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BackTable / VI / Article
Lung Biopsy Procedure: Patient Communication, Medications & Device Selection
Rajat Mohanka • Aug 10, 2023 • 157 hits
CT-guided needle lung biopsy is one of the most common methods for determining the pathology of lung nodules. The key to a successful lung biopsy procedure is proper patient preparation. Dr. Robert Suh, an interventional radiologist from the University of California Los Angeles, shares his approach to patient prep for lung biopsy, including methods of pain control, specific indications to involve a cytopathologist, and specific devices to have on the back table.
This article features excerpts from the BackTable Podcast. You can listen to the full episode below.
The Backtable Brief
• Informed consent should include information about common occurrences and expected outcomes of the procedure, with the acknowledgment that complications like air embolism, death, or stroke can happen, though rarely (below 1% incidence).
• Patient communication is crucial during lung biopsy procedures. Dr. Suh instructs patients to take small, comfortable breaths to reduce anxiety.
• Effective lung biopsy pain management is essential, with the numbing of the parietal pleura using anesthetics like lidocaine, ropivacaine, or bupivacaine being a common practice.
• The preferred biopsy tools are a 19 gauge introducer needle and 20 gauge sampling needle. However, a 17 gauge introducer needle with an 18 gauge core may be used for larger masses.
• Cytopathologists are usually present for in-hospital biopsies but not for outpatient procedures. In the outpatient setting, samples are placed in formalin for offsite evaluation. Access to cytopathology is essential for cases involving necrotic tissue or previously unsuccessful biopsies.
Table of Contents
(1) Lung Biopsy Procedure Consent
(2) Patient Communication
(3) Medications for Lung Biopsy
(4) Lung Needle Biopsy
(5) Cytopathology Onsite vs Offsite for Biopsy Procedures
Lung Biopsy Procedure Consent
Informed consent should focus on informing patients about common occurrences and expected outcomes of the procedure. While complications such as air embolism, death, or stroke can happen, their incidence is well below 1%.
[Dr. Christopher Beck]
One thing that I meant to mention, so I'll go back to it as far as your consent forms, whenever you consent your patients, I assume there's all the standard stuff, pain bleeding infection, risk of pneumothorax, risk of needing additional surgery or a chest tube or something. Do you guys discuss rare instances of stroke or death for the consent?
[Dr. Robert Suh]
You know, to go back in time, way back early in my career, I had two big complications, and they had to do a systemic air embolus. I kind of rethought, well, what should be in the consent, or how should you approach the consent at that time, and I even consulted with our risk management lawyers at UCLA. I think they gave some very practical advice, which I still hold to today, is that, I think, when you do an informed consent or you're talking about a procedure, it's really about making sure that the patient is informed about things that can commonly happen. Commonly is, people's definitions vary a little bit, but things that you're most likely to anticipate or expect with the procedure.
Now, things like air embolism, death, stroke, all these kinds of things can certainly happen, but they're well under the 1%, if that, threshold. So the advice that I got is, well, you can mention them in passing, but I don't think when you give the numbers that in terms of how often or frequent these things happen, the patient is not going to say no to the procedure based on that. Again, you can mention these things in passing, but I generally don't.
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Patient Communication
Dr. Robert Suh emphasizes the importance of patient communication and the patient’s role in the procedure. He instructs his patients to take a small comfortable breath, a technique which he finds mitigates patient anxiety during the procedure.
[Dr. Robert Suh]
So I think the first thing is you look at the board and what's going on and go through the cases. Sometimes we have residents and fellows as you can imagine. It's important to sit down and go through the target and the needs of the patient and the procedure, and then when I see the patient, it's really just running through the procedure, just what they're going to expect, and then I'd like to conclude that with maybe some expectations that I have for them in that I think one of the keys to have a successful procedure, and especially a lung biopsy, is to put the ball back into the patient's court, so to speak, so that they feel like that they have some sort of skin in the game.
So one of the last things I lead with is I ask them if they remember when they had their CAT scan or PET scan and if they remember that they took a big breath in and held it. Usually, they go, "Yeah, yeah, I remember that happened,” and I go, "Here, we just want you to take a small comfortable breath." Something that whether I ask them or our fellow or our technologist, just try to do it the same way each time. I think in many cases that sort of takes the, I guess the nervousness or the anxiety from the procedure because when they're laying, they're on the table, they're concentrating on something else and focusing on trying to do something else.
[Dr. Christopher Beck]
Yeah that's nice. So let's dig in a little bit into the breath-hold thing. Are you basically talking to your patients ahead of time in anticipation that you may have to do some breath-hold maneuvers throughout the case?
[Dr. Robert Suh]
In fact, we talk to all of them.
[Dr. Christopher Beck]
Do you do it on inspiration, expiration, or it depends on where the lesion ends up?
[Dr. Robert Suh]
No. Just a small breath in and hold it. It's like end tidal inspiration.
Medications for Lung Biopsy
Dr. Suh stresses the importance of effective lung biopsy pain management, and shares his strategy of numbing the parietal pleura with lidocaine. Following the injection of anesthetics like lidocaine, ropivacaine, or bupivacaine, a small lens-shaped fluid, visible on CT scans, forms over the parietal pleura.
[Dr. Christopher Beck]
Okay. Are all the cases being done with moderate sedation? Local?
[Dr. Robert Suh]
Yes. So you know every so often there may be a need for general anesthesia or deep conscious sedation. But most of the time they're going to be moderate or mild conscious sedation.
[Dr. Christopher Beck]
Mild to moderate conscious sedation, keeping them light so they're not completely snowed and obviously not able to comply with the breath hold. You keep them a little bit light.
