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Thoracic Imaging |
1 From the Department of Diagnostic Imaging, University of Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario, Canada K1Y 4E9. Received November 10, 1999; revision requested December 21; final revision received August 22, 2000; accepted September 19. Address correspondence to C.J.D. (e-mail: cdennie@ottawahospital.on.ca).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: In a prospective study of 506 consecutive outpatients who underwent TTNB of the lung, 440 patients underwent fine-needle aspiration biopsy (FNAB) only, and 66 underwent FNAB and core biopsy. Patients were discharged after 30-minute postbiopsy chest radiography if there was no pneumothorax. Patients were discharged after 60-minute chest radiography if they had a stable asymptomatic pneumothorax. These patients were followed up 1 day and/or 1 week after biopsy to identify delayed complications. Patients with a symptomatic or enlarging pneumothorax were treated with an 8-F pigtail catheter attached to a Heimlich valve, discharged, and followed up 24 hours later for chest tube removal.
RESULTS: The pneumothorax rate was 22.9% (116 patients). Eighty-one patients (16.0%) had an asymptomatic pneumothorax, and 33 (6.5%) had a pigtail catheter in place. Seven (1.4%) patients developed a symptomatic pneumothorax after discharge; two of them (0.4%) underwent large-bore chest tube insertion. The other five (1.0%) underwent delayed pigtail catheter insertion. There were no deaths or other major complications.
CONCLUSION: Early discharge after outpatient TTNB of the lung is associated with little morbidity and no mortality.
Index terms: Biopsies, complications, 60.126, 60.4129, 60.458 • Lung, biopsy, 60.126
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In spite of the frequent complication of pneumothorax, there is no uniform method of surveillance for its detection after TTNB. It has been estimated that most pneumothoraces occur within 30 minutes after biopsy (13). In a retrospective study of 673 TTNB procedures, Perlmutt et al (11) tried to determine the optimum time for performing postbiopsy chest radiography. Of the pneumothoraces requiring chest tube insertion, 88% were detected immediately, and none requiring intervention were detected after 1-hour radiography. A 30-minute radiograph was not obtained. Despite their conclusions, the authors recommended obtaining 1- and 4-hour postbiopsy radiographs in all outpatients, even if there was no pneumothorax on the 1-hour radiographs.
Even as recently as 1998, Moore (14) recommended 1-, 2-, and 3-hour chest radiography as routine surveillance after biopsy, and some authors (15) admit patients to a surgical day care unit before and after the procedure and incur costs in addition to those of the procedure. To our knowledge, the shortest reported observation period from lung biopsy to discharge of patients without a pneumothorax is 1 hour. Even so, the authors of the study in which this occurred (9) have their patients return to the hospital for 24-hour postprocedure chest radiography.
Since 1986, we have performed approximately 4,000 TTNBs. Almost all were performed on a completely outpatient basis with fluoroscopic guidance. Three to six biopsies are routinely performed per day, with patients scheduled 30 minutes apart; the procedure itself lasts 10–15 minutes. Our postbiopsy protocol has consisted of obtaining a chest radiograph 30 minutes after biopsy and discharging the patient if there is no pneumothorax. Although this procedure had never posed a problem to the patients as far as they knew, the purpose of the current study was to prospectively evaluate the safety of early discharge after TTNB of the lung.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Demographic information collected included patient age and sex, size and location of the lesion, number of pleural punctures, types of needle used, patient smoking history, and presence or absence of emphysema on the chest radiograph or CT scan. A visual assessment method similar to the pathologic panel-grading system was used for grading emphysema in patients who had undergone CT (16). Patients with less than 25% of the pulmonary parenchyma affected by emphysema received a classification of mild; patients with 26%–59%, moderate; and patients with more than 60%, severe.
The only contraindication to biopsy was anticoagulation therapy. Patients also were excluded from the study if no aerated lung was traversed during the biopsy. All complications were recorded, including whether pneumothorax was present or absent, and size if present; whether catheter placement was necessary; and whether patients had hemoptysis or pleuritic chest pain that was unrelated to pneumothorax.
After biopsy, all patients were placed in the decubitus position, with the side of the body on which biopsy had been performed facing down. We did not routinely monitor oxygen saturation after biopsy. A posteroanterior inspiratory chest radiograph was obtained with the patient in an erect position 30 minutes after biopsy, and the patient was again placed in the decubitus position, with the biopsy side down. If there was no pneumothorax, the patient was discharged with an information sheet. If there was a small asymptomatic pneumothorax, the patient was left in the decubitus position, with the biopsy side down, for another 30 minutes, and a posteroanterior inspiratory chest radiograph was obtained with the patient sitting erect 60 minutes after biopsy. If there had been no change in the size of the pneumothorax, patients also were discharged with the information sheet. All of the postbiopsy chest radiographs were interpreted by one of the two chest radiologists who performed or supervised the procedure.
Patients were telephoned 24 hours (n = 464) and/or 1 week (n = 506) after biopsy. Patients were asked whether they had experienced delayed symptoms such as shortness of breath or chest pain and whether this had led to repeat chest radiography and/or chest tube insertion at another institution.
