Elizabeth H. Moore, Philip A. Templeton,
MD MD
Positional Aspiration
#{149} Jo-Anne #{149} John
Precautions Lung Biopsy’
The authors performed 308 needle aspiration biopsies of parenchymal lung masses. The patients were then placed with the puncture site down for a period of at least 1 hour or until air leakage stopped. Coughing, talking, and activity were restricted. Complications included pneumothorax, at a rate of 25.0%, and chest tube placement, at a rate of 1.6%. In a subgroup of 262 patients who required only one pleural puncture at biopsy, a pneumothorax rate of 17.9% and a chest tube placement rate of 0.4% were encountered. When compared with a similar series of 143 control patients, signif icant reductions in both pneumothorax rate (P = .0004) and chest tube placement rate (P .0001) were demonstrated.
Index
terms:
Biopsies,
#{149} Lung,
66.732 mothorax,
From
the
Department
Received
quested
#{149} Pneu-
of Radiology,
24, 1990;
5, 1989;
revision
2; accepted February requests to E.H.M.
c RSNA,
1990
Massa-
Hospital, 55 Fruit St, Boston, the 1989 RSNA annual meet-
December
January
February print
60.458,
66.732
1990; 175:733-735
chusetts Ceneral MA 02114. From ing.
complications, 60.458,
66.732
Radiology
I
biopsy,
0. Shepard, MD P. Kosiuk, MD
revision
re-
received
15. Address
re-
T
RANSTHORACIC
#{149} Theresa
C. McLoud,
MD
in Needle
needle
PATIENTS
aspiration
lung biopsy is a widely practiced technique used to determine the cause of lung masses; in some cases it eliminates the need for surgery. It is routinely performed in the outpatient setting, but complications of the procedure may necessitate hospital admission, resulting in a substantial increase in cost. Numerous methods have been proposed to diminish the likelihood and severity of biopsy-induced pneumothorax. These include measures to prevent excessive pleural damage (by limiting the number of pleural on fissumal punctures or by ceasing respiration during pleural puncture) and measures to control air leakage from the puncture site (by employing 100% oxygen during and after the procedure, by using an autologous “blood patch”, fragments of Gelfoam [Upjohn, Kalamazoo, Mich], or tissue adhesives injected through the needle track, by placing the patient in a lateral decubitus position with the affected lung dependent aften the biopsy, and by placing the patient in a recumbent position after the biopsy) (1-6). In a 1982 study, Zidulka and coworkers compared the rates of air leakage after lateral pleural punctures in dogs positioned with the puncture site up versus with the puncture site down (7). Dependent positioning of the puncture site diminished the leakage rate in all dogs and was associated with sealing of the leak in 52% of cases compared with no sealing when the puncture site was up. In chests of human crosssectional shape, this technique corresponds to prone on supine patient positioning after an anterior or postenior needle approach, respectively. We wished to determine if employing such relatively innocuous maneuvers would influence the rate of complications in our large needle-biopsy population.
