1	Flexible Bronchoscopy Part 4C: Transbronchial lung biopsy VOLUME 3 Prepared By Bronchoscopy International Contact us at BI@bronchoscopy.org
2	Transbronchial lung biopsy (TBLB) Prepared and distributed by Bronchoscopy International
3	Manipulating the bronchoscope during TBLB
4	Techniques of TBLB without Fluoroscopy
5	Advance the forceps until gentle resistance is met. Then pull back. Patient may have pain if forceps is out to far
6	Advance the open forceps again until gentle resistance is met. After closing the forceps, pull back immediately without entering the bronchoscope. Keep the scope wedged.
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8	Similar technique is used under fluoroscopic guidance Usually 4-5 specimens are obtained Lung parenchyma is obtained by tearing the respiratory bronchioles Forceps to distal may cause pneumothorax Forceps too proximal may cause bleeding
9	Left lower lobe fluoroscopic guidance Anterobasal LB 8 Lateral basal LB 9 Posterior basal LB 10 Superior segment LB 6
10	Left upper lobe fluoroscopic guidance Apical posterior LB 1+2 Anterior segment LB 3 Lingula LB 4+5
11	Right lower lobe fluoroscopic guidance Anterior basal RB 8 Lateral basal RB 9
12	Fluoroscopy is especially useful in case of focal disease
13	Fluoroscopy can be performed using C-arm with patient supine or sitting
14	Indications for fluoroscopy To localize abnormalities TO help prevent pneumothorax TO extract foreign bodies TO perform biopsy or brushing of solitary pulmonary nodules To improve diagnostic yield To detect pneumothorax
15	If necessary, forceps can be advanced into various segments. Position is verified using fluoroscopy before biopsies are obtained
16	However, TBLB is “safe” without fluoroscopy Andres G et al, Chest 1988;94:557 TBLB: 122 with & 135 without Fluoroscopy Diagnostic yield higher for focal diseases with Fluoro (pre-CT era), complication rate same Mulligan S et al, ARRD 1988; 137:486 N=168, Retrospective, AIDS & PCP, yield and complications same Puar HS, Chest 1985: 87:303 N=68, Sarcoidosis, Yield 76%, 1 Pneumo Computed tomography scans can help avoids need for double image fluoroscopy
17	Complications 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
18	Preventing bleeds during and after TBLB 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
19	True or False: A chest radiograph should always be performed after TBLB
20	False. Chest radiographs are not always necessary after TBLB Fluoroscopy can reveal lung collapse Pneumothorax occurs in < 3 % of patients. Chest 2006;129:1561-1564 Among 350 consecutive biopsies, chest radiograph within 2 hours after procedure revealed pneumothorax in 10 patients, 7 of whom were symptomatic Chest radiographs are probably indicated only in symptomatic patients.
21	TBLB in special circumstances Pulmonary arterial hypertension Renal failure Antiplatelet agents
22	TBLB in Pulmonary arterial hypertension TBLB is not a primary diagnostic test for PAH. Bleeding following TBBX is from bronchial artery circulation which carry systemic pressures. In patients with supra-systemic PAH, bronchoscopy itself is high risk because of severe hypoxemia. As of 2007, a single animal study has shown safety of TBLB when MPA pressure were high (33 mm Hg).
23	TBLB in Renal Failure Check INR & platelet count Bleeding time can be misleading Dialysis within 24 hrs prior to procedure with TBLB Correct INR and platelet count if necessary (<1.5, >50,000) Desmopressin (DDAVP) 3µg/kg, IV 30 min prior to the procedure costs $ 1000, potential use of DDAVP analogues, estrogen, Cryoprecipitate) Risk of bleeding is about 8%
24	Clopidogrel should be discontinued at least 5 days before TBLB N=604 patients, Clopidogrel = 18 Clopidogrel + aspirin = 12 Control = 574 Bleeding frequency: Clopidogrel = 16/18 (89%) Clopidogrel + aspirin = 12/12 (100%) Control group = 20/574 (3.4%)
25	Other antiplatelet agents and Anticoagulants Aspirin ⁽¹⁾ , Ticlopidine need not be discontinued Warfarin (Coumadin) should be discontinued until INR <1.5 (or INR corrected using Fresh Frozen Plasma or Vitamin K) I.V. Heparin should be stopped 2-6 hrs prior to biopsy. Check PTT. Low molecular weight heparin should be held 12 hrs (hold previous dose). S.Q. Heparin is safe and can be continued. Follow recommendations for all other newer anti-coagulants and other agents.
26	Prepared with the exert assistance of Udaya Prakash M.D. (Mayo Clinic, USA), and Atul Mehta M.D. (Cleveland Clinic, USA), and John Conforti M.D. (Wake Forrest, USA)
27	This presentation is part of a comprehensive curriculum for Flexible Bronchoscopy. Our goals are to help health care workers become better at what they do, and to decrease the burden of procedure-related training on patients.
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29	All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as: Bronchoscopy International: Art of Bronchoscopy, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. Published 2007 (Please add “Date Accessed”).