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Yield:Yield: 94% endoscopically visible/peripheral 94% endoscopically visible/peripheral

78%78%11

92% central and peripheral with fluoro92% central and peripheral with fluoro22

77% endoscopically visible/20% 77% endoscopically visible/20% peripheral with fluoroperipheral with fluoro33

1CHEST 1973;63:889-892

1Am Rev Respir Dis 1974;109:63-66

2CHEST 1974;65:616-619

3CHEST 1976;69:752-757

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Complications:Complications: BleedingBleeding PneumothoraxPneumothorax

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Biopsy vs cytology:Biopsy vs cytology: 154 patients with malignant pulmonary lesions154 patients with malignant pulmonary lesions Each patient had (EBB or TBB) AND (TBNA or Each patient had (EBB or TBB) AND (TBNA or

brushing)brushing) EBB/TBB sensitivity 62.8%EBB/TBB sensitivity 62.8% TBNA/brush (cyto) sensitivity 69.2%TBNA/brush (cyto) sensitivity 69.2% Combined sensitivity 87.2%Combined sensitivity 87.2%

J Bronchol 2004;11:154-159

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Additional literature:Additional literature:

J Bronchol 2004;11:154-159

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Endobronchial BrushingEndobronchial Brushing

Brush samples large area of mucosal Brush samples large area of mucosal abnormalityabnormality

May be done under direct May be done under direct visualization, or with fluoroscopic visualization, or with fluoroscopic guidanceguidance

Brushes may be bare of within Brushes may be bare of within a covering sheatha covering sheathBrush Video

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Indications and brushing Indications and brushing techniquestechniques

IndicationsIndications Visible airway mucosal abnormalityVisible airway mucosal abnormality Peripheral lesion (lung nodule, abcess etc)Peripheral lesion (lung nodule, abcess etc) Peripheral lung infiltratePeripheral lung infiltrate

TechniquesTechniques Extend catheter into target segmentExtend catheter into target segment Extend brush “Brush out”. Be certain extended Extend brush “Brush out”. Be certain extended

brush does not cause pain or pneumothorax, nor brush does not cause pain or pneumothorax, nor push bronchoscope proximally.push bronchoscope proximally.

Brush forcefully and gently and frequently (5-10 Brush forcefully and gently and frequently (5-10 times) with and without brush rotation so that all times) with and without brush rotation so that all parts of brush touch the lesion.parts of brush touch the lesion.

Retract brush “Brush in”.Retract brush “Brush in”. Remove the catheter-brush from the working Remove the catheter-brush from the working

channel.channel.

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Brushing YieldBrushing Yield Greatest when Greatest when

cancer is cancer is presentpresent 94% in case of 94% in case of

central lesion, central lesion, 78% in case of 78% in case of peripheral peripheral lesions. But lesions. But yields can also yields can also be as low as 20 be as low as 20 % for peripheral % for peripheral lesions.lesions.

Chest 1973;63:889, Chest 1976;69:752, J Bronchol 2004;11:154*

**

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Brushing-related Brushing-related ComplicationsComplications

BleedingBleeding PneumothoraxPneumothorax Perforation of lung Perforation of lung

abscessabscess

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Bleeding risk if Bleeding risk if Thrombocytopenia: Thrombocytopenia:

<50,000<50,000 Risk of bleeding: 0-26% (TBBx, post Risk of bleeding: 0-26% (TBBx, post

transfusion) transfusion) (1)(1)

Brushing with mean platelet count of 30,000:Brushing with mean platelet count of 30,000:Bleed: 16% , Death: 4% Bleed: 16% , Death: 4% (2) (2)

What to do? Transfuse 6 packs before & What to do? Transfuse 6 packs before & during bronchoscopy, no need to recheck during bronchoscopy, no need to recheck platelets platelets (3)(3)

Platelet half-life 6 hours!Platelet half-life 6 hours!

(1) Weiss S, Chest, 1993;104:1025(1) Weiss S, Chest, 1993;104:1025(2) Papin T, Chest, 1985; 88:54(2) Papin T, Chest, 1985; 88:54(3)Wahidi M, Respiration 2005;72:285(3)Wahidi M, Respiration 2005;72:285

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Combined procedures have Combined procedures have greatest greatest

yield for malignancyyield for malignancy Arch Bronchoneumol. 2006;42(6):278-82 75 patients underwent bronchial washing 75 patients underwent bronchial washing

before (pre) and after (post) endobronchial before (pre) and after (post) endobronchial biopsy and brushingbiopsy and brushing

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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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All efforts are made by Bronchoscopy All efforts are made by Bronchoscopy International to maintain currency of online International to maintain currency of online information. All published multimedia slide information. All published multimedia slide

shows, streaming videos, and essays can be shows, streaming videos, and essays can be cited for reference as:cited for reference as:

Bronchoscopy International: Art of Bronchoscopy, an Bronchoscopy International: Art of Bronchoscopy, an Electronic On-Line Multimedia Slide Presentation. Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. Published 2007 (Please add “Date Accessed”).Published 2007 (Please add “Date Accessed”).

Thank you

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Prepared with the expert assistance of Udaya Prepared with the expert 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 Wes Shepherd M.D. (Cleveland Clinic, USA), and Wes Shepherd M.D. (Virginia Commonwealth University, USA)M.D. (Virginia Commonwealth University, USA)

www.bronchoscopy.org

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