AND
METHODS
Information for all patients undergoing needle aspiration lung biopsy in our hospital is entered into an information database that includes age, sex, reason for biopsy, size and location of lesion, number of pleural punctures required, type(s) of needle used, use of single-needle or coaxial
technique,
and
approach
used
as docu-
mented on spot films of needle placement. The timing of the occurrence of complications, including pneumothorax, progression of pneumothorax, chest tube placement, and hemoptysis, are recorded. Prior to instituting the following protocol, no particular postprocedural instructions regarding body position or restrictions
of activity
were
given
to the
pa-
tients. Between July 1986 and March 1989, all C-arm fluoroscopically-guided needle aspiration biopsies of parenchymal lung masses performed by four participating radiologists (E.H.M., J.O.S., P.A.T., J.P.K.) or by residents under their supervision were included in the study group. Biopsy technique (coaxial versus non-coaxial) and needle choice were left to the discretion of the radiologist but were recorded. In most cases, a chest computed tomographic (CT) scan was available for biopsy planning. Immediate on-site evaluation of aspirated specimens was performed by pathologists experienced in lung cytology. Patients remained in the biopsy position (ie, puncture site up) until cytologic evaluation was complete, a procedure lasting from 10 to 20 minutes. When a coaxial technique was used, the outer needie remained in place in the lung during this period. In each case, after completion of the biopsy,
“positional
precautions”
were
insti-
tuted as follows: The patient was rolled off the procedure table onto a stretcher with the puncture site dependent (ie, with the patient prone, supine, or, in some cases, in an oblique lateral decubitus
or slight
Trendelenberg
position,
de-
pending on puncture location). Coughing, talking, and all forms of activity were restricted;
the
patients
were
specifically
told that these behaviors could induce complications. A postenoanterior upright chest radio-
733
graph was obtained within 5-10 minutes after the procedure (the slight delay was necessitated by transportation to another floor of the department) and at 1 and 2 hours after the procedure unless an increasing pneumothonax made more frequent examinations necessary. In compiicated cases, additional radiognaphs were obtained at later times and, in some cases, the following day. After the initial radiograph was obtained, the patient was quickly returned to a puncture-site-down position
for
a minimum
of
1 hour
Table 1 Summary
Study Current
on until
for
at least
1 additional
hour
and a radiograph was obtained. If no leakage had occurred, the patient was dischanged from the department. If air leakage occurred with the patient in the seated position, the patient was returned to the biopsy-site-dependent position for at least 1 hour, and this sequence was repeated until leakage stopped on placement of a chest tube was required. Patients with pneumothoraces greater than a few millimeters were given oxygen by means of nasal cannulae at 2-5 L/min. Indications for chest tube placement included dyspnea, a pneumothorax that showed progressive increase over time on several follow-up nadiognaphs, or a pneumothorax that had reached an estimated volume of 35%. Percutaneously placed 9-F Teflon catheters (Cook, Bloomington, Ind) were used for initial evacuation of pneumothonaces
and
were
replaced
with
surgically placed chest tubes in cases with prolonged air leak on other catheter failures. All patients requiring intervention were admitted to the hospital for observation. Needle aspiration of pneumothonaces was not performed. The frequencies of pneumothonax and pneumothonax requiring drainage were examined with reference to standards in the literature. In addition, to eliminate the important variable of total number of pleural punctures, biopsies requiring only one pleural puncture were examined as a separate
compared
subgroup.
with
These
a consecutive
single-puncture
lung
cases
were
series
of
biopsies
performed
in our institution between July 1983 and October 1984 as part of a randomized study on the efficacy of the blood-patch technique (8). No positional precautions on activity
cases. Three nated from development the procedure this
group
restrictions
were
used
in
those
patients who had been elimithe prior study because of the of pneumothonax during were replaced as pant of of historical
controls.
RESULTS During the study period, 310 consecutive biopsies were performed or supervised by four participating radiologists; two cases were excluded because in each instance, biopsy of two nodules in the same lung had been performed at one sitting. Patients ranged in age 734
#{149} Radiology
Complication
Rates of
Occurrence Pneumothorax (%)
Group
study
Occurrence
of
Chest Tube Placement (%)
No. of Biopsies
25
1.6
Jereb(9)(l980)
19
5
Westcott(l0)(1980) Jacksonetal(ll)(1980)
27 44
10 12
30.1
14.3
229 146
41
10
348
Gibneyetal(12)(l98l)
Stevens
andJackman
Khouni
et al (14)(1985)
Perlmutt
any pneumothorax that was present was stable for at least 1 hour. The patient was then placed in a sitting position without restrictions
of Reported
(13)(1984)
et al (15)(1986)
Stanleyetal(l6)(1987)
Table
308
117 432
19.8
5
650
23.8
11.5
673
29
10
458
2
Complications
in Single
Pleural
Punctures Positional
Precautions (n
(%) 262)
No Restrictions (n
143)
(%) P
Pneumothorax
Immediate Delayed Total Pneumothorax
requiring
chest
from 21 to 91 years (mean, 64 years); a large majority were outpatients. Approximately one-third of the procedunes were performed by supervised but inexperienced residents. Although for some biopsies different needles and techniques were used at the same sitting, approximately 55% were performed by means of a coaxial technique with use of a 19-gauge Greene outer needle (Cook) and a 22-gauge Greene or 21-gauge E-Z-Em cut biopsy inner needle (E-Z-Em, Westbury, NY). In these patients, a blood patch was placed on withdrawal of the outer needle. The remaining 45% of biopsies were performed with a non-coaxial technique, approximately 40% with a 22-gauge Greene needle and approximately 5% with a 21-gauge E-Z-Em cut biopsy needle. In the absence of diagnostic material on initial cytologic smears, further specimens (additional aspirates, core specimens, or culture material) were obtained. Of 308 cases, 262 biopsies (85%) required only a single pleural or fissural puncture, and 46 biopsies (15%) required multiple (up to five) punctures.
