Advances in Interventional Pulmonology E-Book
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- Herausgeber: Bentham Science Publishers
- Kategorie: Fachliteratur
- Serie: Frontiers in Respiratory Medicine
- Sprache: Englisch
Advances in Interventional Pulmonology is a comprehensive, evidence-based text on diagnostic and therapeutic bronchoscopic procedures. This volume covers basic and advanced procedures in the subspecialty of interventional pulmonology (IP). The material presented in this text book is also supported with expert opinion (where evidence is lacking) of authors who are leading researchers in the field of IP from around the world. The book delivers information about anatomical, physiological, pathological, and therapeutic concepts in IP to physicians and is, therefore, suitable for readers having different levels of expertise. The authors have also discussed novel and experimental techniques, and procedures when indicated for the benefit of research oriented readers.
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Veröffentlichungsjahr: 2017
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Frontiers in Respiratory
Medicine
(Volume 1)
Advances in Interventional Pulmonology
Editor
Ali I. Musani
&
Associate Editor
Hervé Dutau
BENTHAM SCIENCE PUBLISHERS LTD.
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PREFACE
The vast spectrum of Interventional Pulmonology (IP) spans from preventative to palliative medicine. Interventional Pulmonology offers cost effective, out-patient, and minimally-invasive diagnostic and therapeutic strategies for chest diseases. Examples of such interventions include lung cancer diagnosis and staging with minimally invasive approaches such as Endobronchial Ultrasound (EBUS) and navigation technologies. Similarly, from the therapeutic aspect, examples include management of complex airway strictures and stenoses with rigid bronchoscopy and airway stenting as well as treatment of severe emphysema with Bronchoscopic Lung Volume Reduction (BLVR) with novel devices such as airway valves and coils. IP also has dramatically changed how we manage complex pleural effusions in this day and age with indwelling pleural catheters and medical pleuroscopy.
The brisk progress of IP over the last 15 years has expanded its horizons beyond anyone's wildest imagination. Millions of patients with a broad spectrum of pulmonary diseases benefit from the cutting-edge diagnostic and therapeutic approaches offered by IP around the globe.
Some of the current clinical studies and device trials underway include bronchoscopic ablative therapies utilizing navigation technology and manually created tunnels through the lung parenchyma, robotic devices allowing multiple instruments to operate simultaneously in the airways, bronchoscopes with multiple working channels, and steerable and trackable instruments.
IP has already shifted decades-old diagnostic and therapeutic paradigms in many areas of pulmonary diseases. The relentless progress in technologies and skills of IP physicians undoubtedly carries the promise to revolutionize the field of pulmonary medicine.
Finally, I am incredibly thankful to my associate editor and good friend, Dr. Herve Duatau and all the contributing authors who volunteered their precious time and expertise in writing evidence-based, state of the art review articles for this edition of eBook on Interventional Pulmonology.
I would like to thank my wife Lubna Sorathia and our children Sara and Sef for allowing me to pursue my ambitions by sacrificing their needs. They allow me to dedicate a major portion of my life to many academic endeavors. Their support and love make it all possible.
List of Contributors
Flexible Bronchoscopy
Donald R. Lazarus1,Roberto F. Casal*,2Abstract
Since its advent in the late 1960s, flexible bronchoscopy has revolutionized pulmonary practice. It allows the pulmonologist to examine the airways to the subsegmental level while obtaining diagnostic samples using techniques such as bronchoalveolar lavage, endobronchial biopsy, cytology brushing, transbronchial lung biopsy, and transbronchial needle aspiration. Even recent advancements in bronchoscopic technology have not rendered essential bronchoscopic techniques irrelevant, and the well-trained pulmonologist must be well versed in all of these techniques to provide optimal patient care.
