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

2. 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.
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3. Strategy and planning Techniques and results Response to complications
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4. 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
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5. 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:
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6. 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”
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7. Bronchial Brushing
Brushing samples a large area of mucosal abnormality
May be done under direct visualization, or with fluoroscopic guidance
Brush Video
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8. Complications Complications: Bleeding Pneumothorax
Rupture of peripheral lung access
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9. 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
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10. TRUE OR FALSE: Bronchial brushing samples require correct processing
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11. 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.
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12. 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:
1Am Rev Respir Dis 1974;109:63-66
2CHEST 1974;65:
3CHEST 1976;69:
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13. Comparative results with biopsy, wash, and TBNA
J Bronchol 2004;11:
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14. 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:
bronchoscopy.org

15. 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*
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16. 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
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17. 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)