Complications Among 308 biopsies, 77 pneumothoraces occurred (25.0%). These ranged in size from a 1-mm apical pneumothorax to a large tension pneumothorax. Five patients required placement of chest tubes (1.6%). These included three patients (1.0%) in whom large pneumoafter
occurred
the
procedure
during
that
or
24.5 9.1
.0385 .0008
17.9
33.6
.0004
0.4
9.8
.0001
tube
placement
thoraces
16.0 1.9
immediately
required
emer-
gent chest tube placement before positional precautions could be instituted. Two patients (0.6%) required chest tube placement after positional precautions had been instituted. Among patients requiring chest tube placement, chest tubes remained in place for 4-13 days because of persistent air leak (mean, 7 days). The largest pneumothorax for which a chest tube was not placed was estimated at 20%. No patient required hospital admission for biopsy-related complications occurring after discharge from the outpatient department. The complications encountered are compared with those reported in several large studies published within the past 10 years in Table 1 (9-16). Table 1 shows that although the pneumothorax rate did not differ from the expected rate, the chest tube placement rate was far lower than that previously encountered without the use of positional precautions as a part of care after biopsy. Biopsies requiring only one pleural puncture were reexamined as a separate subgroup to eliminate the crucial variable of number of pleural punctunes in the assessment of the complication rate. Among 262 cases requiring a single pleural puncture, 47 pneumothoraces occurred (17.9%). One patient (0.4%) required chest tube placement. These data show a statistically significant decrease in both the pneumothomax rate (P = .0004) and chest tube placement rate (P .0001) when cornpared with results obtained in a prior consecutive study of 143 single-punctune biopsies performed at this institution without positional precautions or
June
1990
activity restriction. In this prior study 33.6% of patients developed pneumothorax and 9.8% required chest tube placement (8). Within the subgroup of patients who underwent
the
single-puncture
timing
thorax
whom used, mothorax
biopsies,
of development
of pneumowas examined. In the patients in positional precautions were 16.0% were found to have a pneuon
radiographs
obtained
im-
mediately after biopsy, and 1.9% developed a delayed pneumothorax. In the group given no position or activity mestrictions, 24.5% showed an immediate pneumothorax, and 9.1% developed a delayed pneumothorax. The rates for both immediate pneumothorax (P = .0385) and delayed pneumothorax (P .0008) were significantly improved with use of positional precautions. Complications encountered in these studies and their statistical significance are summarized in Table 2.
DISCUSSION Needle aspiration lung biopsy provides for nonsurgical diagnosis of benign, malignant, and metastatic lung nodules and may alter the surgical approach to a lesion even when a specific diagnosis cannot be made. Although pneumothorax is an expected complication of pleural puncture, a pneumothorax that requires chest tube placement and hospital admission is a painful and distressing
experience
usually
judged
by the
patient and referring clinician as an unsatisfactory outcome. It is also expensive; in our hospital, an uncomplicated outpatient lung biopsy costs $802, while a biopsy complicated by pneumothonax requiring chest tube placement and a 3-day hospital admission costs a minimum of $3,279. Most attempts to limit complications of lung biopsy have concentrated on the procedure itself. Less attention has been paid to damage-control efforts aften the biopsy. Many large series contam no information on postbiopsy care, and an informal survey of chest radiologists has produced a wide variety of policies, the majority of which are relatively nonrestrictive. In the original article by Zidulka et al describing a dependent-puncture-site technique in dogs, various theories were proposed to explain its efficacy (7). These included the smaller alveolar size in dependent portions of the lung and a reduction of the alveolar-to-pleural pressure gradient achieved at the puncture
site
by
means
of
dependent
positioning. We suspect that diminution of air delivery to the site of pleural puncture (dependent atelectasis) is a factor. In addition, after the development of a pneumothorax, the lung falls to the dependent portion of the pleural
Volume
175
Number
#{149}
3
space, and the close contact between the visceral and parietal surfaces provides a physical barrier to further air leakage until the puncture is sealed by means of fibrin deposition or other mechanisms. Because of the substantially lower frequency of pneumothorax requiring chest tube drainage in our series as compared with previous reports in the literature, we suggest that while pneumothoraces are apt to occur in a substantial number of patients undergoing lung biopsy, postbiopsy care is critical in
their
some small have by
management.
