Bacteremia following transbronchial fine needle aspiration

Evolving role of interventional pulmonology in the interdisciplinary approach to the staging and management of lung cancer: bronchoscopic mediastinal staging of lung cancer

Mediastinal lymph node involvement is present in 26%-38% of patients with non-small-cell lung cancer at the time of diagnosis, and it is often the most significant factor in determining surgical resectability. Complete and accurate mediastinal staging of lung cancer is essential for determining prognosis and for guiding optimal treatment strategies. Computed tomography and positron emission tomography are the most widely used noninvasive means for mediastinal staging in lung cancer. However, based on their reported specificities, computed tomography and positron emission tomography findings should be verified by cytohistologic sampling. In recent decades, the technique of transbronchial needle aspiration (TBNA) has been developed, permitting the bronchoscopist to obtain cytohistologic material from the hilar and mediastinal lymph nodes adjacent to the tracheobronchial wall. The technique of TBNA has a great specificity, is safe and cost-effective compared with surgical methods, and can be performed during the initial diagnostic bronchoscopy. Transbronchial needle aspiration sensitivity is 76%-78% but is highly influenced by several factors. Endobronchial ultrasound has been proposed as a means for improving TBNA sensitivity. Recently, a new type of bronchoscope with a built-in convex ultrasound probe directly attached to the tip has been developed to guide TBNA under real-time imaging. Reports on this innovative technique reveal a sensitivity of 94%-95.7%, which is superior to the reported sensitivity of surgical methods. However, ultrasound-guided TBNA and traditional TBNA should be considered complementary techniques, because their integration is likely to become the optimal staging strategy for patients with lung cancer.

Role of transbronchial needle aspiration in patients receiving mechanical ventilation

STUDY OBJECTIVE

s: To evaluate the diagnostic accuracy and safety of transbronchial needle aspiration (TBNA) in patients receiving mechanical ventilation in the ICU.

METHODS

Retrospective review of all patients in the medical and surgical ICUs from February 1999 to July 2001 who underwent TBNA while receiving mechanical ventilation.

RESULTS

A total of eight histology (19 gauge) and eight cytology (22 gauge) TBNAs were performed on eight patients (four men and four women). TBNA yielded a definitive pathologic diagnosis in five of eight patients (62.5%). Diagnoses were posttransplantation lymphoproliferative disorder, large cell carcinoma, poorly differentiated non-small cell carcinoma, squamous cell carcinoma, and adenocarcinoma. Among patients with negative TBNA results (n = 3), two patients underwent mediastinoscopy. Results of mediastinoscopy were non-small cell carcinoma and inflamed tissue. TBNA led to management changes in five of these patients. Excluding one patient in whom a negative TBNA result could not be further confirmed, TBNA yielded a sensitivity of 83%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 50%. The overall accuracy of the procedure was 75%. There were no complications following any of the TBNAs.

CONCLUSIONS

In this small group of patients, TBNA was safe and had a high diagnostic accuracy in selected patients receiving mechanical ventilation in the ICU.

Semi-invasive and invasive procedures for the diagnosis and staging of lung cancer. II. Bronchoscopic and surgical procedures

Each of the various techniques used for the diagnosis and staging of lung cancer has its advantages and limitations (Table 1). Imaging has a major role in guiding these procedures and deciding which of them is most appropriate in a given clinical setting. A CT examination by which the size and location of the parenchymal lesion and the presence and location of enlarged lymph nodes can be determined is a prerequisite for all sampling procedures. As a general rule, when attempting to diagnose a solitary pulmonary nodule or mass, central lesions are more easily approached by the bronchoscopic route, whereas a transthoracic route is preferred for peripheral lesions. Bronchoscopy is often performed using fluoroscopic guidance, and the recently developed CT fluoroscopy and endoscopic ultrasound have the potential to facilitate transbronchial needle aspiration. A recent advent in imaging of lung cancer has been the introduction of positron emission tomography to the diagnostic work-up of lung cancer. Although this technique has been shown to be highly accurate in determining the malignant or benign nature of lesions, it does not enable histologic diagnosis. In each case, the most appropriate diagnostic procedure should be tailored to suit the specific requirements determined by the characteristics of the disease process, institutional availability of the various diagnostic procedures, and patient preferences, when possible.

Infection control in the bronchoscopy suite. A review

Bronchoscopy can occasionally transmit disease. Infection control in the bronchoscopy suite is especially important because of the risk of transmitting HIV or tuberculosis. Many case reports, patient series, and small studies have been published, but little comprehensive guidance is available for clinicians who wish to learn more about the problem and prevent it. We review the literature and describe three ways in which bronchoscopy can cause disease: by transmitting infections between patients, by transferring microorganisms within a patient, and by triggering coughing that can cause airborne infection of patients or health-care workers. Recommendations for infection control are listed; they include installing powerful air filters, using disposable bronchoscope suction valves, manually cleaning all equipment before disinfection, controlling patient coughing, and in some cases, giving patients prophylactic antibiotics.

