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Flexible BronchoscopyFlexible BronchoscopyPart 4A: Transbronchial lung biopsy VOLUME 1Part 4A: Transbronchial lung biopsy VOLUME 1

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

Strategy and Planning

Execution

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HistoryHistory

TBLB began to replace open lung biopsy in TBLB began to replace open lung biopsy in 1970’s in selected patients.1970’s in selected patients. TBLB was originally considered very high riskTBLB was originally considered very high risk TBLB was originally performed in the operating TBLB was originally performed in the operating

theater . theater . TBLB performed by pulmonologists faced TBLB performed by pulmonologists faced

substantial opposition by surgeons.substantial opposition by surgeons. TBLB was performed after endotracheal TBLB was performed after endotracheal

intubation.intubation. Early history of TBLB was marked by frequent of Early history of TBLB was marked by frequent of

bleeding, pneumothorax or respiratory failure.bleeding, pneumothorax or respiratory failure.

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TBLB TBLB todaytoday

Easily performed as outpatient procedure in a Easily performed as outpatient procedure in a bronchoscopy suite.bronchoscopy suite.

Ideally performed using conscious sedation and Ideally performed using conscious sedation and topical anesthetic.topical anesthetic.

Fluoroscopy eliminates need for post-procedure Fluoroscopy eliminates need for post-procedure chest radiograph and may increase patient chest radiograph and may increase patient safety.safety. Because most TBLB-related pneumothoraces Because most TBLB-related pneumothoraces

occur during or immediately after TBLB, occur during or immediately after TBLB, patients should probably be kept under patients should probably be kept under observation for at least 1-2 hours after TBLB observation for at least 1-2 hours after TBLB before being discharged home. Chest before being discharged home. Chest radiograph post-procedure should be radiograph post-procedure should be obtained if symptoms are present.obtained if symptoms are present.

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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 excessive procedure-related Avoid excessive procedure-related

complicationscomplications Learn to treat procedure-related bleeding, Learn to treat procedure-related bleeding,

pneumothorax, and respiratory failurepneumothorax, and respiratory failure Learn to protect the equipment and avoid Learn to protect the equipment and avoid

breaking the bronchoscopebreaking the bronchoscope avoid forced passage of the forceps avoid forced passage of the forceps

through the scope at ANY time, through the scope at ANY time, especially if the scope is flexedespecially if the scope is flexed

Avoid opening the forceps while it is Avoid opening the forceps while it is inside the working channel of the inside the working channel of the bronchoscopebronchoscope..

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When to perform TBLBWhen to perform TBLB

Usually, only after results from other Usually, only after results from other bronchoscopic procedures such as BAL bronchoscopic procedures such as BAL are negative, nondiagnostic, or are negative, nondiagnostic, or considered not helpful depending on considered not helpful depending on differential diagnosis.differential diagnosis.

Usually, only when results from TBLB Usually, only when results from TBLB will impact on disease management.will impact on disease management.

Usually, only when risks of the Usually, only when risks of the procedure have been satisfactorily procedure have been satisfactorily understood by patient or family.understood by patient or family.

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Contraindications to Contraindications to TBLBTBLB Inadequate equipmentInadequate equipment

Insufficient training to assure efficacy and Insufficient training to assure efficacy and patient comfort and safetypatient comfort and safety

Coagulopathy, patient on anticoagulationCoagulopathy, patient on anticoagulation ThrombocytopeniaThrombocytopenia Uremia (increases risks of bleeding)Uremia (increases risks of bleeding) Pulmonary hypertension (may increase bleeding Pulmonary hypertension (may increase bleeding

risk)risk) Undue risk for respiratory failure or death in Undue risk for respiratory failure or death in

case of TBLB-related pneumothorax or bleedingcase of TBLB-related pneumothorax or bleeding Examples: History of pneumonectomy, Examples: History of pneumonectomy,

impending respiratory failure, poor lung impending respiratory failure, poor lung function.function.

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Presumed dangers of TBLBPresumed dangers of TBLB

Biopsies of emphysematous lungs

Biopsies around bullae and blebs

Biopsies of stiff lungs of ILD

Biopsies in vasculitis

Biopsies of the middle lobe or lingula are adjacent to fissures

Biopsies of superior segment of lower lobes are adjacent to fissures

Avoid Non gravity dependent areas (anterior segment upper lobes) because bleeding may be difficult to control in these areas.

Gough section: Upper lobe Emphysema

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Complications of TBLBComplications of TBLB PneumothoraxPneumothorax

Risk 1-4 %Risk 1-4 % BleedingBleeding

1.2 – 40% varies with studies and patient 1.2 – 40% varies with studies and patient population.population.