In
our
study,
patients with initial air leaks of and moderate degrees appear to been spared chest tube placement
means
of
the
institution
of a pro-
gram including positional precautions. Certainly, large pleural tears remain a relatively unretnievable situation, meflected by the lengthy air leaks averaging 7 days in our patients requiring chest tubes, which far exceeds the mean of 2.2 days noted by Perlmutt et al (17). It is possible that our pneumothonax rate could be further improved by means of immediate dependent positioning of the biopsy site while awaiting cytologic evaluation in those patients who underwent a biopsy with a non-coaxial technique. Similarly, elimination of the immediate upright postbiopsy radiograph may further diminish the pneumothorax rate, as suggested in a recent communication of Cassel and Birnberg (18). For the present, however, we continue to obtain a madiograph immediately after the procedune for the early identification of potentially symptomatic pneumothoraces to initiate such measures as nasal oxygen delivery and charting of vital signs, to increase the frequency of follow-up radiographs, and to postpone the following biopsy case if intervention seems imminent. We are uncertain, however, of what portion of the improvement in complication rates is due to dependent positioning of the biopsy site and what portion is due to restrictions of coughing, talking, and activity. Examination of this problem in a prospective, randomized fashion is currently being undertaken by one of our radiologists by comparing
a group
in
which
the
can be diminished by using the program of postbiopsy precautions outlined in this article. It is not, however, a substitute for impeccable biopsy technique. Essential factors in diminishing the risk at lung biopsy include careful planning to avoid fissures and bullae, rigorous patient coaching on breathing, painstaking navigation of the chest wall to optimize position prior to pleuma! puncture, accurate and delicate performance of needle manipulations, and the use of a single pleural puncture with the coaxial technique when the size on the nature of a lesion suggests that multiple specimens may be needed. U
References 1.
St. Louis E, Hyland R, Gray RR, Hutcheon Jones D, Grosman H. Percutaneous needle biopsy of lung lesions (letter). Chest 1984; 86:940-941.
2.
Greene biopsy. Greene
3.
RE. Transthoracic needle aspiration In: Athanasoulis CA, Pfister RC, RE, Roberson GH, eds. Interventional
radiology. Philadelphia: Saunders, 1982; 587634. Cormier Y, Laviolette M, Tardif A. Prevention of pneumothorax in needle lung biopsy by breathing 100% oxygen. Thorax 1980; 35:37-41.
4.
McCartney technique
5.
Skupin A, Comez F, Husain M, Skupin C, Bigman 0. Complications of transthoracic fleedie biopsy decreased with isobutyl 2-cyanoa-
R, Tait D, Stilson for the prevention
rax in pulmonary 1974;
crulate:
aspiration
M, Seidel CF. of pneumotho-
biopsy.
AJR
a pilot
study.
Ann
Thorac
Surg
1987;
43:406-408.
Suprenant tion biopsy: technique
7.
Zidulka
8.
9.
10.
11.
12.
13.
EL. Transthoracic needle aspiraevaluation of the blood patch (letter). Radiology 1988; 168:285.
A, Braidy
TF, Rizzi
MC, Shiner
RJ.