The information sheet (Fig 1) instructed patients to return to the nearest emergency department if they developed symptoms after leaving the radiology suite. They were instructed to give the sheet to the emergency medicine physician, since it provided information regarding the side of the body on which biopsy had been performed, as well as the presence or absence of pneumothorax and its size, if present, at discharge. Other complications also were documented on this sheet.
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A posteroanterior inspiratory chest radiograph was obtained with the patients sitting erect after catheter placement to ensure complete or nearly complete resolution of the pneumothorax. If complete pleural symphysis was not present and the patient continued to have symptoms, the patient was admitted for underwater suction. If there was satisfactory repeat expansion of the lung, the patient was discharged with the tube in place and returned to our department after 24 hours. The tip of the Heimlich valve was then placed in a cup of water, and the patient was instructed to cough. If there was no bubbling, then the tube was removed, and a chest radiograph was obtained to document resolution of the pneumothorax prior to discharge. If an air leak was present, the tube was left in situ, and the patient returned home and was followed up every 24 hours until the leak had stopped. If subcutaneous emphysema developed 24 hours after catheter placement, a chest radiograph was obtained, since the emphysema was a clue that the air leak was beyond the capacity of the Heimlich valve. If the pneumothorax was larger than that seen on the chest radiograph obtained immediately after catheter placement, then the patient was admitted for underwater suction. If patients developed symptoms of a delayed pneumothorax and returned to our institution, they were referred back to us for 8-F catheter insertion and followed up in the same manner as detailed previously. These cases were labeled as delayed catheter insertions.
The rates of pneumothorax and of immediate and delayed catheter insertion were calculated. The percentage of patients who were admitted or experienced chest pain, hemoptysis, or a vasovagal reaction was also tabulated. The 
2 test was performed to determine whether there was a significant difference between the rate of pneumothorax and catheter placement in patients who underwent FNAB versus in those who underwent FNAB and core biopsy.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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There were 260 smokers. Forty-one patients had quit smoking 1–10 years before the biopsy, and 57 had quit smoking more than 10 years prior to the biopsy. There were 74 nonsmokers. Smoking history was unknown in 74 patients. One hundred ninety-nine patients had no visible emphysema on the chest radiograph or CT scan, 206 had mild emphysema, 85 had moderate emphysema, and 16 had severe emphysema.
Table 1 summarizes the complications in the 506 patients who underwent biopsy. The pneumothorax rate was 22.9% (116 patients). Eighty-one (16.0%) patients were discharged with a small asymptomatic pneumothorax, and 35 (6.9%) underwent chest tube placement. Of these 35, 33 had 8-F tubes inserted by us at our institution. Twenty-eight of these 33 had tubes placed prior to discharge; these procedures were labeled as immediate catheter insertions. The other five had tubes placed by us when the patients returned to the hospital. Three of these five patients were aware of a small asymptomatic pneumothorax after biopsy. These patients’ procedures were labeled as delayed catheter insertions.
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2 test showed no difference in the rates of pneumothorax and catheter placement in patients who underwent FNAB only versus those who underwent FNAB and core biopsy (P > .5). The rates were 16.6% and 7.0%, respectively, for FNAB and 15.2% and 6.1%, respectively, for core biopsy and FNAB. Only two patients underwent large-bore (28-F) tube insertion by a surgeon at a peripheral hospital. These procedures were both delayed chest tube insertions. One patient was aware of the presence of a small pneumothorax after biopsy.
Twelve (2.4%) patients experienced pleuritic chest pain that was unrelated to a pneumothorax. These patients were given analgesics, observed until the pain resolved, and then discharged. Thirty-five (6.9%) patients had transient hemoptysis and four (0.8%) had a vasovagal reaction that was unrelated to pneumothorax. These patients were treated with intravenously administered saline with or without atropine.
The time to delayed catheter insertion varied from 3 hours in two patients to 6 days in one. Most patients presented at the emergency department more than 3 hours after biopsy (Table 2). A majority of patients (n = 19) had a catheter placed for 24–48 hours. The longest duration of catheter drainage was 12 days (n = 1).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In their study of 447 biopsies, Stevens and Jackman (9) obtained immediate and 1- and 24-hour postbiopsy chest radiographs. They did not publish exact numeric results but stated that a pneumothorax developed only rarely after 1-hour chest radiography and that although the size of the pneumothorax enlarged between 1- and 24-hour chest radiography in 43% of patients, only a few required chest tube placement at 24 hours. In 1996, Kazerooni and colleages (22) published a study on the risk of pneumothorax in 121 CT-guided lung biopsies. Their pneumothorax rate was 44.6%, and they obtained chest radiographs 1 and 3 hours after the procedure. Ninety-one percent of pneumothoraces were depicted on the 1-hour chest radiograph, and 9% were depicted on only the 3-hour postbiopsy chest radiograph. None of the pneumothoraces detected 3 hours after biopsy required chest tube insertion.
