Fundamentals of Flexible Bronchoscopy Conventional Transbronchial Needle Aspiration

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

Results and complications bronchoscopy. org 2

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

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 4

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

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

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

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

Equipment-related complications ■ Equipment-related ■ ■ ■ 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 www. bronchoscopy. org 9

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

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 11

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 12

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 13

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 www. bronchoscopy. org 14

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