Position may stop pneumothorax progression in dogs. Am Rev Respir Dis 1982; 126:51-53. Bourgouin PM, Shepard JO, McLoud TC, Spizarny DL, Dedrick CC. Transthoracic needle aspiration biopsy: evaluation of the blood patch technique. Radiology 1988; 166:93-95. Jereb M. The usefulness of needle biopsy in chest lesions of different sizes and locations. Radiology 1980; 134:13-15. Westcott JL. Direct percutaneous needle aspiration of localized pulmonary lesions: resuits in 422 patients. Radiology 1980; 137:3135. Jackson R, Coffin LH, DeMeules JE, Miller DB, Dietrich P. Fairbank J. Percutaneous needle biopsy of pulmonary lesions. Am Surg 1980; 139:586-589. Cibney RTN, Man CCW, King EC, leRiche J. Aspiration biopsy in the diagnosis of pulmonary disease. Chest 1981; 80:300-303. Stevens CM, Jackman J. Outpatient needle biopsy of the lung: its safety and utility. Radi-
ology 1984; 151:301-304. 14.
15.
16.
Khouri NF, Stitik FP, Erozan YS, et al. Transthoracic needle aspiration biopsy of benign and malignant lung lesions. AJR 1985; 144:281-288. Perlmutt LM, Braun SD, Newman CE, et al. Timing of chest film follow-up after transthoracic needle aspiration biopsy. AJR 1986; 146:1049-1050. Stanley JH, Fish CD, Andriole JC, et al. Lung lesions: cytologic diagnosis by fine nee-
dle biopsy. 17.
18.
A
120:872-875.
6.
punc-
tune site is placed in a dependent position with a group in which the punctune site is placed upward but patient activity is restricted as described above. Such a study is necessary to establish with statistical significance any improvement in complication rates directly attributable to this maneuver. However, prior to completion of such a study, we believe that the percentage of patients requiring chest tube drainage of pneumothorax after lung biopsy
M,
Radiology
1987;
162:389-391.
Perlmutt LM, Braun SD, Newman CE, et al. Transthoracic needle aspiration: use of a small chest tube to treat pneumothorax. AJR 1987; 148:849-851. Cassel DM, Birnberg FA. Preventing pneumothorax after lung biopsy: the roll-over technique (letter). Radiology 1990; 174:282.
Radiology
#{149} 735
MD MD
Positional Aspiration
#{149} Jo-Anne #{149} John
Precautions Lung Biopsy’
The authors performed 308 needle aspiration biopsies of parenchymal lung masses. The patients were then placed with the puncture site down for a period of at least 1 hour or until air leakage stopped. Coughing, talking, and activity were restricted. Complications included pneumothorax, at a rate of 25.0%, and chest tube placement, at a rate of 1.6%. In a subgroup of 262 patients who required only one pleural puncture at biopsy, a pneumothorax rate of 17.9% and a chest tube placement rate of 0.4% were encountered. When compared with a similar series of 143 control patients, signif icant reductions in both pneumothorax rate (P = .0004) and chest tube placement rate (P .0001) were demonstrated.
Index
terms:
Biopsies,
#{149} Lung,
66.732 mothorax,
From
the
Department
Received
quested
#{149} Pneu-
of Radiology,
24, 1990;
5, 1989;
revision
2; accepted February requests to E.H.M.
c RSNA,
1990
Massa-
Hospital, 55 Fruit St, Boston, the 1989 RSNA annual meet-
December
January
February print
60.458,
66.732
1990; 175:733-735
chusetts Ceneral MA 02114. From ing.
complications, 60.458,
66.732
Radiology
I
biopsy,
0. Shepard, MD P. Kosiuk, MD
revision
re-
received
15. Address
re-
T
RANSTHORACIC
#{149} Theresa
C. McLoud,
MD
in Needle
needle
PATIENTS
aspiration
lung biopsy is a widely practiced technique used to determine the cause of lung masses; in some cases it eliminates the need for surgery. It is routinely performed in the outpatient setting, but complications of the procedure may necessitate hospital admission, resulting in a substantial increase in cost. Numerous methods have been proposed to diminish the likelihood and severity of biopsy-induced pneumothorax. These include measures to prevent excessive pleural damage (by limiting the number of pleural on fissumal punctures or by ceasing respiration during pleural puncture) and measures to control air leakage from the puncture site (by employing 100% oxygen during and after the procedure, by using an autologous “blood patch”, fragments of Gelfoam [Upjohn, Kalamazoo, Mich], or tissue adhesives injected through the needle track, by placing the patient in a lateral decubitus position with the affected lung dependent aften the biopsy, and by placing the patient in a recumbent position after the biopsy) (1-6). In a 1982 study, Zidulka and coworkers compared the rates of air leakage after lateral pleural punctures in dogs positioned with the puncture site up versus with the puncture site down (7). Dependent positioning of the puncture site diminished the leakage rate in all dogs and was associated with sealing of the leak in 52% of cases compared with no sealing when the puncture site was up. In chests of human crosssectional shape, this technique corresponds to prone on supine patient positioning after an anterior or postenior needle approach, respectively. We wished to determine if employing such relatively innocuous maneuvers would influence the rate of complications in our large needle-biopsy population.
