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Pleural & Parenchymal Blood Patching Techniques in Lung Biopsy
Taylor J. Robinson • Feb 16, 2022 • 64 hits
CT guided lung biopsies are essential in the diagnosis, staging, and treatment of various types of nodular lung pathologies. While it is most often a safe and effective practice, complications are possible, including pneumothorax and the subsequent need for a chest tube. A radiologist must be well-equipped with the tools and techniques necessary to prevent and address said complications.
Blood patching began to emerge in the early 2000’s as a technique to reduce the incidence of chest tube placements subsequent to pneumothoraces. Blood patching is a technique in which the operator introduces the patient's own blood into the pulmonary space to promote coagulation of air passages created upon biopsy. The operator uses the already introduced needle and withdraws autologous blood from the patient's IV injecting as they pull back.
Dr. Fred Lee, an Abdominal Radiologist from the University of Wisconsin, discusses the different types of blood patching and how they are utilized in his practice. This article features excerpts from the BackTable Podcast. You can listen to the full episode below.
The BackTable Brief
• Parenchymal blood patching is an efficient and effective technique that decreases the risk of air leakage from the puncture site.
• The goal of pleural blood patching is to decrease the rate of lung biopsy complications, including pneumothorax and chest tube placement.
• In Dr. Lee’s practice, the inspiration for pleural blood patching in lung biopsy came from its use in thoracic surgery for bronchogenic fistulas.
• A 2011 study by Dr. Lee and colleagues showed that 80% of patients receiving aspiration plus blood patching did not require a chest tube.
Table of Contents
(1) Parenchymal Blood Patching
(2) Pleural Blood Patching
(3) How Effective is Blood Patching in Lung Biopsy?
Parenchymal Blood Patching
Blood patching is an efficient, safe, and effective technique that anecdotally decreases the risk of air leakage from the puncture site. The interventionalist draws a few millimeters of blood directly from the patient's IV, anywhere from three to ten depending on the depth of the lesion. Then, as the needle is withdrawn from the parenchyma, the autologous blood is injected simultaneously. This technique, referred to as parenchymal blood patching is discussed in further detail below by Dr. Lee.
[Dr. Christopher Beck]:
So at the very tail end of the procedure, it takes 10 to 20 seconds. You're just adding a little bit of blood as an introducer needle's being pulled out?
[Dr. Fred Lee]:
Exactly. So once I'm getting near the end of the procedure and I've taken my last or second to last core, Marsha's watching and she starts drawing blood from the patient's IV. If the patient has a saline infusion, when she withdraws the blood, she discards the first couple of cc's, so you're not just injecting saline, you're injecting whole blood. She usually draws maybe, it depends on the depth of the lesion. If it's deep up to 10 cc's, if it's superficial, maybe three, four, or five cc, something like that. And then as you're withdrawing the needle, you have to get the rate exactly right. You want to inject as you're pulling back and you would like to inject the bulk of the blood at the pleural surface if, at all, possible.
So you have a good feel for how far the needle’s in, and so you assume, okay, the nodule is three centimeters deep from the pleural surface. So when you get near the three centimeters, then you inject the bulk of the blood. The idea is just that the whole blood will go into the airspaces and clot. And then it also fills the track as you pull the needle out, and this should, in theory and now I think in practice, reduce the air leakage that you get from the puncture site. So it's a really simple procedure, it doesn't take any extra time, and it's just really routine. The only caution I would say is that patients will sometimes, if you forcibly inject the blood and the blood goes into the airways, they can get some coughing from irritation of the airways, and even I tell patients, they occasionally get a little bit of hemoptysis from it.
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Pleural Blood Patching
Similar to parenchymal blood patching, the goal of pleural blood patching is to decrease the rate of lung biopsy complications, including pneumothorax and chest tube placement. First emerging in the early 2000’s Dr. Lee learned of the technique from his thoracic surgeon colleagues for a different, but parallel use. Dr. Lee saw the potential of this for lung biopsies and in 2011 they began incorporating this into the practice. Below, Dr. Beck and Dr. Lee discuss how aspiration with the advent of pleural blood patching has affected chest tube placement rates.
[Dr. Christopher Beck]:
Right. A small amount of Voodoo and everyone's technique is okay. So we talked about the parenchymal blood patch. Now, can we switch gears? And you discuss the technique of the slightly different pleural blood patch?
[Dr. Fred Lee]:
So the pleural blood patch is a salvage technique. And I first got the idea for the pleural blood patch back in the early 2000’s when I was speaking to a thoracic surgeon about bronchopleural fistulas. And he explained to me that some of the postoperative fistulas that the thoracic surgeons encounter after thoracotomy can be cured essentially by a large volume pleural blood patch. And how the thoracic surgeons do it is a little different than how we do it, but they have a preexisting large chest tube in patients. And they'll inject up to like 500 cc’s of the patient's blood into the pleural space in an attempt to really seal a suture line that might be leaking.