Transbronchial needle aspiration. An underused diagnostic technique

Despite its proven usefulness, TBNA is not widely used. An American College of Chest Physicians (ACCP) survey showed that only 11.8% of pulmonologists use TBNA. Most pulmonologists in the 1980s were not formally trained in TBNA. This lack of training has unfortunately translated to minimal emphasis on TBNA in current training programs in a large number of institutions. Technical problems with the procedure (faulty site selection, incomplete needle penetration, catheter kinking that prevents adequate suction, etc.), the confusing array of needles, low diagnostic yields, unproven concerns regarding the safety of the procedure, inadequate cytopathology support, and bronchoscopic damage have all perpetuated the image of limited usefulness for this procedure. Limitations to the practice of TBNA are: Lack of training during fellowship Technical inadequacies Lack of cytopathologists trained in TBNA interpretation Fear of bronchoscope damage Safety issues Failure to reproduce published successes Reservations regarding usefulness of TBNA results Hands-on experience with TBNA, developing familiarity and expertise with only a few needles, and paying careful attention to anatomy, procedure techniques, and specimen acquisition may all help to increase yield. The following lists how better results can be obtained with TBNA: Preprocedure Review TBNA instruction tapes Attend hands-on courses Practice with lung models Review patient's CAT scans Familiarize with one-two cytology and histology needle Obtain a trained assistant Procedural Identify target site Needle to airway angle at least greater than 45 degrees Insert entire length of the needle Use scope channel to support the catheter Release suction before withdrawing needle (for staging) Specimen acquisition Avoid delay in preparing slides Adequate sampling (at least two) Use smear method for cytology specimen Analyze all samples flush solutions cell block Postprocedure Find an experienced cytopathologist Review your procedure (by watching video) Review pathology slides Acquisition of skills with cytology needles should precede the use of the histology needle. Increasing education and experience can also increase diagnostic yields. Transbronchial needle aspiration has been proven to be accurate in staging lung cancers, identifying inoperable carcinomas, and diagnosing a variety of lung diseases. Few complications have been encountered and the technique is less invasive and less costly than surgical procedures. Drawing on evidence from published literature, we suggest the following guidelines for TBNA: All patients presenting with mediastinal or hilar adenopathy or both, should have 22-ga and/or 19-ga TBNA as the initial procedure. These procedures would help diagnose malignant and nonmalignant diseases, and stage lung cancers. All patients with evidence of submucosal and peribronchial disease should have 22-ga needle cytology sampling. In patients with visible endobronchial disease, 22-ga TBNA should be optional. In the presence of a necrotic or a hemorrhagic tumor, or in a patient with a bleeding diathesis, TBNA would be helpful. In all patients with Type III and IV peripheral nodules, TBNA should be the initial diagnostic procedure. There remains no doubt about the diagnostic usefulness of TBNA. Guidelines must be developed to ensure that pulmonary fellows are adequately trained in this procedure. Regional workshops with hands-on experience targeted to practicing pulmonologists organized by the ACCP would help popularize the procedure. Initial low yields should not discourage pulmonologists from using the procedure. Collaboration between thoracic surgeons, oncologists, and pulmonary physicians is essential to set up TBNA programs within institutions. With time, as more and more pulmonologists attain expertise in TBNA, the full potential of this nonsurgical, cost-effective, and safe procedure will be realized.

Fatal Haemophilus influenzae septicemia following bronchoscopy in a splenectomized patient

We describe a 46-year-old splenectomized patient who died of Haemophilus influenzae septicemia 16 h following bronchoscopy. Although rare, postsplenectomy overwhelming sepsis is always a danger in splenectomized patients undergoing invasive procedures. Chemoprophylaxis should be considered in asplenic patients peribronchoscopy.

Does the bronchoscope propagate infection?

The flexible and rigid bronchoscopes traverse the nasopharynx or oropharynx and carry with them the indigenous microbial flora to distal regions and may thus inoculate the tracheobronchial tree and possibly the pulmonary parenchyma. The three potential consequences of this event include: (1) onset of new infection in the tracheobronchial tree or lung parenchyma or, if the patient has preexisting infection, further spread of infection locally or to extrapulmonary sites; (2) spread of infection from one patient to another via the bronchoscope, if the methods of disinfection and sterilization are inadequate; and (3) pseudoinfection due to cross-contamination of the bronchoscope, resulting in isolation of organisms from the bronchoscopic specimens of a patient who is clinically not infected. Review of the literature indicates that the last-mentioned consequence is more commonly encountered in clinical practice. The occurrence of pseudoinfection inevitably leads to costly and time-consuming procedures to guarantee that the patients are not infected. Rigorous adherence to sterilization and disinfection procedures and a common sense approach to protecting the uninfected patients and bronchoscopy personnel from infected patients and instruments will prevent the risk of propagating infection through the bronchoscope. This can be accomplished by establishing a set of policies regarding disinfection, sterilization, and protection of uninfected patients, as well as the bronchoscopist and paramedical personnel involved in bronchoscopy.