INTRODUCTION
Flexible bronchoscopy is the most commonly used invasive technique for diagnosing and treating diseases of the lungs and bronchi [1, 2]. The flexible bronchoscope can be used to visually examine the airways to the subsegmental level using only moderate sedation in most cases. Various complementary techniques and instruments allow them to be used to sample the bronchi and lung parenchyma as well, and its versatility and ease of use have significantly contributed to its popularity among pulmonologists in the modern era. This chapter will briefly discuss the history and development of the flexible bronchoscope. It will also review the indications and contraindications of the procedure and discuss basic diagnostic techniques, including bronchoalveolar lavage (BAL), endobronchial biopsy (EBBX), transbronchial lung biopsy (TBLB), and transbronchial needle aspiration (TBNA). More advanced diagnostic
and therapeutic techniques are beyond the scope of this chapter and will be addressed elsewhere in this book.
HISTORY
Rigid bronchoscopy, introduced by Gustav Killian in 1897, was the primary invasive tool available to pulmonologists for the diagnosis and treatment of bronchial and pulmonary conditions through most of the 20th century [3]. While the rigid instrument remains the preferred tool for therapeutic bronchoscopy, its general application is limited by its invasiveness, requirement for general anesthesia, and inability to reach distal areas or access the upper lobes. The introduction of flexible bronchoscopy has largely overcome these limitations [4].
Shigeto Ikeda developed the first flexible fiberoptic bronchoscope in the 1960s, revolutionizing pulmonary practice [3, 5]. Machida manufactured the first commercially available flexible bronchoscope and commercialized it in 1968, quickly followed by bronchoscopes made by Olympus which also included a working channel through which suction or instruments could be applied [3, 6, 7]. Over the next few years, rapid improvements in image quality, flexibility, and angulation followed. By the mid-1970s, the flexible fiberoptic bronchoscope was being commonly used worldwide. Technological advances continued, with the introduction of the first video bronchoscope by Pentax in 1987. This progress improved the quality of the bronchoscopic image by using a miniaturized video camera rather than optical fibers. That allowed the image enhancement on a large screen rather than just through an eyepiece [3, 5].
Some additional diagnostic and therapeutic techniques were developed to make use of the newly expanded reach given to the bronchoscopist by the advent of flexible bronchoscopy. Many of these techniques were originally used in rigid bronchoscopy but were not widely adopted because of the limitations of reach and flexibility intrinsic to the utilization of the rigid instrument and the discomfort of many pulmonologists with its use. Reynolds et al. published the first report of BAL using the flexible bronchoscope in 1974 [8]. This innovation allowed bronchoscopists to obtain material from the lower respiratory tract for analysis conveniently. Rigid bronchoscopy has been used for transbronchial biopsy at various centers for several years. Its use was limited to diffuse lung diseases due to the inability to reach lesions with precision, particularly in the upper lobes [9, 10]. The development of flexible forceps allowed this technique to be adapted to flexible bronchoscopy, increasing the ease and accuracy of TBLB and placing the technique within reach of most general pulmonologists [11-13]. First described by Schiepatti in 1948 using a needle inserted using a rigid bronchoscope [14, 15],TBNA was revived by Wang and colleagues in 1978 and adapted for use through the flexible bronchoscope [16-18].
In addition to the development of these basic diagnostic techniques both therapeutic and advanced diagnostic techniques have been developed or adapted for use with the flexible bronchoscope. Therapeutic techniques adapted for use in flexible bronchoscopy include the laser bronchoscopy, flexible cryotherapy probes, electrosurgery using various instruments, argon plasma coagulation, bronchial thermoplasty, and much more [19-22]. The rapid development of advanced diagnostic techniques for flexible bronchoscopy has continued, with the advent of autofluorescence bronchoscopy, narrow band imaging, confocal microscopy, optical coherence tomography, endobronchial ultrasound (EBUS), electromagnetic navigation (EMN), and others [23-29]. While these and other advanced bronchoscopic techniques are beyond the scope of this chapter and will be reviewed elsewhere in this book, they must be mentioned as further evidence of the ongoing revolution in pulmonary practice that began with the development of flexible bronchoscopy.
