1. Fundamentals of Flexible Bronchoscopy Conventional Transbronchial Needle Aspiration RESULTS AND COMPLICATIONS

2. Results and complications
bronchoscopy.org

3. Indications for cTBNA: When to perform TBNA
Mediastinal staging for suspected carcinoma (espeically level 7 and 4R)
Mediastinal tumors of unclear origin
Submucosal needles for diagnosis of endobronchial disease
Endobronchial needle aspiration of airway lesions.
TBNA of Subcarinal mass

4. Indications for TBNA
Focal or diffuse endobronchial mucosal or submucosal infiltration suggestive of
Infection
Carcinoma or lymphoma
Pulmonary nodules and masses
Mediastinal adenopathy or masses
Endobronchial lesions, especially in cases of substantial neovascularization where biopsy may cause bleeding, or necrotic lesions where a core, rather than surface biopsy is warranted.

5. TBNA can also be used to sample peripheral lung nodules
Courtesy P. Lee, Singapore

6. Contraindications to TBNA
Patients unable to tolerate bronchoscopy
Careful consideration should be given to patients with bleeding disorders.

7. Complications of cTBNA
Perforation of great vessels
Pneumomediastinum
Air embolus
Airway bleeding
Pneumothorax

8. Patient-related complications
Fever
Transient bacteremia
Pneumomediastinum
Pneumothorax
Bleeding
Inadvertent puncture of mediastinal structures
Aortic arch
Left Pulmonary artery

9. Equipment-related complications
Puncture of bronchoscope
Tear of working channel of bronchoscope
Broken needles
Do not retract or advance
Be sure the needle is fully inside the sheath
Staff-related
Needle stick injury

10. Preventing needle-related complications
Control flexion-extension.
Avoid advancing needle through fully flexed scope.
Caution if resistance is felt while advancing needle-catheter through working channel.
Never withdraw needle catheter without first assuring that needle is retracted into the catheter.
Straighten scope during needle withdrawal BI

11. Results: Yield of TBNA
Sensitivity generally reported to be >70 % for malignancy
Specificity generally reported to be > 90% for malignancy
Positive predictive value 100%,and negative predictive value 70% for malignancy.
Negative TBNA warrants confirmation by mediastinal exploration results.

12. Diagnostic yield depends on
Bronchoscopist’s experience
Cytopathologist's experience
Use of Rapid On-site examination
Location of abnormality being sampled (yield is highest for subcarina and right paratracheal nodes)
Needles used (cytology and histology)
Nodule size
Lymph node size
Cell type (usually higher for small cell carcinoma than for nonsmall cell carcinoma)

13. Rapid on-site examination
Rapid On-Site Examination (ROSE) by cyto-pathologist improves diagnostic yield.
Identifies “representative” material.
Helps assure sufficient material is obtained for diagnosis and molecular studies.

14. Number of specimens needed
Even one pass may be enough
If on site examination provides diagnosis
Best to obtain several specimens
Process specimens according to protocol developed in partnership with cytopathology department.
Obtain sample for cell block
Obtain sufficient material for molecular studies
ROSE shortens duration of procedure, increases diagnostic yield, accelerates patient management decisions, and enhances chances for rapid treatment

15. 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), Stefano Gasparini, and Wes Shepherd M.D. (USA)