Bleeding > 50 ml approximately 1-2% Bleeding > 50 ml approximately 1-2% Increased in uremia and immunocompromised Increased in uremia and immunocompromised

patientspatients DeathDeath

Risk estimated at 0.04 -0.12 %Risk estimated at 0.04 -0.12 %

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How does that compare to flexible bronchoscopy without

TBLB ? Bleeding in only 0.5 - 26 %. Other adverse events include vaso-vagal

reactions, reactions to anesthetics, bronchospasm, cardiac arrhythmias, and pneumothorax.

Mortality 0.01 - 0.05 %.

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Risk of bleeding after Risk of bleeding after Transbronchial lung Transbronchial lung

biopsybiopsy Perhaps a a 45 % incidence in uremia (older studies). < 15% incidence if PLT < 50,000. Other concerns

Preprocedure laboratory studies often preferred Importance of individualizing decisions based on H&P,

Past medical History, Family History, and risk-benefit analysis.

One may consider stopping aspirin, other antiplatelet agents, and nonsteroidal anti-inflammatory drugs. One should definitely stop Plavix and anticoagulants (except subcutaneous Heparin used for prophylaxis).

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Indications for TBLBIndications for TBLB Diffuse and localized lung infiltrates suggestive ofDiffuse and localized lung infiltrates suggestive of

Infectious lung disease (with negative or non helpful BAL)Infectious lung disease (with negative or non helpful BAL) Interstitial lung diseaseInterstitial lung disease Carcinoma or lymphomaCarcinoma or lymphoma

Pulmonary nodules and massesPulmonary nodules and masses

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Yield of TBLBYield of TBLB Nodules > 2 cmNodules > 2 cm

60% for lung cancer, 50% for metastatic disease60% for lung cancer, 50% for metastatic disease Inferior diagnosis in benign diseaseInferior diagnosis in benign disease

AIDSAIDS PCPPCP MycobacteriaMycobacteria KaposiKaposi

Kidney transplant and other immunocompromised Kidney transplant and other immunocompromised hosts (poor for aspergillus, CMV, Mucor, Nocardia), hosts (poor for aspergillus, CMV, Mucor, Nocardia), but does add up to 10% yield to BAL ?)but does add up to 10% yield to BAL ?)

Sarcoidosis: Usually > 80%Sarcoidosis: Usually > 80% Interstitial lung disease: A diagnosis of fibrosis is Interstitial lung disease: A diagnosis of fibrosis is

Nonspecific and should be called NONDIAGNOSTICNonspecific and should be called NONDIAGNOSTIC

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Yield in Yield in tumorstumors Primary tumor: yield > 60%

Metastases yield > 50% Brushing increases yield Lesions > 2.0 cm yield > 60 % Lesions < 2.0 cm yield < 25% Yields are lower in benign

nodules

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Yield in infiltratesYield in infiltrates

yield is usually > 75 % for Sarcoidosis Alveolar proteinosis, Lymphangitic carcinomatosis Pneumoconiosis PCP, CMV Lung rejection Bronchoalveolar cell carcinoma Diffuse pulmonary lymphoma Hypersensitivity pneumonitis

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Diagnostic yield Diagnostic yield depends ondepends on

Bronchoscopist’s experience Pathologist's experience Predetermined criteria

if broad: yield > 72% if narrow < 38%

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predetermined criteriapredetermined criteria Determine when results are accepted and Determine when results are accepted and

acceptable.acceptable. Pathology interpretations may be difficult because of small Pathology interpretations may be difficult because of small

specimensspecimens

TBLB Forceps

VATS

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Number of specimens Number of specimens neededneeded PCP :PCP : at least 2 specimens if chest x-ray is Abnormal, at least 2 specimens if chest x-ray is Abnormal,

and at least 4 specimens if chest x-ray is Normal (97% and at least 4 specimens if chest x-ray is Normal (97% yield).yield).

Sarcoid:Sarcoid: Stage III, sensitivity increases with number Stage III, sensitivity increases with number (73-80% yield with at least 4 specimens, and increases (73-80% yield with at least 4 specimens, and increases further if endobronchial biopsies are done also. For further if endobronchial biopsies are done also. For Stage I Sarcoid, up to 10 specimens might be needed.Stage I Sarcoid, up to 10 specimens might be needed.

Transplant and lung rejection:Transplant and lung rejection: Multiple specimens Multiple specimens from multiple lobes are warranted. Yield > 60% for from multiple lobes are warranted. Yield > 60% for infection of rejection, but only 15 % for BO. Multiple infection of rejection, but only 15 % for BO. Multiple specimens (> 6) are necessary.specimens (> 6) are necessary.