Moore (14) must be commended for obtaining such a low pneumothorax and chest tube insertion rate (12% and 1%, respectively). The study protocol consisted of performing 1- and 2-hour postprocedure chest radiography and keeping the patient in the biopsy-side-down position until after the second radiographic examination was performed. Then 3-hour postbiopsy radiography was performed after allowing the patient to resume regular activity. The patient was discharged if there was no pneumothorax. This approach definitely yielded a lower pneumothorax and chest tube insertion rate, but many patients at Moore’s institution, especially obese patients and patients with moderate to severe emphysema, had difficulty lying in a prone position for a prolonged time after anterior-approach biopsy. These patients seemed to make up most of Moore’s biopsy population.
In the current study, patients were discharged 30 minutes after biopsy if there was no pneumothorax and 60 minutes after biopsy if there was a stable asymptomatic pneumothorax. Of note, the patients included in the current study were referred from a surrounding geographic area of up to 120 miles. Only seven, or 1.4%, of the patients had delayed pneumothoraces that required catheter drainage. All except three of the patients were aware of a pneumothorax at discharge. There was no tension pneumothorax or death related to the procedure.
On occasion, the pneumothorax enlarged slightly between 30- and 60-minute radiography. Patients with such enlargements underwent radiography every 30 minutes until the pneumothorax stabilized or the patient developed symptoms.
Eleven patients underwent 90-minute postbiopsy chest radiography: Two subsequently underwent chest tube insertion, and nine were subsequently discharged without a chest tube. One patient was kept 2 hours after biopsy with a pneumothorax that stabilized between 90- and 120-minute postbiopsy chest radiography, only to return the same evening for delayed chest tube insertion. In general, a pneumothorax was treated if the patient had symptoms, but if the pneumothorax extended down to the costophrenic sulcus in a patient without symptoms who lived more than 30 minutes from the nearest hospital, a catheter was inserted unless the patient could stay nearby overnight. Patients with severe emphysema were treated in the same manner as those without. However, these patients tended to develop symptoms with a much smaller pneumothorax than those without emphysema.
TTNB of pulmonary lesions is a safe and accurate procedure with minimal complications, as compared with those of thoracotomy (2%–3% mortality for lobectomy, and 1%–2% mortality for open biopsy) or video-assisted thoracoscopic surgery (<1% mortality) for diagnosis. At our institution, all patients with focal parenchymal lesions more than 5 mm in diameter and suspicious for cancer or requiring a tissue diagnosis undergo FNAB and/or core biopsy before more invasive procedures are performed. We attempt to make the procedure as innocuous and non–anxiety provoking as possible for patients.
One of the limitations of this study was that there was no control group in which a more traditional 1–2-hour postbiopsy observation period could have been compared with one of 30 minutes; in such a case, the two patients who returned 3 hours after biopsy for delayed catheter insertion might have avoided the inconvenience. The pneumothorax rate of 22.9% might also have been higher if patients had undergone radiography more than 1–2 hours after biopsy rather than only 30 minutes after biopsy. Finally, discharging patients earlier after biopsy may depend on the comfort level of the radiologist who is performing the procedure. Early discharge saves only the cost of two or three additional chest radiographs. However, it enables more flexibility in scheduling the procedures. In our institution, biopsies are performed in the afternoon, without incurring additional costs for keeping nurses and/or radiologic technologists overtime to monitor patients after biopsy and perform chest radiography. In this way, procedures that require patient fasting may be performed in the morning in the same room.
The results of the current study show that an observation period of 30 minutes after lung biopsy can be sufficient for those patients without a pneumothorax. Our postbiopsy patient treatment algorithm for outpatient lung biopsy is shown in Figure 2: A 30-minute postbiopsy chest radiograph is obtained; if there is no pneumothorax and the patient has no symptoms, the patient is discharged with an information sheet. If the patient has a pneumothorax and symptoms, an 8-F catheter is placed, and the patient is discharged with 24-hour outpatient follow-up until the air leak stops. For those patients experiencing pleuritic chest pain that is unrelated to pneumothorax, appropriate analgesics are given, and the patient is observed until the pain resolves and is then discharged. If there is a pneumothorax and the patient has symptoms, a second chest radiograph is obtained 60 minutes after biopsy. If the pneumothorax is stable in size on the 60-minute postbiopsy chest radiograph and the patient remains symptom free, he or she is discharged with an information sheet. However, if the pneumothorax has markedly enlarged and/or the patient has developed symptoms at the time of 60-minute chest radiography, a catheter is placed, with 24-hour outpatient follow-up.
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FOOTNOTES |
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Abbreviations: FNAB = fine-needle aspiration biopsy, TTNB = transthoracic needle biopsy
Author contributions: Guarantors of integrity of entire study, C.J.D., F.R.M.; study concepts, F.R.M.; study design, C.J.D., F.R.M.; literature research, C.J.D.; clinical studies, C.J.D., F.R.M., D.E.M.; data acquisition, J.R.M.; data analysis, C.J.D., D.E.M.; statistical analysis, C.J.D., D.E.M.; manuscript preparation, C.J.D.; definition of intellectual content, C.J.D.; manuscript editing and review, all authors; manuscript final version approval, C.J.D.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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