Bronchus-blocked ultrasound-guided percutaneous transthoracic needle biopsy (BUS-PTNB) for intubated patients with severe lung diseases

Abstract

Background: Examinations based on lung tissue specimen can play a significant role in the diagnosis for critically ill and intubated patients with lung infiltration. However, severe complications including tension pneumothorax and intrabronchial hemorrhage limit the application of needle biopsy.

Methods: A refined needle biopsy technique, named bronchus-blocked ultrasound-guided percutaneous transthoracic needle biopsy (BUS-PTNB), was performed on four intubated patients between August 2020 and April 2021. BUS-PTNB was done at bedside, following an EPUBNOW (evaluation, preparation, ultrasound location, bronchus blocking, needle biopsy, observation, and withdrawal of blocker) workflow. Parameters including procedure feasibility, sample acquisition, perioperative conditions, and complications were observed. Tissue specimens were sent to pathological examinations and microbial tests.

Results: Adequate specimens were successfully obtained from four patients. Diagnosis and treatment were correspondingly refined based on pathological and microbial tests. Intrabronchial hemorrhage occurred in patient 1 but was stopped by endobronchial blocker. Mild pneumothorax happened in patient 4 due to little air leakage, and closed thoracic drainage was placed. During the procedure, peripheral capillary hemoglobin oxygen saturation (SPO₂), blood pressure, and heart rate of patient 4 fluctuated but recovered quickly. Vital signs were stable for patient 1-3.

Conclusions: BUS-PTNB provides a promising, practical and feasible method in acquiring tissue specimen for critically ill patients under intratracheal intubation. It may facilitate the pathological diagnosis or other tissue-based tests for intubated patients and improve clinical outcomes.

Keywords: Bronchoscopy; Endobronchial blocker; Intubation; Needle biopsy; Sonography.

Fig. 1

Key Steps of BUS-PTNB. Needle biopsy was carried out at bedside under ultrasound guidance. To prevent severe complications, mainly tension pneumothorax and massive intrabronchial hemorrhage, an endobronchial blocker was placed at lobar bronchus by a bronchoscope while sampling

Fig. 2

Biopsy site and vision of bronchial blocking under bronchoscopy for patient 1. a, b Chest CT of patient 1 showed diffuse patchy ground glass opacity with local interstitial changes over bilateral lung fields. Arrowheads indicate the site of puncture. c Bronchoscopy showing the endobronchial blocker was initially placed in the common basal segmental bronchus. d, e Then bleeding occurred in the dorsal segmental bronchus. f The endobronchial blocker was withdrawn backwards to inferior lobar bronchus to stop bleeding

Fig. 3

Biopsy sites for patient 2, 3 and 4. a, b Needle biopsy site was carefully chosen based on CT evaluation before procedure and sonography during the procedure. Right anterior segment was chosen for biopsy in patient 2. c, d And right posterior basal segment was chosen in patient 3. e For patient 4, right dorsal segment was chosen for puncture. f After closed thoracic drainage, sonography showed no air left in thoracic cavity

Fig. 4

Hematoxylin and eosin staining of acquired tissue specimen. a H&E staining of patient 1 showed non-specific inflammation accompanied with interstitial fibrosis with lymphocyte and plasma cell infiltration. Mild alveolar epithelial hyperplasia can be observed and red staining materials aggregated in alveolar lumen with dispersed tissue cells. b H&E staining of patient 2 showed alveolar hyaline membrane formation with large nuclei hyperchromatic cells in the alveolar space. c H&E staining of patient 3 showed alveolar epithelial and interstitial fibrous tissue hyperplasia, inflammatory exudate, foam cell aggregation and inflammatory cell infiltration in alveolar cavity. d H&E staining of patient 4 showed focal chronic inflammation with fibrous hyperplasia