INDICATIONS AND CONTRAINDICATIONS FOR FLEXIBLE BRONCHOSCOPY
Flexible bronchoscopy is performed for either diagnostic or therapeutic reason. Diagnostic indications predominate. A review of over 4000 flexible bronchoscopies carried out at an academic center over a 5-year period revealed that over 86% of procedures had a diagnostic indication, with only about 10% of procedures performed for a therapeutic one. The remaining 3% were conducted in volunteers for research purposes [30]. The indications for flexible diagnostic bronchoscopy include pulmonary signs and symptoms, abnormal imaging or other diagnostic studies, and indications related to known disease processes [5, 31] as summarized in Table 1. The bronchoscopist must also remember that a diagnostic procedure occasionally becomes a therapeutic one when there are unexpected bronchoscopic findings or a complication of a diagnostic technique occurs [5]. Therapeutic indications for flexible bronchoscopy are summarized in Table 2.
Flexible bronchoscopy is a very safe procedure with low complication rates. Major complications include significant hemorrhage, pneumothorax requiring chest tube placement, respiratory distress, cardiac arrhythmias, seizures, and cardiopulmonary arrest. Minor complications include laryngospasm, broncho-spasm, epistaxis, transient hoarseness, fever, nausea, and cough. Large retrospective surveys evaluating over 68,000 procedures estimate a rate of major complications from 0.08-0.3%, although this may be an underestimate due to response bias related to the study design [32-35]. Prospective studies and a more recent large retrospective study of consecutive patients suggest a slightly higher major complication rate, somewhere between 0.1% and 5%, with the majority of major complications related to TBLB [30, 35-38]. Mortality is rare, less than 0.04% [34, 35, 39].
There are few absolute contraindications to flexible bronchoscopy. They include refractory hypoxemia, hemodynamic instability, life-threatening arrhythmias, lack of informed consent, inappropriate equipment or facility, and an inexperienced operator [5, 31, 40]. Relative contraindications which increase the risk of flexible bronchoscopy are much more common, and in such cases, the risk and benefit of the procedure must be weighed carefully and measures taken to mitigate the risk when possible. Severe hypoxemia is a relative contraindication to flexible bronchoscopy. It may be preferable to perform the procedure under general anesthesia if it cannot be postponed. Patients who are uncooperative or delirious also have an increased risk of complications and may also benefit from general anesthesia to enable a necessary procedure to be safely performed [5]. While bronchoscopy using moderate sedation is considered safe for patients with stable coronary artery disease, hemodynamic changes associated with the procedure may induce ischemia in rare cases [41]. For this reason, most bronchoscopists postpone elective procedures for at least six weeks after acute coronary syndrome or an episode of decompensated heart failure. The presence of large bullae or extensive emphysema in the area near the target lesion is a relative contraindication to TBLB in patients with poor respiratory function because of the increased risk of symptomatic pneumothorax in that setting [5].
Coagulopathy is another relative contraindication to flexible bronchoscopy, but its importance depends on the type of procedure to be performed. A simple bronchoscopic airway exam and BAL can be conducted with minimal bleeding risk, even in patients with mild coagulopathy. If the coagulopathy is severe and not corrected, the oral route of insertion for the bronchoscope may be preferred. If the planned procedure will require tissue sampling with TBNA, biopsies, or brushing then the correcting the coagulopathy becomes much more important. The risk of bleeding is higher with TBLB than with TBNA or other methods of sampling [5, 30, 35, 42]. Good quality data regarding TBLB in the setting of coagulopathy is scanty. One study reviewed the risk of bleeding from TBLB in 24 patients with thrombocytopenia (less than 60,000/mm3) due to chemotherapy or bone marrow invasion. In 20 of the cases, patients received a transfusion of platelets within 60 minutes before the procedure. The rate of significant bleeding was 21%, and there was one fatal hemorrhage [43]. Two retrospective studies evaluating the predictive value of pre-bronchoscopy coagulation studies did not show increased risk of bleeding from TBLB in patients with high partial thromboplastin time (PTT), prothrombin time (PT), or international normalized ratio (INR). Only 45 patients had abnormal coagulation parameters (out of a total of 731 who underwent a biopsy in the two studies), and it is likely that some patients with abnormal coagulation studies at who were thought to be at high risk of bleeding were not biopsied [44, 45]. When the relative risk of bleeding for patients in the previous studies was subsequently calculated the confidence intervals were very wide, and stronger evidence is needed before forgoing pre-biopsy assessment of coagulation in patients at risk for bleeding [46]. For this reason, guidelines still recommend checking platelets and coagulation studies before bronchoscopy with planned biopsy, and this is our practice as well [35]. Personal experience and expert opinion suggest that platelet counts below 50,000/mm3, elevated PTT, and INR above 1.5 should be considered relative contraindications to biopsy unless corrected [5].
