Transbronchoscopic Lung Biopsy (TBLB)
Xiaoping Wang, Department of Respiratory Medicine, Shandong Chest Hospital
Transbronchiallung biopsy (TBLB) is a procedure in which a bendable bronchoscope is inserted into a branch of the patient’s bronchus, and then pathological lung tissue is clamped under no X-ray or X-ray fluoroscopy to diagnose diffuse and peripheral focal lung lesions.
Indications.
1. Diffuse lung lesions. (e.g., pulmonary infection, cor pulmonale tuberculosis, alveolar protein deposition, interstitial lung disease, alveolar cell carcinoma, etc.)
2. masses, nodules and infiltrative lesions in the periphery of the lung.
Contraindications.
Severe cardiopulmonary insufficiency, intense cough or inability to cooperate with the examination, severe pulmonary hypertension, hypertension, more severe pulmonary alveoli in the puncture area, coagulation dysfunction, bleeding quality.
Preoperative preparation.
1. Detailed medical history, physical examination, preparation of relevant examinations and laboratory tests (such as coagulation, electrocardiogram, chest CT, etc.).
2. Define the location of the lesion and estimate the distance from the segmental bronchial opening to the lesion or the proposed biopsy site.
3. explain the condition and sign the consent form. (The possibility of possible pneumothorax and hemorrhage needs to be especially explained to the patient and family.)
4. Pre-operative preparation for routine examination, adequate anesthesia, preparation of local hemostatic drugs, ice saline, etc., and establishment of intravenous access in advance if necessary.
The operation method of transbronchoscopic lung biopsy (TBLB) includes the operation without x-ray fluoroscopic guidance, which is called “blind”, and is the method currently adopted by our department; the other method is TBLB under x-ray fluoroscopic guidance and TBLB under CT guidance.
TBLB without X-ray fluoroscopy: i.e. “blind”, which is more dependent on the operator’s film reading and positioning level and operation technique. If the lesions are similar on both sides, the right lower lobe should be the main biopsy site.
For transbronchoscopic lung biopsy without X-ray, the procedure for limited lesions is as follows
1. Chest radiograph and CT to determine the lung segment in which the lesion is located and the distance from the lesion.
2. Bronchoscopic observation of the bronchi in the lesion area for abnormalities such as congestion, copious secretions, hypertrophy, erosion, deformation, etc.
3. After the bronchoscope reaches the bronchus or subsegment of the diseased lung segment, insert the biopsy forceps. (It is recommended to choose round mouth biopsy forceps, not the biopsy forceps with teeth, which have a higher risk of bleeding.)
4. Transport the biopsy forceps to the distal end of the lesion, light pressure can not be advanced, and the depth is sufficient, it is estimated that the biopsy forceps have reached the edge of the lesion.
5. If the depth is not enough, gently rotate and gently pressurize until you can not continue to advance.
6. At this point, slightly back (about 1-2cm), ask the patient to inhale, open the biopsy forceps forward slightly when encountering resistance to clamp the tissue, quickly pull out. (Slowly pull out easy to tear the mucosa, causing hemorrhage.)
7. generally take 2-3 pieces of tissue is optimal, (assistant or with the nurse to make sure that the tissue is indeed taken, their experience is particularly important at this time.) Taking too much tissue does not necessarily improve the positive rate, but increases the risk of bleeding.
Closely observe bleeding at the site of the clamped lesion during the procedure.
The operation of transbronchoscopic lung biopsy (TBLB) includes the operation without X-ray fluoroscopic guidance, which is called “blind” and is the method currently adopted by our department; the other method is TBLB under X-ray fluoroscopic guidance and TBLB under CT guidance. lesion.
Location: Right lower lobe or a more concentrated lesion.
Methods: 1. Electronic bronchoscopy reaches the selected segment of the bronchus.
The biopsy forceps are fed in until resistance is encountered or the patient feels slight pain, then the forceps are withdrawn 1-2 cm.
3. Generally, a depth of 4 cm from the opening of the segmental bronchus is sufficient.
4. Ask the patient to breathe deeply, open the biopsy forceps at the end of deep inspiration, slowly advance about 1cm and then clamp and quickly pull out. (Clamp can feel whether to take the pathological tissue)
5. Reach in different segments or subsegments of the bronchus to take the material.
The operation of transbronchoscopic lung biopsy (TBLB) includes performing TBLB without X-ray fluoroscopic guidance, which is called “blind”, and TBLB under X-ray fluoroscopic guidance and TBLB under CT guidance.
1. X-ray guided lung biopsy – diffuse lesions.
Location: Diffuse lesions in both lungs – B8, B9 and B10 in the right lower lung, and bronchioles in each segment of the upper lobe.
Methods: ① electronic bronchoscopy to reach the segmental bronchi; ② biopsy forceps sent to the subsegmental bronchi; ③ X-ray fluoroscopy to determine the site, guide the biopsy forceps until the expected clamp site; ④ open the biopsy forceps, at the end of expiration biopsy forceps then advance 1-50px, then clamp the tissue and quickly pull out; ⑤ change other lung segment biopsy repeat the above steps to take pathological tissue, usually about 5 pieces of tissue.
2. X-ray guided lung biopsy – limited lesions.
Methods: ① electronic bronchoscopy to the segment bronchus where the lesion is located; ② X-ray fluoroscopy to determine the clamping site, guide the biopsy forceps to reach the lesion area; ③ rotate the body position, multi-axis fluoroscopy, or change the fluoroscopic position; ④ confirm good biopsy forceps in the lesion area after opening, clamping at the end of the patient’s expiration, and quickly withdraw to see if there is pathological tissue removed, generally about 5 pieces of tissue.
Precautions.
1. accurate preoperative lesion localization, determination of distance, intraoperative attention to the corresponding bronchus for any abnormalities.
2. Technically proficient and familiar with anatomy, and make reasonable analysis and judgment in case of variation.
3. Diffuse lesions should not be biopsied in the middle lobe of the right lung and the lingual lobe of the left lung.
4. Lung biopsy is usually performed in one lobe, avoiding simultaneous biopsy of both lungs.
5. Bactrim 1U can be dropped into the bronchus of the lobe segment before biopsy, which can reduce bleeding to some extent.
6. If the patient has significant chest pain when the biopsy forceps are clamped, the biopsy forceps should be released immediately and withdrawn, and the depth should be adjusted or the site should be changed before biopsy.
7. According to the patient’s condition, the diagnostic positivity rate can be improved by combining brush examination, lavage, TBNA and other examinations when necessary.
8. Postoperative sputum examination can increase the positive rate for tumor and tuberculosis.
9. Intraoperative bronchial mucosa biopsy can increase the positive rate of nodular disease.
Prevention and management of complications.
1. Bleeding: the incidence is about 9%.
Treatment: Ice saline local instillation is sufficient for a small amount of bleeding. If the bleeding is observed to be large, intravenous access should be established, and haemostatic drugs and posterior pituitary hormone should be administered immediately, such as tracheal intubation, if it is still difficult to stop bleeding. (The management of hemorrhage associated with tracheoscopic operations is probably one of the most worrisome complications for tracheoscopists. The “Respiratory Endoscopy” WeChat public platform has recently been compiling information on the prevention and treatment of hemorrhage, welcome your attention!)
2. Pneumothorax: the incidence is about 5%.
Treatment: Generally, it can mostly be absorbed by itself. When the patient has obvious respiratory distress and pneumothorax > 30%, perform chest puncture or closed chest drainage. (Note: Doctors should raise patients’ awareness of pneumothorax, such as asking patients to pay attention to the observation of any chest tightness and breathlessness in recent days after TBLB examination.)