Michael P. D'Alessandro, M.D.
Peer Review Status: Internally Peer Reviewed
Absolute contraindications: none
Relative contraindications: mod/severe COPD (FEV1 < 1.0 L), patient on PEEP, adjacent bullae, patient > 3 sec over control, plt < 50K, possible echinococcal cyst/AVM, patient uncooperative, coughing, contralat pneumonectomy, pulmonary HTN
Check Hgb, plt, PTT, PT
Get pre biopsy CXR
If you do it under fluoroscopy make sure you have chest CT done 1st
Go over a rib - don't go near IMA which are 1.25 cm lat to lat sternal border Coaxial 18G-> 22G through it - anchor the 18 G just above lesion making sure it is through pleura - then when you make passes through it you don't re puncture the pleura with 22G
Pt to hold breath @ FRC while traversing pleura
Make sure to occlude lumen of 18 G p pass
If under CT take p biopsy slice to r/o pneumothorax - if under fluoroscopy get upright PA expiratory film
If pneumothorax large or symptomatic, put in 9 Fr CT
Position patient with biopsy side down (dependent positioning) to decrease rate of pneumothorax and prevent transbronchial aspiration of blood
Post Lung Bx Orders
Position patient with biopsy side down x 3 hours
Check VS and BS q 15 ' x 4, q 30 ' x 4
Repeat PA expiratory at 3 hours : if no pneumothorax or if small stable PTX: d/c
to home; if small PTX: check VS, give O2 via NC, repeat CXR if symptomatic
D/C Home instructions: no straining or exertion till next AM, go to ER if you develop pleuritic CP/hemoptysis/SOB
Tips on lung biopsy: if you are going for thymoma or lymphoma - get a core, make your outer needle an 18 or 19 G cutting needle
Treat via 7-9 Fr cath inserted via trocar technique in 2nd intercostal space in mid clavicular line under fluoroscopy making sure to angle cath cephalad Cath can be placed from post or lat position if patient is undergoing CT biopsy in prone position
Catheter is attached to Pleurevac with (-20) cm suction, secure all connections with tape and put petroleum gauze around cath entry site
When pneumothorax is gone clamp cath and repeat CXR in 4 hours: no pneumothorax - remove catheter, recurrent pneumothorax - unclamp cath and put it back on suction
Views to Take:
See References Chapter.
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