Medications that may increase bleeding risk must also be considered relative contraindications to flexible bronchoscopy. Although little evidence exists regarding management of anticoagulants for bronchoscopy, recommendations extrapolated from the surgical literature have been incorporated into guidelines for bronchoscopy [47]. Warfarin should be stopped approximately five days before bronchoscopy, and low-molecular-weight heparin should be held for at least 12 hours before the procedure. Direct factor Xa inhibitors such as apixaban, edoxaban, and rivaroxaban and direct thrombin inhibitors such as dabigatran should be held for at least 72 hours before bronchoscopy [35, 48]. There is literature evaluating antiplatelet agents in bronchoscopy, and this is particularly relevant in the current age of drug-eluting coronary stents requiring dual antiplatelet therapy. Daily use of aspirin was not associated with increased risk of bleeding after TBLB in a prospective study of over 1200 patients, 285 of whom were taking aspirin [49]. A prospective study of 604 patients undergoing TBLB, 30 of whom were taking clopidogrel, demonstrated a very high rate of significant bleeding in those patients--89% of patients on clopidogrel alone, and 100% of patients on clopidogrel and aspirin [50]. For this reason, clopidogrel should be stopped if possible 5-7 days before bronchoscopy. Aspirin may be continued. For those patients with drug-eluting coronary stents which have been in place for less than 12 months delaying bronchoscopy is recommended [35]. Interventional cardiology should be consulted for urgent procedures.
BASIC DIAGNOSTIC PROCEDURES IN FLEXIBLE BRONCHOSCOPY
The most important part of a flexible diagnostic bronchoscopy is the planning of the procedure. The patient's clinical presentation, radiographic images, suspected etiology of the condition, and the location of the intrathoracic lesions must be evaluated carefully. This information is used to select the most appropriate procedure or combination of procedures. All flexible diagnostic bronchoscopies should include a thorough airway exam, and detailed knowledge of the anatomy of the bronchial tree is essential to the bronchoscopist. In addition to the visual inspection of the airways flexible bronchoscopy can provide several types of samples. These specimens are useful in diagnosing diseases of the chest. For example, cytology (washings, BAL, brushings, and TBNA), histologic (forceps biopsy, core needle biopsy, and cryo biopsy), and microbiologic samples. Using multiple techniques (such as TBLB, cytology brush, and BAL) to obtain samples tends to increase the diagnostic yield of the procedure [51-54].
Bronchial Washings, Bronchial Brushing, and Endobronchial Biopsy
Bronchial washings, brushings, and endobronchial biopsies are taken from the large airways under direct visualization, although cytology brushes can be used to take samples from peripheral parts of the lung as well. They are frequently used together to diagnose visible endobronchial malignancy or pulmonary infections [51, 53]. Bronchial washing just involves the instillation of saline through the working channel of the bronchoscope into the airway. The bronchoscopist then suctions the saline (mixed with local secretions and cellular elements) back through the bronchoscope and into a fluid trap. Available evidence does not suggest that waiting until after forceps biopsy to obtain bronchial washings increases yield, although this is a common practice [52, 54].
