Comprehensive Guide to Flexible Bronchoscopy and Transbronchial Needle Aspiration: Results and Complications

1. Fundamentals of Flexible BronchoscopyConventional Transbronchial Needle AspirationRESULTS AND COMPLICATIONS www.Bronchoscopy.org

2. Results and complications bronchoscopy.org

3. 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. Indications for cTBNA: When to perform TBNA TBNA of Subcarinal mass www.bronchoscopy.org

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. www.bronchoscopy.org

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

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

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

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

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

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. www.bronchoscopy.org

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) www.bronchoscopy.org

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. www.bronchoscopy.org

14. 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 Number of specimens needed ROSE shortens duration of procedure, increases diagnostic yield, accelerates patient management decisions, and enhances chances for rapid treatment www.bronchoscopy.org

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