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Pleural Space Jam: Techniques for CT Guided Lung Biopsy
Taylor J. Robinson • Jan 27, 2022 • 89 hits
The pleural space can contain many life threatening cancer pathologies. It is essential to the timely diagnosis and treatment of said pathologies to obtain an accurate biopsy specimen. However, as the lung is a very dynamic organ, CT guided lung biopsies can be quite challenging. There is a risk of injuring the many pulmonary and intercostal vessels, the time consuming process of sticking the nodule, and determining what patients are viable candidates.
In this BackTable podcast, Dr. Fred Lee, an Abdominal Radiologist at the University of Wisconsin, discusses the techniques his practice has used to improve their lung biopsies. He and Dr. Beck discuss relevant techniques he has developed over time, his personal opinions on local anesthetics, and more on the BackTable Podcast.
The BackTable Brief
• Adding epinephrine and bicarbonate to your local anesthetic can decrease your chances of intercostal vessel damage.
• Performing lung biopsies at end expiration with a small breath hold can help stabilize the target nodule's location.
• If you’re working in a high-volume practice, having a dedicated CT Guided lung biopsy nurse can help streamline your service.
Image provided by Dr. Aaron Fritts.
Table of Contents
(1) Using Local Anesthesia in CT Guided Lung Biopsy
(2) CT Guided Lung Biopsy Under Moderate Sedation
(3) The Benefits of Dedicated Lung Biopsy Support Staff
Using Local Anesthesia in CT Guided Lung Biopsy
When performing a CT guided lung biopsy, Dr. Lee is able to leverage his local anesthesia to reduce the chances of complications. One method he prefers to employ is adding epinephrine to the lidocaine anesthetic to enhance its local effect duration. Another additional benefit of this is that it causes vasospasm of the intercostal vessels, which he believes reduces the chance of damaging them.
[Dr. Fred Lee]
The other thing that I think we don't think about enough sometimes as interventionalists is local anesthesia. And I spend a lot of time making sure that we have adequate and excellent local anesthesia. And how I particularly do it is I use lidocaine with epinephrine and we buffer it with a little bit of bicarb.
And the reason that I use lido with epi is multifold one is that, of course it lasts longer and so patients tend to have less pain in the recovery area and maybe are a little less distressed if they were going to have some pain. That's number one.
Number two is that lidocaine with epi is a vaso, it causes vasospasm. And especially when I'm going between ribs, I want to inject the lidocaine with epi ahead of myself and try to spasm the intercostal vessels down so I'm less likely to hit them. I don't have great data that this decreases the incidence of damaging the intercostal artery or vein, but I think it probably does. As I said, I haven't done a controlled study on this, but I think it probably does a good job in that.
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CT Guided Lung Biopsy Under Moderate Sedation
When performing a CT guided lung biopsy under moderate sedation, one challenge practitioners commonly face is that the pulmonary circuit is dynamic. This can be challenging particularly if you are targeting a smaller lesion in which the positioning is changing with respiration. One way Dr. Lee and his partners try to overcome this is by performing all biopsies at end expiration.
[Dr. Christopher Beck]:
And you also talked about another thing I wanted to bring up, and I was going to bring it up in the context of moderate sedation versus local. It sounds like you guys do moderate sedation for everything, but making it a point to do your biopsies on end-expiration, I think that's a good practice to get into.
I think sometimes there's room for variation where if you happen to... Sometimes lesions can pop into a better area if you happen to use a different breath-hole. But I think end-expiration tends to create the most reproducible location of a lesion.
[Dr. Fred Lee]:
Absolutely. And you can use respiration to your advantage, as you were saying. If you need to pull the nodule down to you a little bit, just have 'em take a very small breath and hold it. My issue is that when we start giving little sedation to patients, it's very hard to get a reproducible breath hold ….
Getting back to the balloon analogy again, puncturing a patient during inspiration is like filling a balloon and then sticking a needle into it. And I would rather have a deflated balloon and stick a needle into it with less pressure in the lung. I think it probably decreases your pneumothorax rate as well. But again, something we haven't proven, but we suspect.
The Benefits of Dedicated Lung Biopsy Support Staff
Given the potentially dangerous nature of lung biopsies, it is essential to have the standards for them in your practice down to a science. Having standardized indications and planning how to manage complications as they arise for every patient are necessary to have a systematic, streamlined approach to lung biopsies. Dr. Lee discusses below why he finds it nearly essential to have a dedicated CT guided lung biopsy nurse.
[Dr. Fred Lee]:
Lung biopsy is not something that you want to dabble in, you want to do it real well. And so along those lines, we thought about every aspect of the procedure from what patients we're going to do to how to manage complications, and tried to drill down and understand how to do it better in each of those little sub areas.
In our practice, we do a lot of lung biopsies. We have a dedicated lung biopsy nurse named Marcia Foltz, who's really fantastic. And we have an intake service which is primarily Marcia with some other help. And our referring doctors will directly call Marcia with many cases, otherwise they run into us in the hallway or they message us through the electronic medical record system as the broad intake.
…having a dedicated nursing resource is really important. Marcia knows all the indications for the procedure, she knows all the referring physicians, she attends every procedure as well. And so if something is going haywire, she's a really good canary in the coal mine and can warn physicians that something's going wrong or something along those lines. So a very, very valuable resource.
[Dr. Christopher Beck]:
Well, one, I just wanted to take a beat and recognize how fantastic it is to have someone, it sounds like Marcia, a dedicated RN to all your CT-guided procedures. I think that speaks to the volume of what you guys are doing.
Dr. Fred Lee
Fred T. Lee Jr, MD is a professor of Radiology, Biomedical Engineering, and Urology, The Robert A. Turrell Professor of Imaging Science, and the Chief of Abdominal Intervention at the University of Wisconsin.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2021, September 27). Ep. 156 – Percutaneous Lung Biopsies: The Basics [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.