AND
METHODS
Information for all patients undergoing needle aspiration lung biopsy in our hospital is entered into an information database that includes age, sex, reason for biopsy, size and location of lesion, number of pleural punctures required, type(s) of needle used, use of single-needle or coaxial
technique,
and
approach
used
as docu-
mented on spot films of needle placement. The timing of the occurrence of complications, including pneumothorax, progression of pneumothorax, chest tube placement, and hemoptysis, are recorded. Prior to instituting the following protocol, no particular postprocedural instructions regarding body position or restrictions
of activity
were
given
to the
pa-
tients. Between July 1986 and March 1989, all C-arm fluoroscopically-guided needle aspiration biopsies of parenchymal lung masses performed by four participating radiologists (E.H.M., J.O.S., P.A.T., J.P.K.) or by residents under their supervision were included in the study group. Biopsy technique (coaxial versus non-coaxial) and needle choice were left to the discretion of the radiologist but were recorded. In most cases, a chest computed tomographic (CT) scan was available for biopsy planning. Immediate on-site evaluation of aspirated specimens was performed by pathologists experienced in lung cytology. Patients remained in the biopsy position (ie, puncture site up) until cytologic evaluation was complete, a procedure lasting from 10 to 20 minutes. When a coaxial technique was used, the outer needie remained in place in the lung during this period. In each case, after completion of the biopsy,
“positional
precautions”
were
insti-
tuted as follows: The patient was rolled off the procedure table onto a stretcher with the puncture site dependent (ie, with the patient prone, supine, or, in some cases, in an oblique lateral decubitus
or slight
Trendelenberg
position,
de-
pending on puncture location). Coughing, talking, and all forms of activity were restricted;
the
patients
were
specifically
told that these behaviors could induce complications. A postenoanterior upright chest radio-
733
graph was obtained within 5-10 minutes after the procedure (the slight delay was necessitated by transportation to another floor of the department) and at 1 and 2 hours after the procedure unless an increasing pneumothonax made more frequent examinations necessary. In compiicated cases, additional radiognaphs were obtained at later times and, in some cases, the following day. After the initial radiograph was obtained, the patient was quickly returned to a puncture-site-down position
for
a minimum
of
1 hour
Table 1 Summary
Study Current
on until
for
at least
1 additional
hour
and a radiograph was obtained. If no leakage had occurred, the patient was dischanged from the department. If air leakage occurred with the patient in the seated position, the patient was returned to the biopsy-site-dependent position for at least 1 hour, and this sequence was repeated until leakage stopped on placement of a chest tube was required. Patients with pneumothoraces greater than a few millimeters were given oxygen by means of nasal cannulae at 2-5 L/min. Indications for chest tube placement included dyspnea, a pneumothorax that showed progressive increase over time on several follow-up nadiognaphs, or a pneumothorax that had reached an estimated volume of 35%. Percutaneously placed 9-F Teflon catheters (Cook, Bloomington, Ind) were used for initial evacuation of pneumothonaces
and
were
replaced
with
surgically placed chest tubes in cases with prolonged air leak on other catheter failures. All patients requiring intervention were admitted to the hospital for observation. Needle aspiration of pneumothonaces was not performed. The frequencies of pneumothonax and pneumothonax requiring drainage were examined with reference to standards in the literature. In addition, to eliminate the important variable of total number of pleural punctures, biopsies requiring only one pleural puncture were examined as a separate
compared
subgroup.
with
These
a consecutive
single-puncture
lung
cases
were
series
of
biopsies
performed
in our institution between July 1983 and October 1984 as part of a randomized study on the efficacy of the blood-patch technique (8). No positional precautions on activity
cases. Three nated from development the procedure this
group
restrictions
were
used
in
those
patients who had been elimithe prior study because of the of pneumothonax during were replaced as pant of of historical
controls.
