Lung biopsy

(mucosal/transbronchial/open lung)

Ernst Eber, MD

Respiratory and Allergic Disease Division, Paediatric Department, Medical University of Graz, Austria

ERS Task Force. Eur Respir J 2003;22:698-708.

• Sampling of cellular material

• Sampling of bronchial tissue

• Sampling of lung parenchyma

Biopsy

• Brush biopsy

• Mucosal (endobronchial) biopsy

• Transbronchial lung biopsy

Biopsy techniques

Brush biopsy

• Sampling of

superficial cells

- unsheathed brush

- protected brush

1.2 mm 2.0 mm

Brush biopsy

Unsheathed brushes

Brush left protruding from the bronchoscope

or hidden in the tip of the scope while the

instrument is withdrawn

Brush biopsy

Assessment of

• inflammation

• infection (e.g. tuberculosis)

• malignancy

• ciliary motility / ultrastructure

• Cup

• Fenestrated cup

• Alligator jaw

Endobronchial biopsy

Forceps

• Coagulation screen

• Sampling under visual control

• Monitoring

• Routine chest x-ray not necessary

Endobronchial biopsy

Safety precautions

De Blic J et al. Eur Respir J 2002

• Haemorrhagic conditions

• Severe respiratory failure

Endobronchial biopsy

Contraindications

Endobronchial biopsy

• Sampling from pathological lesion

• Sampling from (sub)segmental subcarinae

• Repeated samples

Technique

Endobronchial biopsy

• Diagnosis of tuberculosis and other infectious

or granulomatous disorders

• Diagnosis of PCD

• Research: Bronchial inflammation in asthma

and CF patients

Endobronchial biopsy

Safe and useful procedure in children with

respiratory disease, even in infants

Payne et al. Arch Dis Child 2001, de Blic et al. Eur Respir J 2002,

Saglani et al. Thorax 2003, Salva et al. Thorax 2003, Saglani et al.

Am J Respir Crit Care Med 2005, Molina-Teran et al. Pediatr

Pulmonol 2006

• Cup

• Fenestrated cup

• Alligator jaw

Transbronchial biopsy

Forceps

• 2 mm channel: ~ 2.0 μl

• 1.2 mm channel: ~ 0.5 μl

Adequate tissue samples: 97% vs. 85%

Visner Chest

2004

Transbronchial biopsy

Forceps – cup volume

• Chest radiograph

• Full blood count incl. platelet count

• Coagulation screen

Transbronchial biopsy

Investigations prior to TBB

• Flexible bronchoscope2 mm (1.2 mm) working channel

• Rigid bronchoscope

• “Indirect” technique with plastic catheter Mullins Pediatr Pulmonol

1995

Transbronchial biopsy

Technique

• Sedation / GA

• Fluoroscopy

(mandatory!)

Transbronchial biopsy

Technique

Transbronchial biopsy

Technique

• Only one lung on same occasion

• Middle lobe & lingula avoided if possible

• At least three biopsies (microbiological and

histological studies)

Transbronchial biopsy

Technique

• Small saline lavage

• Visualisation of the bronchial tree

• Chest radiograph (after 2-4 h)

Transbronchial biopsy

Post TBB

• Pneumothorax (~3%)

• Haemorrhage (resolves spontaneously / lavage

with saline / instillation of adrenaline solution)

• Septicemia, transient pyrexia

Transbronchial biopsy

Complications

Lung transplant recipients

• High sensitivity and specificity

• Gold standard for diagnosing acute rejection and

delineating opportunistic infection

• Of less use in diagnosing chronic rejection (BO)

Scott Pediatrics 1990, Whitehead Pediatr Pulmonol 1992,

Visner Chest 2004

Transbronchial biopsy

Indications - established

88 91

8 72

60

100

0102030405060708090

100

Sensit

ivity

Specif

icity

Pneum

otho

rax

Pyrex

ia

Dyspn

oea

Acute rejection

Chronic rejection

Transbronchial biopsy

n = 92(86 in HLT group)

%

Whitehead B et al. Pediatr Pulmonol 1992

429 TBB procedures in 46 patients (2 months – 21 years) post

HLTx or LTx and in 38 non-LTx patients (2 weeks – 18 years)

Paediatric bronchoscope in 86 procedures

Non-LTx patients: Biopsy findings considered to be

diagnostic in 58%, contributory in 21%

Complications: 5x pneumothorax, 5x excessive bleeding

Visner et al. Chest 2004

Transbronchial biopsy

• HIV infection (noninfective pulmonary pathology)

• Bone marrow transplantation (BO)

• Interstitial lung disease

Whitehead Pediatr Pulmonol 1992, Fan J Pediatr 1997,

Visner Chest 2004

Transbronchial biopsy

Indications - controversial

Chronic interstitial lung disease

Lung biopsy

• Percutaneous needle lung biopsy

(PNLB)

• Transbronchial lung biopsy

(TBLB)

• Open lung biopsy (OLB)

• Video-assisted thoracoscopic

biopsy (VATB)

Recommendations:

• Target clearly affected lung areas (HRCT)!

• Obtain sufficiently dimensioned tissue sample!

Chronic interstitial lung disease

Lung biopsy

Chronic interstitial lung disease

Lung biopsy

• Many children with ILD require a biopsy for

diagnosis.

• For most paediatric ILD, transbronchial or

percutaneous lung biopsy gives insufficient

tissue for diagnosis and carries increased risk

(bleeding, pneumothorax).

Smyth et al. Arch Dis Child 1994, Spencer et al. Pediatr

Pulmonol 1996, Fan et al. J Pediatr 1997, Kramer et al.

Ann Thorac Surg 1998, Coren et al. Eur Respir J 1999

Chronic interstitial lung disease

Lung biopsy

• Lung biopsy under direct vision is safe, well

tolerated and should be regarded as the gold

standard.

• Open lung biopsy through a mini-thoracotomy

incision vs. video-assisted thoracoscopic biopsy:

depending on size of the child and experience of

the surgeon

Fan et al. J Pediatr 1997, Kramer et al. Ann Thorac Surg

1998, Coren et al. Eur Respir J 1999

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