So having heard that from one of my thoracic surgery colleagues, I thought that this may be applicable to lung biopsies. And so back in 2011, we published our early experience doing this primarily with a fine needle aspiration lung biopsies. And we found that it was successful, especially when you compare to simple aspiration. So we compared simple aspiration of a pneumothorax versus aspiration plus a pleural blood patch. And we found that the need for a chest tube was down when you combined aspiration and pleural blood patching. Now, what pleural blood patching is in the context of a lung biopsy is it's a salvage technique, and what it does is in most cases, it prevents you from having to place a conventional chest tube.
And the reason I was interested in this is primarily, I have to say that I have a touch of laziness in me, and I realized that every time I had to put a chest tube in a patient after a lung biopsy, the next day was quite a hassle. I mean, you're checking chest x-rays, and you're doing extra rounding on patients, and you're clamping chest tubes, and eventually you're pulling chest tubes and more chest x-rays and more monitoring of patients. And that became very user intensive, so to speak. And so in an effort to decrease my own efforts in this area, I thought there has to be a better way. And an ounce of prevention, of course, is better than the pound of cure. And so the next time I had a patient on the table, I tried this technique with just a smaller volume of blood than what the thoracic surgeons were doing, and lo and behold, it worked.
And based on that single first attempt at it, me and a couple of my partners started doing it a little bit more routinely, and I think we were able to prove in 2011 that it probably works. And so since then, it's become a stalwart of our practice…
How Effective is Blood Patching in Lung Biopsy?
While the concept of pleural blood patching makes sense in theory to help coagulate into punctured parenchyma and pleura, how well does it actually work? Dr. Lee and his colleagues at University of Wisconsin dove into just this question in their 2011 study and determined that over 80% of patients with blood patching resolved the pneumothorax while foregoing the need for a chest tube. This data alone is encouraging, but how did and when did they transition from standard chest tubes and in which patient cases? We are in luck. Below, Dr. Beck and Dr. Lee discuss the intricacies of altering standard practice within an interventional department.
[Dr. Christopher Beck]:
I totally agree. And that's to say nothing of the patient experience and to improve how fast they get out of the hospital. The longer you're in the hospital, the more things that can happen to people, especially in the days of COVID. So yes, I echo that sentiment. And that's one of the things I wanted to point out in the paper is that of the patients you did that on, and I don't remember the in, but of the patients without emphysema, work in all but one. And I think the overall rate, and you can correct me if I'm wrong, Fred, but it was five out of six, or 50 out of 60 patients who were able to do the pleural blood patch went on to have no additional intervention, and they just got discharged the same day.
[Dr. Fred Lee]:
Yes, that's exactly right. It was over 80% of the patients the blood patching resolved the pneumothorax without the need for a chest tube. And our numbers would have been better, I think. Our overall pneumothorax and chest tube numbers would have been better except there were something like one and a half... Our overall chest tube rate then is 2.5% or so. And that number is one of the lowest in the literature. And it would have been around 1%, but it turns out that back in the early parts of the study earlier in our practice, some of my partners and me too, I'm guilty of this as well, when we had one of those new authorities that the lung just dropped when you touched it kind of thing. And everybody that does lung biopsies know what I'm talking about. They would just put a chest tube in.
And so, as we were just learning about blood patching, there were still some people that were sticking in chest tubes in that situation. And I think that if we first tried a pleural blood patch as a salvage procedure, I think our chest tube rate would have been down around 1%, which is, I think, by far the best in the literature. And if you use a 19-gauge introducer, 20-gauge needle, I think most people's practice will be very similar to ours.
[Dr. Christopher Beck]:
That's great. So one of the things I wanted to ask about in the 60 patients who you guys did the pleural blood patch, is it always in scenarios where the biopsy is still in progress or being done? Or were there ever circumstances where you do the biopsy, you do the parenchymal blood patch, and so everything's out, and then you say, oh, I think sometimes just inherently you either have a symptomatic pneumothorax or a pneumothorax that you just have the feeling is larger like the little tiny postbox in the pneumothoraces that we sometimes see? So I guess my question is, in some of those patients, the 60 patients with pneumothoraces, were some of those patients included patients who have already completed their biopsy and the parenchymal blood patch had been done?
[Dr. Fred Lee]:
Yes to all the above. The pleural blood patch is really versatile and we use it all the way from the minute you start…
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 28). Ep. 157 – Percutaneous Lung Biopsies: Pleural & Parenchymal Blood Patching [Audio podcast]. Retrieved from https://www.backtable.com
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