Fundamentals of Bronchoscopy: BRONCHIAL BRUSHING www.Bronchoscopy.org 5/10/17 BI, All Rights Reserved, 2017

Training is essential in order to learn Proper techniques and indications To obtain adequate tissue for diagnosis To avoid damaging the working channel To avoid excess patient discomfort (cough, anxiety, shortness of breath). To avoid bleeding, that might also prompt cough and patient agitation. How to protect equipment and patients How to avoid procedure-related complications. bronchoscopy.org

Strategy and planning Techniques and results Response to complications bronchoscopy.org

Indications for brushing Visible airway mucosal abnormalities Visible airway nodules or masses In case of suspected sarcoidosis (even if airway mucosa appears normal) In case of abnormal autofluorescence to diagnose intraepithelial lesions (dysplasia, metaplasia, carcinoma in-situ) To sample peripheral infiltrates To sample peripheral nodular abnormalities bronchoscopy.org

Equipment Different size brushes Protected specimen brush Standard 3 mm cytology 7 mm brush (rarely used) No sheath For visible lesions only Cannot be retracted into scope Collects more cells but yield and bleeding equivalent to 3 mm1 Protected specimen brush Avoid upper airway contamination For diagnosis of infection/ quantitative cultures From Flexible Bronchoscopy Wang and Mehta 1Cleve Clin J Med 1987;54:195-203 bronchoscopy.org

Brushing techniques Technique: Advance catheter into desired segment – then extend brush (up to 5 cm) “Brush out” Make sure brush extension doesn’t push back the scope or catheter Move back and forth over the visible lesion or blindly in distal airway (5-10 times). Consider rotating the brush to increase sampling. Cells are collected in brush bristles Retract the brush into the bronchoscope “Brush in” bronchoscopy.org

Bronchial Brushing Brushing samples a large area of mucosal abnormality May be done under direct visualization, or with fluoroscopic guidance Brush Video bronchoscopy.org

Complications Complications: Bleeding Pneumothorax Rupture of peripheral lung access bronchoscopy.org

Bleeding risk if Thrombocytopenia: <50,000 Risk of bleeding: 0-26% (TBBx, post transfusion) (1) Brushing with mean platelet count of 30,000: Bleed: 16% , Death: 4% (2) What to do? Transfuse 6 packs before & during bronchoscopy, no need to recheck platelets (3) Platelet half-life 6 hours! (1) Weiss S, Chest, 1993;104:1025 (2) Papin T, Chest, 1985; 88:54 (3) Wahidi M, Respiration 2005;72:285 bronchoscopy.org

TRUE OR FALSE: Bronchial brushing samples require correct processing bronchoscopy.org

Other ways to potentially increase diagnostic yield include TRUE. Brushing samples must be processed correctly and according to the needs and preferences of your institution’s cytology and microbiology laboratories. Other ways to potentially increase diagnostic yield include Using brushes with longer bristles Brushing vigorously and for a longer period of time. Making sure that all parts of the brush are in contact with the mucosal abnormality. Using the pirouette technique (rotation) in combination with long-axis motion. bronchoscopy.org

Bronchial brushing Results Yield: 94% endoscopically visible/peripheral 78%1 92% central and peripheral with fluoro2 77% endoscopically visible/20% peripheral with fluoroscopy3 1CHEST 1973;63:889-892 1Am Rev Respir Dis 1974;109:63-66 2CHEST 1974;65:616-619 3CHEST 1976;69:752-757 bronchoscopy.org

Comparative results with biopsy, wash, and TBNA J Bronchol 2004;11:154-159 bronchoscopy.org

Combined cytology and histology results 154 patients with malignant pulmonary lesions Each patient had (EBB or TBB) AND (TBNA or brushing) EBB/TBB sensitivity 62.8% TBNA/brush (cyto) sensitivity 69.2% Combined sensitivity 87.2% J Bronchol 2004;11:154-159 bronchoscopy.org

Brushing Yield * Greatest when cancer is present 94% in case of central lesion, 78% in case of peripheral lesions. But yields can also be as low as 20 % for peripheral lesions. * Chest 1973;63:889, Chest 1976;69:752, J Bronchol 2004;11:154* bronchoscopy.org

Combined procedures have greatest yield for malignancy Arch Bronchoneumol. 2006;42(6):278-82 75 patients underwent bronchial washing before (pre) and after (post) endobronchial biopsy and brushing bronchoscopy.org

Prepared with help from Udaya Prakash M. D. (USA), Atul Mehta M. D Prepared with help from Udaya Prakash M.D. (USA), Atul Mehta M.D. (USA), and Wes Shepherd M.D. (USA) www.Bronchoscopy.org