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Type of specimen : the Float Type of specimen : the Float signsign

Float sign definition: Float sign definition: Aerated lung floats, but Aerated lung floats, but nonaerated lung does nonaerated lung does not.not.

BUT, the float sign is not BUT, the float sign is not a reliable sign of a reliable sign of representative alveolar representative alveolar and bronchiolar tissue.and bronchiolar tissue.

Remember that Remember that increased number of increased number of biopsies increases biopsies increases diagnostic yield, but diagnostic yield, but probably increases risk probably increases risk for complications with for complications with each biopsyeach biopsy..

Partially aerated lung in patient with severe emphysema and iatrogenic pneumothorax

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Size of Size of specimensspecimens

Toothed (Alligator) forceps tear the lung Toothed (Alligator) forceps tear the lung more than cup forceps, and may cause more than cup forceps, and may cause more bleeding.more bleeding.

Large forceps obtain more tissue (more Large forceps obtain more tissue (more alveoli) than small forceps; frequency of alveoli) than small forceps; frequency of bleeding is unchanged compared to bleeding is unchanged compared to smaller forceps. smaller forceps.

Am Rev Respir Dis 1993;148:1411-1413Chest 1992;102:748-752.

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Types of ForcepsTypes of Forceps

Cup Toothed

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Fluoroscopy is often used for TBLBFluoroscopy is often used for TBLB Frequency of pneumothorax possibly increased if Frequency of pneumothorax possibly increased if

fluoroscopy is not used.fluoroscopy is not used. Avoids causing pleuritic chest pain with forceps.Avoids causing pleuritic chest pain with forceps. Avoids need for post bronchoscopy radiograph Avoids need for post bronchoscopy radiograph

because fluoroscopic examination at end of because fluoroscopic examination at end of procedure determines presence or absence of procedure determines presence or absence of TBLB-related pneumothorax.TBLB-related pneumothorax.

Improves physician ease, comfort, and securityImproves physician ease, comfort, and security Used routinely by 75% of doctors in the USA.Used routinely by 75% of doctors in the USA.

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Other advantages of fluoroscopyOther advantages of fluoroscopy

Prevention of pneumothoraxPrevention of pneumothorax Position of forceps in relation to pleura is Position of forceps in relation to pleura is

visualizedvisualized Ability to obtain biopsies from localized Ability to obtain biopsies from localized

infiltrateinfiltrate Possibility to accelerate procedurePossibility to accelerate procedure Avoid looking through the bronchoscopeAvoid looking through the bronchoscope Guidance possible using fluoroscopy image Guidance possible using fluoroscopy image

only, therefore scope can be wedged and only, therefore scope can be wedged and forceps can be viewed using fluoroscopy only.forceps can be viewed using fluoroscopy only.

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Fluoroscopy-assisted TBLBFluoroscopy-assisted TBLB

Position C-Arm first

Test before starting bronchoscopy

Be sure abnormalities can be seen on fluoroscopy

Bronchoscopist should operate machine to avoid excess radiation

Be certain that there is enough room in procedure area to assure patient safety in case of complications.

Remove machine after biopsies

Avoids need for post procedure radiograph

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With fluoroscopyWith fluoroscopy

Patients can be done supine or partially sitting

Forceps are easily inserted by the assistant into the bronchoscope if the scope is held “over the shoulder”

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Fluoroscopy-assisted TBLBFluoroscopy-assisted TBLB

Once the scope is wedged, the Bronchoscopist watches the forceps using fluoroscopy only, and does not need to look through the bronchoscope until after all specimens are obtained

In case of bleeding, the scope is kept wedged, suction is applied, and the patient is turned into the lateral safety position, bleeding side down.

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Techniques of TBLBTechniques of TBLB

TBLB of the Right Lower lobe infiltrate, forceps open via lateral basal segment.

TBLB of apical-posterior segment Left Upper Lobe, forceps still closed

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Manipulating the Bronchoscope during Manipulating the Bronchoscope during TBLBTBLB

Wedge techniqueWedge technique Keeps scope in optimal positionKeeps scope in optimal position Allows suction and tamponade in case of Allows suction and tamponade in case of

bleedingbleeding Full view techniqueFull view technique

Keeps segmental airways in viewKeeps segmental airways in view Ability to better visualize bleeding if it Ability to better visualize bleeding if it

occurs and to control patency of contra occurs and to control patency of contra lateral lunglateral lung

Ability to guide forceps into multiple Ability to guide forceps into multiple specific segments specific segments

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Full view and wedge techniques of Full view and wedge techniques of TBLBTBLB