Bronchial brushing can be used to obtain cytologic or microbiologic samples in the large airways under direct visualization or in the peripheral airways using fluoroscopic guidance. A variety of brushes is available to the bronchoscopist. The brush is kept in its protective sheath until the distal end of the sheath exits the working channel of the bronchoscope. Then the sheath is positioned near the target site, an assistant advance the brush out from the sheath, and vigorous brushing of the lesion is carried out. The brush is then retracted back into the sheath before being removed from the working channel. The overall diagnostic yield of brushing for malignancy in visible endobronchial lesions is around 60-90% [51, 53, 54].
The same flexible forceps used for TBLB are also used for endobronchial biopsies. The forceps are advanced through the working channel of the bronchoscope. Once they emerge from the channel, the forceps are positioned near the target lesion and opened by an assistant. The bronchoscopist then advances the forceps until the lesion is within their jaws. The assistant closes the forceps around the tissue, and they are then retracted through the working channel of the bronchoscope to retrieve the biopsy. Several biopsies of the lesion are recommended. Diagnostic yield of endobronchial biopsy for visible endobronchial tumors ranges from 78%-94% [51-54].
Bronchoalveolar Lavage
Bronchoalveolar lavage is used to obtain diagnostic material from the distal airways and alveoli. Although guidelines exist highlighting that the technique is not standardized across centers [55]. In general, after the airway examination the bronchoscope is advanced to the targeted segment (usually the most abnormal appearing portion of the lung by imaging) and wedged into a bronchus in the 4th or 5th generation. Then serial aliquots of 30-60 mL of sterile saline are instilled via the working channel of the bronchoscope. A total of 100-300 mL is typical of most institutions, although the optimal total volume is not known. The saline (mixed with contents of the lower respiratory tract) is then aspirated with the syringes used to instill it or using the suction of the bronchoscope [5, 55]. It is believed that smaller amounts of fluid (60 mL or less) sample primarily the small bronchi, while amounts of 120 mL or larger fill the entire segment more evenly, leading to sampling of fluid from the alveoli as well [56]. The proportion of the instilled volume of fluid recovered is typically 40-60%, with optimal sampling yielding at least 30% of the total instilled volume [55, 57]. Return is diminished with loss of elastic recoil of the airways which leads to easy collapse with suctioning. BAL is very safe with extremely low complication rates, most commonly transient hypoxemia and fever [5].
The differential cell count of BAL fluid in a healthy adult nonsmoker should have 80-95% macrophages, 5-15% lymphocytes, less than 3% neutrophils, and less than 1% eosinophils [55, 57, 58]. The normal ratio of CD4:CD8 lymphocytes in BAL fluid is 1.4-1.8 [58].
The most frequent indication for BAL is probably to diagnose or exclude pulmonary infections, especially in immunocompromised patients or those who have nonresolving pneumonias. For bacterial pneumonia the yield of BAL is around 65%. In ventilator-associated pneumonias the yield is slightly higher. It is commonly used to diagnose mycobacterial infections including tuberculosis with yield around 75%, although the sensitivity is lower in than TBLB in cases of military disease [5, 40]. Bronchoscopy is especially useful for diagnosing infections in immunocompromised patients. Indeed, in a study of 95 immunocompromised patients on broad spectrum antibiotics and antifungals, BAL used to diagnose pneumonia found organisms not targeted by or resistant to current therapy in 40% of cases [59].
In addition to diagnosing pulmonary infections, BAL is also used to evaluate inflammatory processes and malignancies. It is often combined with TBLB to diagnose malignant lung tumors. In diffuse parenchymal lung diseases BAL is most commonly used to help rule out infectious conditions that may mimic non-infectious inflammatory diseases. In a few such inflammatory diseases, such as pulmonary alveolar proteinosis, pulmonary Langerhans cell histiocytosis, and eosinophilic pneumonia, BAL may be diagnostic but these are the exceptions to the general rule [5].
