The nature of lung lesions can be diverse, such as infections, tumors, congenital anomalies, connective tissue diseases, etc. However, various nature of diseases can be difficult to differentiate not only in terms of similarity in symptoms (the so-called phenomenon of multiple diseases and multiple illnesses), but also in terms of similarity in imaging such as X-ray plain film, chest CT, chest MRI or said to be lacking in characteristics to make a clear diagnosis. Although sputum examination provides a simple, inexpensive, noninvasive method, it is mostly unable to carry the burden of confirming the diagnosis because its sensitivity and specificity are too low. Therefore, lung biopsy (Lung Biopsy) has become a very important, critical, and sometimes the only method for the diagnosis and differential diagnosis of lung lesions. Because of this method, many difficult and complex lung pathologies, such as occlusive bronchiectasis with mechanized pneumonia, primary pulmonary histoplasmosis, pulmonary lymphangioleiomyomatosis, various lung tumors, alveolar protein deposition, lymphocytic interstitial pneumonia with alveolar type II epithelial hyperplasia, pulmonary nodulosis, pulmonary cryptococcosis, diffuse panbronchiolitis, Pneumocystis carinii, etc., have been diagnosed in a timely manner. The correct diagnosis has provided crucial evidence for the clinical treatment of the cause, thus promoting the significant development of respiratory pathology.
Lung biopsy can be divided into transbronchial lung biopsy, percutaneous lung biopsy, thoracoscopic lung biopsy and thoracotomy lung biopsy, depending on the mode of invasion during biopsy.
Broadly speaking, transbronchial lung biopsy includes direct transbronchial view lung biopsy, transbronchial needle aspiration biopsy and transbronchial X-ray guided lung biopsy.
Transbronchial direct-view lung biopsy is actually a biopsy of lesions in the trachea and bronchi at all levels or lesions in the lung that invade the trachea and bronchi under direct vision, and has not yet penetrated into the lung parenchyma.
Transbronchial needle aspiration biopsy is an invasive examination method in which a specially designed puncture needle with a bendable catheter is used to enter the tracheobronchus through the bronchoscopic operating channel and then pass through the airway wall to obtain cytological or histological specimens from extra-airway lesions such as nodules, masses, lymph nodes and substantial lung lesions by localization according to chest CT or endotracheal ultrasound.
Transbronchial X-ray guided lung biopsy is a true transbronchial lung biopsy. TBLB presupposes that a substantial lesion is identified on the lung X-ray and then guided or positioned under X-ray fluoroscopy or CT, or it can be performed blindly based on preoperative chest X-ray positioning, and the diagnosis of lung lesions is extended to the surrounding lung tissue.
Depending on the guidance method, it can be divided into X-ray fluoroscopy guidance, CT guidance, and ultrasound guidance.
In addition, transbronchial lung biopsy must be supported by bronchoscopy.
I. Direct transbronchial lung biopsy
In the 1960s, Shigeta Ikeda’s pioneering work led to the introduction of the first generation of optical fiberoptic bronchoscopy, which caused the decades-old rigid bronchoscope to fade into obscurity, and fiberoptic bronchoscopy has been widely used in clinical practice. Therefore, the bronchoscopy referred to in this chapter is fiberoptic bronchoscopy unless otherwise specified.
Bronchoscopy is an important diagnostic technique for respiratory diseases, and has been widely used for lung biopsy, needle aspiration biopsy, bronchoalveolar lavage and brushing, as well as removal of secretions, auxiliary airway dilation, airway stenting, high-frequency electric knife therapy, microwave therapy, laser therapy and brachytherapy to relieve obstruction. .
Transbronchial direct vision lung biopsy is actually a biopsy of the trachea and all levels of bronchial lesions or lesions in the lung that invade the trachea and bronchus under direct vision, and has not yet penetrated into the lung parenchyma.
Indications
1, unexplained cough, sputum, hemoptysis or blood in sputum
2, hoarseness of voice of unknown origin.
3, Those with unknown diagnosis of pulmonary mass or shadow, pulmonary atelectasis, obstructive pneumonia, etc. found on chest film or chest CT.
4.Persons with long-term asthma attacks, or progressive dyspnea, who have been treated with anti-inflammatory and antiasthmatic treatment according to bronchitis or asthma and are not effective
5, occult lung cancer in which cancer cells or suspicious cancer cells are found in sputum and no abnormality is seen in chest X-ray, chest CT, chest MRI and other examinations.
