Fundamentals of Flexible Bronchoscopy Transbronchial lung biopsy: Fluoroscopy and wedge techniques www.Bronchoscopy.org.

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Presentation transcript:

Fundamentals of Flexible Bronchoscopy Transbronchial lung biopsy: Fluoroscopy and wedge techniques www.Bronchoscopy.org

Manipulating the bronchoscope during TBLB Video of TBLB www.bronchoscopy.org

Techniques of TBLB without Fluoroscopy www.bronchoscopy.org

Advance the forceps until gentle resistance is met. Then pull back Advance the forceps until gentle resistance is met. Then pull back. Patient may have pain if forceps is out to far www.bronchoscopy.org

Advance the open forceps again until gentle resistance is met Advance the open forceps again until gentle resistance is met. After closing the forceps, pull back immediately without entering the bronchoscope. Keep the scope wedged. Exhalation www.bronchoscopy.org

Anchor Forceps at Bifurcation of Respiratory Bronchioles www.bronchoscopy.org

Similar technique is used under fluoroscopic guidance Usually 4-5 specimens are obtained Lung parenchyma is obtained by tearing the respiratory bronchioles Forceps to distal may cause pneumothorax Forceps too proximal may cause bleeding www.bronchoscopy.org

Left lower lobe fluoroscopic guidance Anterobasal LB 8 Lateral basal LB 9 Posterior basal LB 10 Superior segment LB 6 www.bronchoscopy.org

Left upper lobe fluoroscopic guidance Apical posterior LB 1+2 Anterior segment LB 3 Lingula LB 4+5 www.bronchoscopy.org

Right lower lobe fluoroscopic guidance Anterior basal RB 8 Lateral basal RB 9 www.bronchoscopy.org

Fluoroscopy is especially useful in case of focal disease www.bronchoscopy.org

Fluoroscopy can be performed using C-arm with patient supine or sitting www.bronchoscopy.org

Indications for fluoroscopy To localize abnormalities TO help prevent pneumothorax TO extract foreign bodies TO perform biopsy or brushing of solitary pulmonary nodules To improve diagnostic yield To detect pneumothorax www.bronchoscopy.org

Video of forceps probing basal segments If necessary, forceps can be advanced into various segments. Position is verified using fluoroscopy before biopsies are obtained Video of forceps probing basal segments www.bronchoscopy.org

However, TBLB is “safe” without fluoroscopy Andres G et al, Chest 1988;94:557 TBLB: 122 with & 135 without Fluoroscopy Diagnostic yield higher for focal diseases with Fluoro (pre-CT era), complication rate same Mulligan S et al, ARRD 1988; 137:486 N=168, Retrospective, AIDS & PCP, yield and complications same Puar HS, Chest 1985: 87:303 N=68, Sarcoidosis, Yield 76%, 1 Pneumo Computed tomography scans can help avoids need for double image fluoroscopy www.bronchoscopy.org

Complications after TBLB Review of 22 prospective studies of BLB (1974-1991)* Fluoroscopy employed in 19 studies BLB PTX Bleed Death Total (n) 4,252 167 89 5 Percent 4.0 2.1 0.1 * Courtesy: Villeneuve and Kvale in: Textbook of Bronchoscopy Editors: Feinsilver and Fein, Williams & Wilkins, 1995, page 64 www.bronchoscopy.org

True or False: A chest radiograph should always be performed after TBLB www.bronchoscopy.org

False. Chest radiographs are not always necessary after TBLB Fluoroscopy can reveal lung collapse Pneumothorax occurs in < 3 % of patients. Chest 2006;129:1561-1564 Among 350 consecutive biopsies, chest radiograph within 2 hours after procedure revealed pneumothorax in 10 patients, 7 of whom were symptomatic Chest radiographs are probably indicated only in symptomatic patients. www.bronchoscopy.org

Fundamentals of Bronchoscopy Multidimensional Curriculum Step by Step© Fundamentals of Bronchoscopy Multidimensional Curriculum BRONCHATLAS© www.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