Transbronchial Lung Biopsy
A transbronchial lung biopsy is a technique in which flexible forceps are used to obtain histologic samples of tissue from the lung parenchyma or from localized lesions sufficiently distal that the forceps can no longer be directly visualized. It is used commonly to diagnose infectious and non-infectious diffuse lung diseases as well as lung tumors. It is frequently combined with guidance techniques, such as radial probe-EBUS and electromagnetic navigation, to improve the diagnostic yield for peripheral lung lesions. One of the most common indications for TBLB is diffuse interstitial lung disease (ILD) if clinical, imaging and laboratory evaluation are unable to reach a definite diagnosis. TBLB is typically indicated for diffuse ILD in patients who have atypical patterns of disease on high-resolution CT, have rapidly progressive disease, are younger, are suspected of conditions more likely to respond to therapy, or to rule out infection before a trial of immunosuppressive treatment [5]. The overall yield of TBLB for diffuse ILDs is around 70%. It is higher for those conditions with a centrilobular or bronchogenic distribution, such as sarcoidosis or hypersensitivity pneumonitis [5, 60]. TBLB is also used in conjunction with BAL to diagnose pulmonary infections, especially in patients who are immunocompromised. In such patients, the combination of TBLB and BAL has higher diagnostic yield than either technique alone [61, 62]. The yield of TBLB for focal peripheral lung lesions varies considerably with the location and size of the lesion as well as the other modalities used to guide biopsy. The yield of TBLB for peripheral lung lesions in conjunction with radial probe-EBUS and EMN will be discussed more fully in another part of this book.
Most TBLBs are performed in the bronchoscopy suite using moderate sedation. Contraindications to TBLB under moderate sedation include allergy to the sedatives to be used, excessive cough, and inability to cooperate with the bronchoscopist. Most institutions use fluoroscopy to guide TBLB, especially for localized lesions. Because bleeding encountered after TBLB may prevent other procedures (such as BAL) from being completed successfully, biopsy should be performed after the airway examination and other desired procedures have been completed. The bronchoscope is advanced to the area of interest and wedged gently into the bronchus. The bronchoscope is kept wedged in the airway to isolate potential bleeding and also to allow more rapid completion of the procedure since several biopsies can be taken without moving the scope each time [5]. The closed biopsy forceps are then advanced through the working channel into the airway, and fluoroscopy is activated once the tip of the forceps is outside the working channel of the bronchoscope. The forceps are then advanced to the target area or lesion and opened when they are 0.5-1 cm proximal to the target. The forceps are then advanced to the target or until resistance is encountered and then closed. Care should be taken to avoid taking the biopsy during a coughing episode. The closed forceps is then retracted while carefully watching the visceral pleural line on the fluoroscopy monitor. If the visceral pleura is “tented” in with retraction, then the forceps should be opened and a different less distal site selected to avoid possible pneumothorax [5]. If the visceral pleura is not tented, the forceps are retracted gently into the working channel of the bronchoscope and removed so that the biopsy specimen can be retrieved. Specimens can be used to create touch-preps for rapid on-site cytology assessment and then placed into formalin for final pathology. They can also be placed into saline for microbiologic analysis when indicated. The more biopsies that are taken, the greater the diagnostic yield, which also varies with the underlying disease. A study of 530 consecutive TBLB in 516 immunocompetent patients with chronic diffuse infiltrates, focal peripheral lesions or hilar adenopathy demonstrated a diagnostic yield of 38% when 1-3 specimens were taken compared to a yield of 69% when 6-10 specimens were obtained. The investigators also noted differences in yield for TBLB among different causes of diffuse chronic infiltrates, with better results for hypersensitivity pneumonitis and sarcoidosis than for pulmonary fibrosis or miliary tuberculosis [63]. While taking more biopsies increases diagnostic yield, it also increased the number of complications such as pneumothorax and bleeding. In most cases, 5-7 biopsies should give sufficient yield without unduly increasing the risk to the patient. Larger forceps do not appear to increase the yield over smaller ones [64].