6.Pleural effusion (various kinds of pleural fluid) whose diagnosis is unknown.
7.Patients with chronic lung diseases such as chronic branch, tuberculosis, bronchial expansion, pneumoconiosis, etc., whose original symptoms are repeated, changing, aggravated or some new symptoms appear or some new lung lesions appear, and whose symptoms are not reduced or disappeared after more than two weeks of anti-infection treatment, and whose lung lesions have no change or tendency to increase.
8.X-ray examination reveals intra-airway occupancy and airway narrowing.
Contraindications
1.Patients with severe cardiopulmonary insufficiency, patients who are extremely weak and cannot tolerate.
2, those with severe coagulation dysfunction or active hemoptysis.
3, severe cardiac arrhythmias.
4.severe superior vena cava obstruction syndrome.
5, severe pulmonary hypertension.
6.Suspected aortic aneurysm.
Patient preparation
1.Pre-operative preparation
Detailed medical examination, application for routine blood, blood group, liver and kidney function, coagulation function, electrocardiogram, X-ray chest frontal and lateral radiographs or chest CT films and other auxiliary examinations, and if necessary, pulmonary function tests to understand whether there are any contraindications to surgery and to determine the lesion site; bronchoscopy and its biopsy is an invasive operation, and there is a possibility of nosocomial infection through the operation, therefore, application for hepatitis immunomarkers, HIV antibody, syphilis antibody, and other tests.
The purpose, significance, general procedure and how to cooperate should be explained in detail to the patient and/or his family, and possible complications including intraoperative respiratory arrest or even death should also be explained in detail, and the consent of the patient and family should be obtained and signed.
Fasting for 4 hours before surgery. Lupin 100mg (or diazepam 10mg) and atropine 0.5mg can be injected intramuscularly half an hour before surgery to sedate and reduce secretions. If necessary, 100mg of prednisolone or pethidine can be injected intramuscularly to facilitate cough suppression and analgesia.
2. Oxygen and anesthesia
Bronchoscopy can cause the partial pressure of oxygen to drop by 10~20mmHg or more, and those with original respiratory insufficiency may have obvious shortness of breath and cyanosis, and severe cases may have asphyxia-like symptoms. Therefore, nasal catheter oxygen should be administered intraoperatively to keep the pulse oxygen saturation above 95% to reduce the occurrence of intraoperative complications.
The anesthetic drug should be 2% lidocaine. The pharyngeal spray method or ultrasonic nebulization method can be used, but the former has poor endotracheal anesthesia and the latter takes longer (about 20 minutes). The transbronchoscopic endotracheal drip anesthesia method is mostly ineffective due to the short duration of anesthetic action. Nasal insertion requires anesthesia and contraction of the nasal mucosa (the latter can be done with furosemide drops). The author used the anesthetic method of pharyngeal spray and cricothyroid puncture injecting 2% lidocaine 3 ml, which was quite effective.
Instrument preparation
1, tracheoscopy and biopsy and other special instruments soaked with 2% glutaraldehyde solution for 15 minutes, rinsed with sterile distilled water and set aside. The insertion part can be coated with a small amount of sterile silicone oil to profit slip effect.
2.Protect the bronchoscope, cold light source, suction device, monitor, monitor and other instruments are connected correctly and function properly.
3.Preparation of bronchoscope.
Operation method
1.Usually use the supine position, but can also choose the lateral, semi-recumbent or sitting position according to the condition. Continuous electrocardiographic and pulse-oxygen saturation monitoring is given during the operation.
2.Usually inserted through the nose, or through the mouth if insertion is difficult. Consider intraoperative drainage difficulties that may require repeated entry and exit of the bronchoscope or intraoperative asphyxiation due to massive bleeding, etc. The scope can be inserted through the mouth and through the tracheal tube. For those with existing tracheal intubation or tracheotomy, enter the scope through the existing tracheal intubation and tracheal tube.
3, in order to carefully peer into the visible range of the nose, pharynx, voice box, trachea, bulge and the distal end of each bronchial mucosa and its branches, and to obtain specimens for histological, cytological and bacteriological examination by biopsy forceps clamping (see Figure 1-3), brush inspection and bronchial flushing for lesions and suspicious areas.