RESULTS During the study period, 310 consecutive biopsies were performed or supervised by four participating radiologists; two cases were excluded because in each instance, biopsy of two nodules in the same lung had been performed at one sitting. Patients ranged in age 734
#{149} Radiology
Complication
Rates of
Occurrence Pneumothorax (%)
Group
study
Occurrence
of
Chest Tube Placement (%)
No. of Biopsies
25
1.6
Jereb(9)(l980)
19
5
Westcott(l0)(1980) Jacksonetal(ll)(1980)
27 44
10 12
30.1
14.3
229 146
41
10
348
Gibneyetal(12)(l98l)
Stevens
andJackman
Khouni
et al (14)(1985)
Perlmutt
any pneumothorax that was present was stable for at least 1 hour. The patient was then placed in a sitting position without restrictions
of Reported
(13)(1984)
et al (15)(1986)
Stanleyetal(l6)(1987)
Table
308
117 432
19.8
5
650
23.8
11.5
673
29
10
458
2
Complications
in Single
Pleural
Punctures Positional
Precautions (n
(%) 262)
No Restrictions (n
143)
(%) P
Pneumothorax
Immediate Delayed Total Pneumothorax
requiring
chest
from 21 to 91 years (mean, 64 years); a large majority were outpatients. Approximately one-third of the procedunes were performed by supervised but inexperienced residents. Although for some biopsies different needles and techniques were used at the same sitting, approximately 55% were performed by means of a coaxial technique with use of a 19-gauge Greene outer needle (Cook) and a 22-gauge Greene or 21-gauge E-Z-Em cut biopsy inner needle (E-Z-Em, Westbury, NY). In these patients, a blood patch was placed on withdrawal of the outer needle. The remaining 45% of biopsies were performed with a non-coaxial technique, approximately 40% with a 22-gauge Greene needle and approximately 5% with a 21-gauge E-Z-Em cut biopsy needle. In the absence of diagnostic material on initial cytologic smears, further specimens (additional aspirates, core specimens, or culture material) were obtained. Of 308 cases, 262 biopsies (85%) required only a single pleural or fissural puncture, and 46 biopsies (15%) required multiple (up to five) punctures.
Complications Among 308 biopsies, 77 pneumothoraces occurred (25.0%). These ranged in size from a 1-mm apical pneumothorax to a large tension pneumothorax. Five patients required placement of chest tubes (1.6%). These included three patients (1.0%) in whom large pneumoafter
occurred
the
procedure
during
that
or
24.5 9.1
.0385 .0008
17.9
33.6
.0004
0.4
9.8
.0001
tube
placement
thoraces
16.0 1.9
immediately
required
emer-
gent chest tube placement before positional precautions could be instituted. Two patients (0.6%) required chest tube placement after positional precautions had been instituted. Among patients requiring chest tube placement, chest tubes remained in place for 4-13 days because of persistent air leak (mean, 7 days). The largest pneumothorax for which a chest tube was not placed was estimated at 20%. No patient required hospital admission for biopsy-related complications occurring after discharge from the outpatient department. The complications encountered are compared with those reported in several large studies published within the past 10 years in Table 1 (9-16). Table 1 shows that although the pneumothorax rate did not differ from the expected rate, the chest tube placement rate was far lower than that previously encountered without the use of positional precautions as a part of care after biopsy. Biopsies requiring only one pleural puncture were reexamined as a separate subgroup to eliminate the crucial variable of number of pleural punctunes in the assessment of the complication rate. Among 262 cases requiring a single pleural puncture, 47 pneumothoraces occurred (17.9%). One patient (0.4%) required chest tube placement. These data show a statistically significant decrease in both the pneumothomax rate (P = .0004) and chest tube placement rate (P .0001) when cornpared with results obtained in a prior consecutive study of 143 single-punctune biopsies performed at this institution without positional precautions or
June
1990
activity restriction. In this prior study 33.6% of patients developed pneumothorax and 9.8% required chest tube placement (8). Within the subgroup of patients who underwent
the
single-puncture
timing
thorax
whom used, mothorax
biopsies,
of development
of pneumowas examined. In the patients in positional precautions were 16.0% were found to have a pneuon
radiographs
obtained
im-
mediately after biopsy, and 1.9% developed a delayed pneumothorax. In the group given no position or activity mestrictions, 24.5% showed an immediate pneumothorax, and 9.1% developed a delayed pneumothorax. The rates for both immediate pneumothorax (P = .0385) and delayed pneumothorax (P .0008) were significantly improved with use of positional precautions. Complications encountered in these studies and their statistical significance are summarized in Table 2.
