Transcript AB part 3B - Bronchoscopy International

Part 3B: Endobronchial Brushing
volume 1
Strategy and Planning
Execution
Bronchoscopy International
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When to perform endobronchial brushing
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Visible airway mucosal abnormalities
Visible airway nodules or masses
In case of suspected sarcoidosis (even if airway
mucosa appears normal)
In case of abnormal autofluorescence to diagnose
intraepithelial lesions (dysplasia, metaplasia,
carcinoma in-situ)
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Training is essential in order to
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Learn proper techniques and indications
Avoid procedure-related complications.
Learn to protect the equipment and the
patient
To obtain adequate tissue for diagnosis
 To avoid damaging the working channel
 To avoid excess patient discomfort (cough,
anxiety, shortness of breath).
 To avoid bleeding, that might also prompt cough
and patient agitation.
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Q1: Optimal endobronchial brushing samples
requires correct processing
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Q8: Optimal endobronchial brushing samples
requires correct processing
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TRUE. Brushing samples must be processed
correctly and according to the needs and
preferences of your institution’s cytology and
microbiology laboratories.
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Other ways to potentially increase diagnostic
yield include
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Using brushes with longer bristles
Brushing vigorously and for a longer period of time.
Making sure that all parts of the brush are in contact
with the mucosal abnormality.
Using the pirouette technique (rotation) in
combination with long-axis motion.
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Bronchial brushing:
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Originally done under fluoroscopy without bronchoscopy
Common indications:
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Visible endobronchial tumors or mucosal abnormality
Peripheral tumors (+/- fluoroscopy)
Peripheral infection – pneumonia, abscess, cavity
Brush samples larger surface area of lesion
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Bronchial brushing:
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Different size brushes
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Standard 3 mm cytology
7 mm brush (rarely used)
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No sheath
For visible lesions only
Cannot be retracted into scope
Collects more cells but yield and
bleeding equivalent to 3 mm1
Protected specimen brush
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Avoid upper airway contamination
For diagnosis of infection/
quantitative cultures
1Cleve
From Flexible Bronchoscopy Wang and Mehta
Clin J Med
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Bronchial brushing:
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Technique:
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Advance catheter into desired segment – then
extend brush (up to 5 cm)
Make sure brush extension doesn’t push back
the scope or catheter
Move back and forth over the visible lesion or
blindly in distal airway (5-10 times) +/rotation
Cells collected in brush bristles
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Bronchial brushing:
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Yield:
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94% endoscopically visible/peripheral 78%1
92% central and peripheral with fluoro2
77% endoscopically visible/20% peripheral
with fluoro3
1CHEST
1Am
1973;63:889-892
Rev Respir Dis 1974;109:63-66
2CHEST
1974;65:616-619
3CHEST
1976;69:752-757
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Bronchial brushing:
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Complications:
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Bleeding
Pneumothorax
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Biopsy vs cytology:
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154 patients with malignant pulmonary lesions
Each patient had (EBB or TBB) AND (TBNA or brushing)
EBB/TBB sensitivity 62.8%
TBNA/brush (cyto) sensitivity 69.2%
Combined sensitivity 87.2%
J Bronchol 2004;11:154-159
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Additional literature:
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J Bronchol 2004;11:154-159
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Endobronchial Brushing
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Brush samples large area of mucosal
abnormality
May be done under direct visualization, or
with fluoroscopic guidance
Brushes may be bare of within
a covering sheath
Brush Video
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Indications and brushing techniques
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Indications
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Visible airway mucosal abnormality
Peripheral lesion (lung nodule, abcess etc)
Peripheral lung infiltrate
Techniques
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Extend catheter into target segment
Extend brush “Brush out”. Be certain extended brush
does not cause pain or pneumothorax, nor push
bronchoscope proximally.
Brush forcefully and gently and frequently (5-10
times) with and without brush rotation so that all parts
of brush touch the lesion.
Retract brush “Brush in”.
Remove the catheter-brush from the working channel.
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Brushing Yield
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Greatest when
cancer is
present
94% in case of
central lesion,
78% in case of
peripheral
lesions. But
yields can also
be as low as 20
% for
Chest 1973;63:889, Chest 1976;69:752, J Bronchol 2004;11:154*
peripheral
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lesions.
*
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Brushing-related Complications
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Bleeding
Pneumothorax
Perforation of lung
abscess
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Bleeding risk if
Thrombocytopenia: <50,000
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Risk of bleeding: 0-26% (TBBx, post
transfusion) (1)
Brushing with mean platelet count of 30,000:
Bleed: 16% , Death: 4% (2)
What to do? Transfuse 6 packs before &
during bronchoscopy, no need to recheck
platelets (3)
 Platelet half-life 6 hours!
(1) Weiss S, Chest, 1993;104:1025
(2) Papin T, Chest, 1985; 88:54
(3)Wahidi M, Respiration 2005;72:285
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Combined procedures have greatest
yield for malignancy
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Arch Bronchoneumol. 2006;42(6):278-82
 75 patients underwent bronchial washing
before (pre) and after (post) endobronchial
biopsy and brushing
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This presentation is part of a
comprehensive curriculum for
Flexible Bronchoscopy. Our goals
are to help health care workers
become better at what they do, and
to decrease the burden of
procedure-related training on
patients.
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Step by Step©
Bronchoscopy.org
BRONCHATLAS©
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to maintain currency of online information. All
published multimedia slide shows, streaming
videos, and essays can be cited for reference as:
Bronchoscopy International: Art of Bronchoscopy, an Electronic OnLine Multimedia Slide Presentation.
http://www.Bronchoscopy.org/Art of Bronchoscopy/htm. Published
2007 (Please add “Date Accessed”).
Thank you
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Prepared with the expert assistance of Udaya Prakash M.D.
(Mayo Clinic, USA), and Atul Mehta M.D. (Cleveland Clinic,
USA), and Wes Shepherd M.D. (Virginia Commonwealth
University, USA)
www.bronchoscopy.org
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