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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 - PowerPoint PPT Presentation
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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instrument is withdrawn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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