[Dr. Robert Suh]
Right. Of course, they're going to have to be awake or somewhat awake. In fact, over the years I've gotten to use less and less benzodiazepines and narcotics. So what I might do is start with something like one milligram of Versed, 50 mm of Fent, and then I give something like Toradol or IV acetaminophen to really give pain control if needed. But, the secret to having a successful lung biopsy is really knowing how to numb the parietal pleura.
[Dr. Christopher Beck]
Okay well what we want to do is uncover all the secrets. So let's hear about it.
[Dr. Robert Suh]
Yeah, so again, if you think about it, probably one of the most sensitive structures that the needle crosses when it's going percutaneously from the skin into the lung into the lesion is the parietal pleura because it's somatically innervated just as the skin is. The way that we numb up the pleura is that you bring the introducer needle or that 19 gauge coaxial needle we typically use for lung biopsy, and we just carefully bring it up to the pleura and you can see the target is what's called the extrapleural space and you'll see a little black band of fat there and that's just inside the endothoracic fascia, but outside or superficial to the parietal pleura.
The trick is to get your needle there and then go ahead and administer about 10 cc's of lidocaine or sometimes if it's a longer procedure like an ablation, we may put bupivacaine, but, again, 10 cc is the low minimum for me. I use at least 10 cc's if not a little bit more. Then once that's numb, it makes the procedure go so much easier because the patient doesn't feel the needle moving or tugging on the parietal pleura with respiration. As you know, the lung itself doesn't have somatic nerves, so once you're in the lung, they don't feel it anyways.
[Dr. Christopher Beck]
Once you have your needle in that position, once you inject the lidocaine like say you're putting down 10 ml of lidocaine or ropivacaine or bupivacaine, do you get that little lens shape fluid? You can see it on CT, where you get this little lens of fluid that's covering the parietal pleura.
[Dr. Robert Suh]
Yeah, perfect, Chris.
Lung Needle Biopsy
Regarding equipment, Dr. Robert Suh typically uses a 19 gauge introducer needle and 20 gauge sampling needle for lung biopsies. These semi-automated devices manually extend the capture chamber and then sever the sample. Occasionally, for larger masses, a 17 gauge introducer needle with an 18 gauge core may be used. However, for smaller lesions, the larger gauge needle can cause hemorrhage, which isn't problematic in itself, but may induce coughing which can complicate the lung biopsy procedure.
[Dr. Christopher Beck]
All right, good good. All right, I like it. So one of the other things you touched on, needle size for lung biopsies. Whenever you guys do your lung biopsies, which kind of devices you're using, which needle size are you guys using?
[Dr. Robert Suh]
We're typically using a 19 gauge introducer needle, and 20 gauge sampling needle. These are the semi-automated type that you manually put out the capture chamber, and then it clicks and cuts off the sample. On occasion, if it's a large mass, and it's pretty safe, I'll go ahead and use a 17 gauge introducer needle with an 18 gauge core. But again, I think for things like ground glass lesions, 1-centimeter, 1.5-centimeter nodules, using the 17, 18 gauge does cause a bit of hemorrhage, whereas hemorrhage isn't too much of a problem, but it's the coughing that the hemorrhage causes that's a problem.
Cytopathology Onsite vs Offsite for Biopsy Procedures
Cytopathologist are typically present for biopsies done in the hospital setting but not at the outpatient imaging center. In the outpatient setting, if lung biopsy tisisue pathology is needed, then the sample is placed in formalin to go to pathology for offsite evaluation. Some examples of cases that require access to cytopathology include necrotic tissue or previous unsuccessful biopsies.
[Dr. Christopher Beck]
“...all right, so going back to the techniques, so we said typically 19 gauge introducer with 20 gauge needle. Do you guys have lung biopsy tissue pathology on site to evaluate the sample or tell you whether or not you have adequate tissue, non-necrotic tissue something like that?
[Dr. Robert Suh]
When we do the biopsies in the outpatient in the hospital setting, we definitely have a cytopathologist on board for these cases. At Santa Monica, the outpatient site or center is just across the street, and so in those situations certainly you can have a cytopathologist come. But when we're in the true Outpatient Imaging and Intervention Center, then we don't have access to cytopathologist and so here basically the sample is placed formalin and then ensured that it gets to pathology, but there is no onsite evaluation of the tissue.
[Dr. Christopher Beck]
You can figure out which ones are going to be at the outpatient versus the hospital site. How do you triage which ones will need access to cyto and which ones won't?
[Dr. Robert Suh]
You know that's a good question, Chris, but we really don't use that as a form of triage as I mentioned in the algorithm that we use to this day. I suppose if something looks very necrotic or it's been biopsied multiple times without a diagnosis at the time of screening, you kind of know that. In those situations we may as another measure of screening, we may place that patient where cytopathology would be available.
[Dr. Christopher Beck]
In our practice, we don't have good access to cyto. We can get them on request and it creates a scheduling burden, but we do re-biopsies or if you think you're going to be in necrotic tissue and so you have a lot of opportunity to redirect the needle. But sometimes I think if you have a 1-centimeter nodule and your cytotech says, "Hey, we don't have good tissue." Some of the things that we biopsy are exceedingly small now what more can you do other than make a couple more passes and then keep your fingers crossed? I was just curious.
[Dr. Robert Suh]
No, I think you're right. I think we're being asked to get smaller and smaller. The ones that we often do, the higher skillset biopsies if you will, they're all routinely about a centimeter, centimeter and a half in tight locations. You're right, how much more tissue can I get safely?
Podcast Contributors
Dr. Robert Suh
Dr. Robert Suh is a chest radiologist and interventional radiologist with UCLA in California.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2023, January 3). Ep. 278 – Minimizing Complications for Lung Biopsies [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.
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