4. With the use of fluorescence bronchoscopy, early lesions such as carcinoma in situ and precancerous lesions that cannot be detected by the naked eye under normal light sources may be detected (see Chapter 8 for fluorescence bronchoscopy). (See Figures 4 and 5 in the Appendix.) 5. Specimen processing: Tissue blocks can be fixed in 10% formalin solution and sent for examination. Brush and flush smears can be fixed in anhydrous ethanol and sent for examination. Bacteriological examination specimens should be placed in sterile containers.
Complications and their management
Bronchoscopy is relatively safe, but serious complications, such as hemorrhagic asphyxia and respiratory arrest, can occur in individual cases. The incidence of complications is about 0.3%, the incidence of serious complications is about 0.1%, and the mortality rate is about 0.01%.
1.Anesthetic allergy or overdose of lidocaine causes allergy is rare, such as overdose or accidental injection into the blood vessels can cause toxic reactions. In case of allergic reaction, the operation should be stopped immediately and vasoactive drugs such as epinephrine should be used, atropine should be given to bradycardic patients, and cardiopulmonary resuscitation should be performed immediately for cardiac arrest.
2.Bronchial asthma attack, laryngospasm and asphyxia during operation are mostly caused by inadequate anesthesia or rough examination technique, or induced during the acute asthma attack. After complications occur, the examination should be stopped immediately, oxygen should be administered, antihistamines and glucocorticoids should be used, and asthma should be treated. If necessary, tracheal intubation or tracheotomy and ventilator-assisted ventilation should be given.
Cardiac arrest during operation may be related to the patient’s pre-existing or underlying organic heart disease and inadequate anesthesia or improper operation. Once it occurs, perform manual cardiopulmonary resuscitation immediately.
4, post-operative airway bleeding where the tissue biopsy, there will be bleeding, but the amount of bleeding varies. A small amount of bleeding can mostly stop bleeding by itself, but also in the biopsy site drop 0.01% ~ 0.02% concentration of epinephrine or norepinephrine solution 2 ~ 10ml, hemostatic effect is obvious. In case of hemorrhage, continuous negative pressure suction should be applied immediately, and posterior pituitary hormone 6U can be injected slowly intravenously if there is no contraindication. Injecting the above drugs at the proposed biopsy site before biopsy is mostly effective in preventing hemorrhage.
5, intraoperative arterial partial pressure of oxygen decreases during bronchoscopy, the arterial partial pressure of oxygen can generally decrease by 10~20mmHg or more, for those who have no preoperative hypoxia, intraoperative oxygen can not be administered; however, for those who have preoperative hypoxia, oxygen should be administered by nasal cannula or non-invasive positive pressure ventilation or high frequency ventilation.
6, postoperative fever after bronchoscopy can have fever, the incidence is about 5%. The cause may be the stimulation of cold flushing fluid, bleeding and absorption of pyrogen, original infection or secondary infection. The fever is mostly transient and low, and generally does not need to be treated. Those suspected of infection should use sensitive antibiotics.
B. Transbronchial needle aspiration biopsy
Although transbronchial direct visual lung biopsy can be performed under direct vision to obtain histological or cytological specimens by biopsy and brush examination, transbronchial direct visual lung biopsy is not useful for lesions that are not visible under the microscope. Transbronchial needle aspiration (TBNA) can be used to obtain tissue from primary or metastatic tumors adjacent to major airways in areas not normally accessible by brush or biopsy forceps biopsy, such as the mediastinum, hilar lymph nodes, or the lungs. In particular, TBNA cytology of hilar or extrabronchial compressive masses can improve the diagnosis of central small cell lung cancer because of the difficulty in detecting endobronchial lesions by fibronectomy.
As early as 1949, Schieppati, an Argentinian physician known as the “father of TBNA”, applied and performed puncture of the inferior bulbar lymph nodes by rigid bronchoscopy, resulting in a positive result of 38% (26/69) of 69 patients suspected of having bronchopulmonary carcinoma. experience. Since then, more and more reports have been published and have progressed to biopsy by bronchoscopy, but mostly for definitive diagnosis and determination of bronchopulmonary carcinoma with or without surgical indications. Nowadays, TBNA is not only used to diagnose lesions in the mediastinum and lung parenchyma, but has also become an important method for staging lung cancer.