The diagnostic yield of bronchoscopy

The endoscopic examination of the tracheobronchial tree is most helpful in the diagnosis and staging of bronchial carcinoma. Tumors that are endoscopically visible may be confirmed in more than 95% of the cases. In localized peripheral tumors, the diagnostic yield of bronchoscopy is significantly lower; for peripheral metastases, only about 10%. In diffuse interstitial pulmonary diseases other than malignancies, some infections, and histiocytosis X, bronchoscopy including transbronchial biopsy is less successful.

Transbronchial needle aspiration in clinical practice. A five-year experience

We conducted a five-year review of our use of TBNA during bronchoscopy in our clinical practice. Out of 1,630 bronchoscopic procedures, 633 patients (39 percent) had TBNA performed as part of the initial examination. Mediastinal nodes were sampled in 86 percent of the patients who had TBNA performed, and 127 (23 percent) of 547 of these aspirates were positive. Other areas of mucosal abnormality of the tracheobronchial tree were also sampled by TBNA under direct vision and showed malignant cells in 44 (25 percent) of 176 aspirates. Of 363 patients first diagnosed as having carcinoma of the lung who had TBNA of N2 nodes, 41 (59 percent) of 70 with small-cell tumors were positive, as were 83 (28 percent) of 293 with non-small-cell malignant neoplasms. Comparison of cytologic results obtained by TBNA with histologic material in 109 cases showed an excellent correlation. In 31 cases (4 percent of all TBNA), the aspirate provided the sole means of establishing the diagnosis of cancer. Two patients were thought to have false-positive aspirates. No complications of therapeutic significance were encountered. We believe that TBNA is a safe and effective way to assess mediastinal lymphatic involvement in the staging of lung cancer and that TBNA can be safely performed as part of the initial bronchoscopic examination in patients suspected of having malignant neoplasms of the chest.

Transbronchial needle aspiration in the practice of bronchoscopy

We reviewed the records of all patients who underwent bronchoscopy with a flexible fiberoptic instrument and transbronchial needle aspiration (TBNA) at our institution between August 1983 and December 1985. During 85 bronchoscopy sessions, 89 TBNAs were performed in 84 patients. Seventy-three aspirates were obtained from 68 patients who were eventually proved to have a malignant lesion. Of these 68 patients, 25 had positive results of TBNA (37%). Of these 25 patients, 15 had non-small-cell cancers (11 bronchogenic and 4 metastatic from extrapulmonary sites), and 10 had small-cell carcinomas. In patients with a malignant lesion, 23% of the central aspirates (from paratracheal regions or within 2 cm of the carina) and 65% of the distal aspirates (beyond 2 cm from the carina) were positive (a total yield of 34%). Five of the distal aspirates were obtained from peripheral lesions under fluoroscopic guidance, and three were positive for a malignant process. In eight patients, the only malignant finding at bronchoscopy was the aspirate. Two of the eight patients had carcinoma metastatic to the lung, three had small-cell carcinoma, and the other three had bronchogenic carcinoma. In five patients, TBNA obviated more invasive diagnostic measures. We find TBNA to be useful in selected patients. It increases our diagnostic yield for small-cell carcinoma and carcinoma metastatic to the chest. TBNA should be considered when a submucosal process is present, extrinsic compression is evident, or an accessible extrabronchial mass is found radiographically.

Incidence of fever and bacteremia following transbronchial needle aspiration

Fiberoptic bronchoscopy and transbronchial needle aspiration were performed on 50 occasions in 47 afebrile patients. The aspirations were followed by endobronchial or transbronchial biopsies in 22 patients, as well as bronchial brushings and washings where appropriate. Blood for cultures was drawn at 5 and 30 minutes following needle aspiration, as well as at the time of any temperature above 38 degrees C during the 24 hours following the procedure. In five (10 percent) of the 50 cases, there was temperature greater than 38 degrees C (100.4 degrees F) in the 24 hours following the bronchoscopy; in no patient were cultures of blood positive, whether done early after the procedure or at the time of fever. We conclude that transbronchial needle aspiration, a new procedure gaining widespread popularity in diagnostic thoracic medicine, is not associated with clinically detectable bacteremia. This procedure should not require antimicrobial prophylaxis in patients susceptible to endocarditis.