- Introduction
- Flexible Bronchoscopy
- Rigid Bronchoscopy
- Pediatric Section
- TBNA
- Autofluorescence Bronchoscopy
- EBUS
- Laser Therapy
- Electrocautery and Argon Plasma Coagulation
- Cryotherapy
- Brachytherapy
- Photodynamic Therapy
- Airway Stents
- Thoracic Percutaneous Needle Aspiration/ Core Biopsy
- Tube Thoracostomy
- Medical Thoracoscopy/Pleuroscopy
- Percutaneous Pleural Biopsy
- Percutaneous Dilatational Tracheostomy
- Transtracheal Oxygen Therapy
TBNA
Definition
TBNA is a minimally invasive procedure that provides a nonsurgical means to diagnose and stage bronchogenic carcinoma by sampling the mediastinal lymph nodes. Applications of bronchoscopic needle aspiration have expanded to include not only sampling of paratracheal or mediastinal lymph nodes, but peripheral, submucosal, and endobronchial lesions. The procedure allows for sampling tissue through the trachea or bronchial wall, and sampling of tissue beyond the vision of the dedicated operator.
Equipment
In addition to the equipment needed for bronchoscopy, the equipment needed specifically for TBNA include TBNA needles, which are designed to pass through a bronchoscope without causing damage and to be flexible enough to facilitate the positioning of the bronchoscope, yet rigid enough to penetrate the airway wall. Two types of TBNA needles, cytology needles and histology needles, should be available for the procedure.
Personnel
A dedicated operator performs the procedure. Personnel required for this procedure include an RN or a respiratory therapist to administer and monitor conscious sedation, as well as a separate RN or a respiratory therapist to assist the dedicated operator. All supporting personnel should be familiar with the procedure being performed, as well as the appropriate handling of specimens. This will maximize patient comfort, safety, and yield.
Anesthesia and Monitoring
This procedure may be performed under local anesthesia, with or without conscious sedation, or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.
Technique
TBNA usually begins with review of the chest radiograph and, in most instances, is greatly facilitated by a CT scan. Knowledge of the anatomy is critical for selecting the proper anatomic location for the needle aspiration or biopsy. This is true for selecting the location of the paratracheal or subcarinal lymph nodes, or for proper location of a peripheral lesion that is to be sampled.
Generally, when performing mediastinal lymph node aspiration for staging bronchogenic carcinoma (either known or suspected), it is critical to perform the needle aspiration prior to general inspection. This will reduce the likelihood of entraining airway secretions in the sample and avoid a false-positive result. A TBNA needle should be selected according to the size and location of the lesion.
Different techniques can be used singularly or in combination to ensure complete penetration of the needle through the tracheobronchial wall. While suction is applied, the catheter (and consequently the needle tip) is agitated back and forth to shear off cells from the node or mass with care not to disengage the tip of the needle from the tracheobronchial wall. This agitation is performed for a few seconds. Once the catheter is removed from the bronchoscope, the smears are prepared.
For submucosal lesions, a similar technique is applied; however, since the goal is to obtain a specimen from the mucosa, the needle and catheter are kept in a position of slight angulation rather than the 90° angle used to obtain lymph node aspirate. For endobronchial lesions that are either necrotic in appearance or highly vascular, TBNA may be used to obtain a sample by altering the technique in order to directly place the needle into the endobronchial lesion.
For peripheral lesions, fluoroscopy is used to localize the lesion. Once the lesion is localized, the needle is locked into position, and the needle is used to shear off cells from the peripheral lesion while suction is applied.
Specimen preparation is the same for the submucosal, endobronchial, or peripheral lesions as it is for the nodal aspirations. Multiple nodal aspirations can be obtained to increase yield.
Indications
Diagnostic and staging information in the presence of malignancy in mediastinal lymph nodes, submucosal, endobronchial, and parenchymal masses are indications for TBNA. Diagnostic information may also be obtained in the same locations for many benign conditions, including sarcoidosis and fungal disease.
Contraindications
Most contraindications to TBNA are relative rather than absolute. Special attention must be paid to respiratory and bleeding status.
Risks
TBNA is extremely safe and has a very low incidence of complications. The most common potential complications are bleeding, pneumothorax, or pneumomediastinum. Significant bleeding rarely occurs even after a major vessel puncture. Fever and bacteremia have been reported following TBNA, although this may be related to the bronchoscopic procedure itself rather than this specific technique.
Training Requirements
In order to protect the bronchoscopy, the needle must be properly and carefully used. In addition, improper technique will result in an inadequate needle aspirate. Trainees should perform at least 25 needle aspirates in a supervised setting to establish basic competency. Trainees should also gain experience in the acquisition of needle aspirates from lymph nodes in mostly paratracheal as well as subcarinal regions. To maintain competency, dedicated operators should perform at least 10 procedures per year.
References
Bilaceroglu S, Perim K, Gunel O, et al. Combining transbronchial aspiration with endobronchial and transbronchial biopsy in sarcoidosis. Monaldi Arch Chest Dis 1999; 54:217-223
Crymes TP, Fish RG, Smith DE, et al. Complications of transbronchial left atrial puncture. Am Heart J 1959; 58:46-52
Garpestad E, Goldberg S, Herth F, et al. CT fluoroscopy guidance for transbronchial needle aspiration: an experience in 35 patients. Chest 2001; 119:329-332
Gay PC, Brutinel WM. Transbronchial needle aspiration in the practice of bronchoscopy. Mayo Clin Proc 1989; 64:158-162
Harrow E, Halber M, Hardy S, et al. Bronchoscopic and roentgenographic correlates of a positive transbronchial needle aspiration in the staging of lung cancer. Chest 1991; 100:1592-1596
Lundgren R, Bligman F, Angstrom T. Comparison of transbronchial fine needle aspiration biopsy, aspiration of bronchial secretion, bronchial washing, brush biopsy, and forceps biopsy in the diagnosis of lung cancer. Eur J Respir Dis 1983; 64:378-385
Shure D, Fedullo PF. Transbronchial needle aspiration in the diagnosis of submucosal and peribronchial bronchogenic carcinoma. Chest 1985; 88:49-51
Wang KP, Terry PB. Transbronchial needle aspiration in the diagnosis and staging of bronchogenic carcinoma. Am Rev Respir Dis 1983; 127:344-347
Authors and Disclosures
Armin Ernst, MD, FCCP, Department of Pulmonary Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Gerard A. Silvestri, MD, FCCP, Division of Pulmonary Medicine, Medical University of South Carolina, Charleston, SC; David Johnstone, MD, FCCP, Division of Cardiothoracic Surgery, University of Rochester, Rochester, NY; for the ACCP Interventional Chest/Diagnostic Procedures Network Steering Committee
CHEST. 2003;123(5) © 2003 American College of Chest Physicians
The ACCP reserves the right to modify this disclaimer in its sole discretion. Use of the Guidelines following the posting of any such modifications shall be subject to such modified disclaimer.