DISCUSSION Needle aspiration lung biopsy provides for nonsurgical diagnosis of benign, malignant, and metastatic lung nodules and may alter the surgical approach to a lesion even when a specific diagnosis cannot be made. Although pneumothorax is an expected complication of pleural puncture, a pneumothorax that requires chest tube placement and hospital admission is a painful and distressing
experience
usually
judged
by the
patient and referring clinician as an unsatisfactory outcome. It is also expensive; in our hospital, an uncomplicated outpatient lung biopsy costs $802, while a biopsy complicated by pneumothonax requiring chest tube placement and a 3-day hospital admission costs a minimum of $3,279. Most attempts to limit complications of lung biopsy have concentrated on the procedure itself. Less attention has been paid to damage-control efforts aften the biopsy. Many large series contam no information on postbiopsy care, and an informal survey of chest radiologists has produced a wide variety of policies, the majority of which are relatively nonrestrictive. In the original article by Zidulka et al describing a dependent-puncture-site technique in dogs, various theories were proposed to explain its efficacy (7). These included the smaller alveolar size in dependent portions of the lung and a reduction of the alveolar-to-pleural pressure gradient achieved at the puncture
site
by
means
of
dependent
positioning. We suspect that diminution of air delivery to the site of pleural puncture (dependent atelectasis) is a factor. In addition, after the development of a pneumothorax, the lung falls to the dependent portion of the pleural
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175
Number
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space, and the close contact between the visceral and parietal surfaces provides a physical barrier to further air leakage until the puncture is sealed by means of fibrin deposition or other mechanisms. Because of the substantially lower frequency of pneumothorax requiring chest tube drainage in our series as compared with previous reports in the literature, we suggest that while pneumothoraces are apt to occur in a substantial number of patients undergoing lung biopsy, postbiopsy care is critical in
their
some small have by
management.
In
our
study,
patients with initial air leaks of and moderate degrees appear to been spared chest tube placement
means
of
the
institution
of a pro-
gram including positional precautions. Certainly, large pleural tears remain a relatively unretnievable situation, meflected by the lengthy air leaks averaging 7 days in our patients requiring chest tubes, which far exceeds the mean of 2.2 days noted by Perlmutt et al (17). It is possible that our pneumothonax rate could be further improved by means of immediate dependent positioning of the biopsy site while awaiting cytologic evaluation in those patients who underwent a biopsy with a non-coaxial technique. Similarly, elimination of the immediate upright postbiopsy radiograph may further diminish the pneumothorax rate, as suggested in a recent communication of Cassel and Birnberg (18). For the present, however, we continue to obtain a madiograph immediately after the procedune for the early identification of potentially symptomatic pneumothoraces to initiate such measures as nasal oxygen delivery and charting of vital signs, to increase the frequency of follow-up radiographs, and to postpone the following biopsy case if intervention seems imminent. We are uncertain, however, of what portion of the improvement in complication rates is due to dependent positioning of the biopsy site and what portion is due to restrictions of coughing, talking, and activity. Examination of this problem in a prospective, randomized fashion is currently being undertaken by one of our radiologists by comparing
a group
in
which
the
can be diminished by using the program of postbiopsy precautions outlined in this article. It is not, however, a substitute for impeccable biopsy technique. Essential factors in diminishing the risk at lung biopsy include careful planning to avoid fissures and bullae, rigorous patient coaching on breathing, painstaking navigation of the chest wall to optimize position prior to pleuma! puncture, accurate and delicate performance of needle manipulations, and the use of a single pleural puncture with the coaxial technique when the size on the nature of a lesion suggests that multiple specimens may be needed. U
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McCartney technique
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