The incidence of pneumothorax with TBLB is influenced by factors including operator experience, type of forceps, number of samples taken, and fluoroscopy guidance [5]. The rate of pneumothorax varies among institutions but is quite small, ranging from 1-5% [30, 36, 39, 65]. Pneumothorax is more common in mechanically ventilated patients, occurring in 7-14% of TBLB procedures, although the information gained changes management in over 40% of cases [66, 67]. Whether or not the use of fluoroscopy to guide TBLB reduces the rate of pneumothorax is controversial. Some investigators have demonstrated a pneumothorax rate of 1% for TBLB without fluoroscopy in 68 patients suspected of having sarcoidosis [65]. However, an extensive mail survey of bronchoscopists in the United Kingdom demonstrated a lower rate of pneumothorax associated with TBLB if fluoroscopy was used, 1.8% with fluoroscopy as opposed to 2.9% without it [39]. Significant bleeding occurs in 2-9% of TBLB procedures [13, 30, 36]. Coagulopathy, uremia, and clopidogrel [43, 47, 50, 68] increase the risk of bleeding with TBLB. Pulmonary hypertension is also thought to increase the risk of bleeding with TBLB although the absolute pressure above which the risk is prohibitive is unknown [47]. Cordasco and colleagues did not identify pulmonary hypertension as a risk factor for bleeding in their retrospective analysis of over 3000 cases in which TBLB or bronchial brushing was used [68]. Another group looked at 37 heart-transplant patients who required TBLB to diagnose pulmonary conditions. No bleeding occurred in the 17 patients with normal mean pulmonary arterial pressures, and moderate bleeding occurred in 3 of 20 patients with mean pulmonary arterial pressures greater than 16 mm Hg. The difference was suggestive of an increased risk, but the number of episodes was too small to reach statistical significance [69]. A subsequent study evaluating TBLB in 24 patients with mild to moderate pulmonary hypertension (compared to 32 controls) did not demonstrate an increased risk of bleeding [70]. Since the evidence is scanty, proceeding with caution seems prudent in patients with pulmonary hypertension. In our practice, we avoid TBLB for patients with systolic pulmonary pressures greater than 50 mm Hg when possible, although we do not consider it an absolute contraindication.
Transbronchial Needle Aspiration
Transbronchial needle aspiration is a very useful technique that uses a small needle advanced through the bronchoscope to sample mediastinal and hilar nodes or masses as well as peripheral lung lesions [17, 18, 71]. Despite its utility, surveys of bronchoscopists have indicated that it is not widely used, primarily because of its perceived low diagnostic yield [1, 2, 72]. The indications for TBNA are summarized in Table 3. The most common indication for TBNA has historically been for the sampling of hilar or mediastinal lymph nodes and masses. The use of conventional (or blind) TBNA for this purpose has decreased significantly in the last decade since the introduction of convex probe-endobronchial ultrasound (CP-EBUS), which allows real-time ultrasound guidance of TBNA using an integrated ultrasonic bronchoscope [28, 73, 74]. The high diagnostic yield of EBUS-TBNA has led to much of the decline in the use of conventional TBNA for mediastinal and hilar lesions. The use of TBNA for visible endobronchial lesions may also occasionally improve the already-high diagnostic yield of endobronchial forceps biopsy by reaching the core of tumors covered in necrotic material [75]. More recently TBNA has been used more frequently for sampling peripheral lung lesions, often in conjunction with new technologies such as radial probe EBUS, EMN, and virtual bronchoscopy [71, 76]. This section will discuss conventional TBNA, and EBUS-TBNA will be reviewed elsewhere in this book.