Full view technique

The scope is kept in a more proximal segmental bronchus

Wedge technique

The scope is wedged distally into the target subsegmental bronchus

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Wedge and nonwedge techniques of Wedge and nonwedge techniques of TBLBTBLB

Click to continue

Click here to view video presentation Wedge technique

Click here to view video presentation nonwedge technique

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Touch and feel techniqueTouch and feel technique

Move forceps through working channel of scope.Move forceps through working channel of scope. As forceps becomes visible, begin fluoroscopy As forceps becomes visible, begin fluoroscopy

(intermittent rather than continuous decreases (intermittent rather than continuous decreases radiation exposure)radiation exposure)

When forceps is at target position, open forceps and When forceps is at target position, open forceps and shake gentlyshake gently

Insert forceps a bit further until some resistance is feltInsert forceps a bit further until some resistance is felt Ask the patient to raise a hand if pain is feltAsk the patient to raise a hand if pain is felt This signals that the forceps is near the periphery This signals that the forceps is near the periphery

of the lung and “touching” the pleuraof the lung and “touching” the pleura Often used when fluoroscopy is NOT availableOften used when fluoroscopy is NOT available

Increases the length of the procedureIncreases the length of the procedure Difficult if patients are well sedatedDifficult if patients are well sedated

Close forceps, stop fluoroscopy, and withdraw forceps Close forceps, stop fluoroscopy, and withdraw forceps gently into working channel of bronchoscope.gently into working channel of bronchoscope.

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Performing TBLBPerforming TBLB

When entering the apical segments of the upper lobes, keep the scope in the central airway and using only fluoroscopy to guide the forceps into the appropriate segment.

Seeing the target infiltrate in the retro cardiac and “sub diaphragmatic” regions.

Shaking the forceps if they don’t open immediately If the scope is “over wedged”, pull forceps back

slightly and bring the working channel into the midline and off the bronchial wall to make room for the forceps as it exits the working channel.

Change the angle of the forceps if they do not advance further into the periphery (forceps are probably caught on a spur)

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Helpful hints for performing Helpful hints for performing TBLBTBLB

Inform the patient that “there are no nerve endings Inform the patient that “there are no nerve endings in the airway, so the biopsy itself will not hurt”.in the airway, so the biopsy itself will not hurt”.

Use conscious sedation to improve patient comfort.Use conscious sedation to improve patient comfort. Forewarn the patient to “raise hand” if pain is felt Forewarn the patient to “raise hand” if pain is felt

at any time during the procedure.at any time during the procedure. Prefer biopsies from the lung periphery (as close to Prefer biopsies from the lung periphery (as close to

the pleura as possible) because bronchial vessels the pleura as possible) because bronchial vessels are smaller in the distal airways and forceps are are smaller in the distal airways and forceps are most likely to “pinch” through bronchial mucosa to most likely to “pinch” through bronchial mucosa to obtain representative tissue (contains alveoli and obtain representative tissue (contains alveoli and bronchioles) from lung parenchyma.bronchioles) from lung parenchyma.

Avoid the lingula and right middle lobe because of Avoid the lingula and right middle lobe because of proximity to fissures and risk of pneumothorax.proximity to fissures and risk of pneumothorax.

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More Helpful hints for performing TBLBMore Helpful hints for performing TBLB

When infiltrates are diffuse and involving the lower When infiltrates are diffuse and involving the lower lobe, prefer biopsies from the lateral segment because lobe, prefer biopsies from the lateral segment because fluoroscopically, the position of the forceps is true in fluoroscopically, the position of the forceps is true in relation to the chest wall.relation to the chest wall.

Patient inhalation as the forceps is opened often allows Patient inhalation as the forceps is opened often allows the operator to advance the forceps further towards the the operator to advance the forceps further towards the periphery.periphery.

Keep the forceps open and advanced into the periphery Keep the forceps open and advanced into the periphery for as short a time as possible, also keeping fluoroscopy for as short a time as possible, also keeping fluoroscopy time to a minimum (Usually < 30 seconds per biopsy).time to a minimum (Usually < 30 seconds per biopsy).

Patient exhalation is followed by closure of the forceps. Patient exhalation is followed by closure of the forceps. A quick and short tug is often followed by a patient A quick and short tug is often followed by a patient inhalation. inhalation.

By advancing the bronchoscope as the forceps is By advancing the bronchoscope as the forceps is withdrawn, the scope is maintained in the wedge withdrawn, the scope is maintained in the wedge position. There is NO need to pull the forceps quickly up position. There is NO need to pull the forceps quickly up into the bronchoscope.into the bronchoscope.

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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”).

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