Lung biopsy (mucosal/transbronchial/open lung) Ernst Eber, MD

1. Lung biopsy (mucosal/transbronchial/open lung)Ernst Eber, MD Respiratory and Allergic Disease Division, Paediatric Department, Medical University of Graz, Austria

2. ERS Task Force. Eur Respir J 2003;22:698-708.

3. Sampling of cellular material Sampling of bronchial tissue Sampling of lung parenchyma Biopsy

4. Brush biopsy Mucosal (endobronchial) biopsy Transbronchial lung biopsy Biopsy techniques

5. Brush biopsy • Sampling of superficial cells - unsheathed brush - protected brush  1.2 mm  2.0 mm

6. Brush biopsy Unsheathed brushes Brush left protruding from the bronchoscope or hidden in the tip of the scope while the instrument is withdrawn

7. Brush biopsy Assessment of • inflammation • infection (e.g. tuberculosis) • malignancy • ciliary motility / ultrastructure

8. Cup Fenestrated cup Alligator jaw Endobronchial biopsy Forceps

9. Coagulation screen Sampling under visual control Monitoring Routine chest x-ray not necessary Endobronchial biopsy Safety precautions

10. De Blic J et al. Eur Respir J 2002

11. Haemorrhagic conditions Severe respiratory failure Endobronchial biopsy Contraindications

12. Endobronchial biopsy Technique • Sampling from pathological lesion • Sampling from (sub)segmental subcarinae • Repeated samples

13. Endobronchial biopsy • Diagnosis of tuberculosis and other infectious or granulomatous disorders • Diagnosis of PCD • Research: Bronchial inflammation in asthma and CF patients

14. Endobronchial biopsy Safe and useful procedure in children with respiratory disease, even in infants Payne et al. Arch Dis Child 2001, de Blic et al. Eur Respir J 2002, Saglani et al. Thorax 2003, Salva et al. Thorax 2003, Saglani et al. Am J Respir Crit Care Med 2005, Molina-Teran et al. Pediatr Pulmonol 2006

15. Cup Fenestrated cup Alligator jaw Transbronchial biopsy Forceps

16. 2 mm channel: ~ 2.0 μl 1.2 mm channel: ~ 0.5 μl Adequate tissue samples: 97% vs. 85%Visner Chest 2004 Transbronchial biopsy Forceps – cup volume

17. Chest radiograph Full blood count incl. platelet count Coagulation screen Transbronchial biopsy Investigations prior to TBB

18. Flexible bronchoscope 2 mm (1.2 mm) working channel Rigid bronchoscope “Indirect” technique with plastic catheter Mullins Pediatr Pulmonol 1995 Transbronchial biopsy Technique

19. Sedation / GA Fluoroscopy (mandatory!) Transbronchial biopsy Technique

20. Transbronchial biopsy Technique

21. Only one lung on same occasion Middle lobe & lingula avoided if possible At least three biopsies (microbiological and histological studies) Transbronchial biopsy Technique

22. Small saline lavage Visualisation of the bronchial tree Chest radiograph (after 2-4 h) Transbronchial biopsy Post TBB

23. Pneumothorax (~3%) Haemorrhage (resolves spontaneously / lavage with saline / instillation of adrenaline solution) Septicemia, transient pyrexia Transbronchial biopsy Complications

24. Lung transplant recipients High sensitivity and specificity Gold standard for diagnosing acute rejection and delineating opportunistic infection Of less use in diagnosing chronic rejection (BO) Scott Pediatrics 1990, Whitehead Pediatr Pulmonol 1992, Visner Chest 2004 Transbronchial biopsy Indications - established

25. Transbronchial biopsy n = 92 (86 in HLT group) % Whitehead B et al. Pediatr Pulmonol 1992

26. 429 TBB procedures in 46 patients (2 months – 21 years) post HLTx or LTx and in 38 non-LTx patients (2 weeks – 18 years) Paediatric bronchoscope in 86 procedures Non-LTx patients: Biopsy findings considered to be diagnostic in 58%, contributory in 21% Complications: 5x pneumothorax, 5x excessive bleeding Visner et al. Chest 2004 Transbronchial biopsy

27. HIV infection (noninfective pulmonary pathology) Bone marrow transplantation (BO) Interstitial lung disease Whitehead Pediatr Pulmonol 1992, Fan J Pediatr 1997, Visner Chest 2004 Transbronchial biopsy Indications - controversial

28. Chronic interstitial lung disease Lung biopsy • Percutaneous needle lung biopsy (PNLB) • Transbronchial lung biopsy (TBLB) • Open lung biopsy (OLB) • Video-assisted thoracoscopic biopsy (VATB)

29. Chronic interstitial lung disease Lung biopsy Recommendations: • Target clearly affected lung areas (HRCT)! • Obtain sufficiently dimensioned tissue sample!

30. Chronic interstitial lung disease Lung biopsy • Many children with ILD require a biopsy for diagnosis. • For most paediatric ILD, transbronchial or percutaneous lung biopsy gives insufficient tissue for diagnosis and carries increased risk (bleeding, pneumothorax). • Smyth et al. Arch Dis Child 1994, Spencer et al. Pediatr Pulmonol 1996, Fan et al. J Pediatr 1997, Kramer et al. Ann Thorac Surg 1998, Coren et al. Eur Respir J 1999

31. Chronic interstitial lung disease Lung biopsy • Lung biopsy under direct vision is safe, well tolerated and should be regarded as the gold standard. • Open lung biopsy through a mini-thoracotomy incision vs. video-assisted thoracoscopic biopsy: depending on size of the child and experience of the surgeon • Fan et al. J Pediatr 1997, Kramer et al. Ann Thorac Surg 1998, Coren et al. Eur Respir J 1999

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