Needles used for TBNA must be retractable to prevent damage to the bronchoscope. They range in diameter from 19G to 22G, with a typical length of 4-15 mm [77]. Most operators will choose a longer, stiffer needle to sample central structures when the bronchial wall must be penetrated. Shorter and more flexible needles are preferred for sampling peripheral lung lesions [5]. For central lesions the catheter containing the TBNA is passed through the working channel until the metal tip is visible outside the bronchoscope. This technique should be used with the bronchoscope in neutral flexion so as to avoid inadvertent damage to the instrument. The catheter is then withdrawn, exposing the tip of the needle. Once it is visible, the bronchoscope is advanced to the target for puncture and anchored on the wall at an angle as close to 90 degrees as possible. Four techniques are commonly used to penetrate the bronchial wall. In the jabbing method, the bronchoscope is held still, and the needle is quickly advanced through the intercartilaginous space with a quick, firm motion. The piggyback method has the bronchoscopist hold the needle fixed at the entrance to the working channel while the bronchoscope and needle are thrust forward together so that the needle penetrates the wall. In the hub-against-the-wall method, the hub of the needle catheter is placed against the target site while the needle is kept retracted. The needle is then pushed out of the catheter and through the wall into the lesion. Finally, during the cough method, the bronchoscopist employs the jabbing technique while asking the patient to cough to facilitate penetration of the wall with the needle. Once the needle has penetrated the wall suction is applied proximally with a syringe, and the needle is agitated back and forth to collect cellular material. Once the suction is released the needle must be withdrawn entirely into the catheter before it is removed from the bronchoscope. If blood is aspirated into the catheter, it may mean that a large vessel has been punctured, so a new site should be selected [77]. For peripheral TBNA the bronchoscope is advanced to the targeted segment. Then the needle catheter is advanced through the working channel into the airway. Using fluoroscopic guidance (and any other techniques are chosen to aid in navigation) the catheter is advanced to the target lesion, stopping 1-2 cm proximal to the lesion to accommodate the length of the needle. The needle is then pushed out of the catheter into the target lesion, suction is applied, and it is agitated within the target for a few seconds to obtain cellular material. Suction is then released, and the needle is withdrawn into the catheter before the catheter is removed via the bronchoscope [5, 71].
The sensitivity of TBNA for identifying malignant involvement of the mediastinum ranges from 40-80%, and despite the lack of randomized controlled trials, it has largely been replaced by EBUS-TBNA for this purpose [18, 78, 79]. Likewise, TBNA has largely been replaced by EBUS-TBNA for sarcoidosis, with a randomized trial showing its inferiority to EBUS-TBNA for diagnosing stage I and II sarcoidosis [80]. The yield of TBNA for mycobacterial or fungal lymphadenitis is variable, but when correlated with cytology showing granulomas may demonstrate added benefit in this setting as well [81, 82]. Using TBNA for peripheral lung nodules has grown in popularity in the last decade in with the availability of new tools for guided bronchoscopy [RP-EBUS, EMN] which are addressed elsewhere in this book. In addition to the availability of guided bronchoscopy, the yield of TBNA for peripheral lesions is influenced by the lesion size, location, and relationship to the bronchus [83]. TBNA has been shown to improve the diagnostic yield for conventional bronchoscopic techniques for peripheral lesions, perhaps because it can penetrate the bronchial wall [71, 84, 85].
Transbronchial needle aspiration is a very safe technique. Damage to the bronchoscope is probably the most common complication of its use [5, 77]. Being careful to keep the needle withdrawn inside the catheter during insertion and removal as well as holding the scope in neutral flexion during insertion minimize this risk. Other complications, such as pneumothorax or bleeding, are exceedingly rare [77, 85, 86].
CONCLUSION
Flexible bronchoscopy has revolutionized pulmonary practice since its inception in the late 1960s. Basic flexible bronchoscopic procedures such as brushings, BAL, TBLB, and TBNA remain essential tools in the armamentarium of the pulmonologist, even in the current era of rapidly advancing technology.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.
ACKNOWLEDGEMENTS
Declared none.
