Safety and diagnostic yield of transbronchial lung cryobiopsy by flexible bronchoscopy using laryngeal mask airway in diffuse and localized peripheral lung diseases: A single-center retrospective analysis of 326 cases

Low bleeding rates following transbronchial lung cryobiopsy in unclassifiable interstitial lung disease

BACKGROUND AND OBJECTIVE

Bronchoscopic transbronchial lung cryobiopsy (TBLC) is a guideline-endorsed alternative to surgical lung biopsy for tissue diagnosis in unclassifiable interstitial lung disease (ILD). The reported incidence of post-procedural bleeding has varied widely. We aimed to characterize the incidence, severity and risk factors for clinically significant bleeding following TBLC using an expert-consensus airway bleeding scale, in addition to other complications and diagnostic yield.

METHODS

A retrospective cohort study of consecutive adult outpatients with unclassifiable ILD who underwent TBLC following multidisciplinary discussion at a single centre in the UK between July 2016 and December 2021. TBLC was performed under general anaesthesia with fluoroscopic guidance and a prophylactic endobronchial balloon.

RESULTS

One hundred twenty-six patients underwent TBLC (68.3% male; mean age 62.7 years; FVC 86.2%; DLCO 54.5%). Significant bleeding requiring balloon blocker reinflation for >20 min, admission to ICU, packed red blood cell transfusion, bronchial artery embolization, resuscitation or procedural abandonment, occurred in 10 cases (7.9%). Significant bleeding was associated with traction bronchiectasis on HRCT (OR 7.1, CI 1.1-59.1, p = 0.042), a TBLC histological pattern of UIP (OR 4.0, CI 1.1-14, p = 0.046) and the presence of medium-large vessels on histology (OR 37.3, CI 6.5-212, p < 0.001). BMI ≥30 (p = 0.017) and traction bronchiectasis on HRCT (p = 0.025) were significant multivariate predictors of longer total bleeding time (p = 0.017). Pneumothorax occurred in nine cases (7.1%) and the 30-day mortality was 0%. Diagnostic yield was 80.6%.

CONCLUSION

TBLC has an acceptable safety profile in experienced hands. Radiological traction bronchiectasis and obesity increase the risk of significant bleeding following TBLC.

[Navigational bronchoscopy with tranbronchial cryobiopsy in differential diagnosis of peripheral pulmonary lesions]

OBJECTIVE

To evaluate the efficacy and safety of tranbronchial cryobiopsy (TBCB) with 1.9-mm and 1.1-mm cryoprobes in patients with peripheral pulmonary lesions (PPLs).

MATERIAL AND METHODS

We analyzed 34 patients (mean age 60 years) with PPLs who underwent bronchoscopy with TBCB. Mean lesion size was 31.5 mm, upper lobe localization was predominant (47% of cases). CT signs of appropriate bronchus were identified in 79% (27/34) of cases. Manual branch tracking and virtual bronchoscopy (VB) were performed pre-procedurally, and radial endobronchial ultrasonography (rEBUS) was performed during bronchoscopy for accurate positioning of PPLs. TBCB was performed using 1.9-mm (n=19) or 1.1-mm (n=15) cryoprobes without fluoroscopic guidance. Incidence and severity of bleeding and pneumothorax were evaluated in all patients.

RESULTS

Total efficacy of TBCB was 76.5% (26/34): 78.9% (15/19) for 1.9-mm cryoprobe and 73.3% (11/15) for 1.1-mm cryoprobe (p=0.702). Efficacy depended on the presence of CT signs of bronchus (presence - 94%, absence 14.3%, p<0.001) and PPL size (94% for PPL >30 mm and 58.8% for PPL <30 mm, p=0.016). Central probe position during rEBUS was associated with 94.7% diagnostic efficacy (18/19), adjacent probe position - 72.7% (8/11) (p=0.088). Bleeding grade 3 (Nasville) occurred in 5.8% (2/34) of cases, and no pneumothorax was observed.

CONCLUSION

TBCB is an effective and safe diagnostic method for PPLs.

Transbronchial lung cryobiopsy for peripheral pulmonary lesions. A narrative review

An increasing number of peripheral pulmonary lesions (PPLs) requiring tissue verification to establish a definite diagnosis for further individualized management are detected due to the growing adoption of lung cancer screening by chest computed tomography (CT), especially low-dose CT. However, the morphological diagnosis of PPLs remains challenging. Transbronchial lung cryobiopsy (TBLC) that can retrieve larger specimens with more preserved cellular architecture and fewer crush artifacts in comparison with conventional transbronchial forceps biopsy (TBFB), as an emerging technology for diagnosing PPLs, has been demonstrated to have the potential to resolve the clinical dilemma pertaining to currently available sampling devices (e.g., forceps, needle and brush) and become a diagnostic cornerstone for PPLs. Of note, with the introduction of the 1.1 mm cryoprobe that will be more compatible with advanced bronchoscopic navigation techniques, such as radial endobronchial ultrasound (r-EBUS), virtual bronchoscopic navigation (VBN) and electromagnetic navigation bronchoscopy (ENB), the use of TBLC is expected to gain more popularity in the diagnosis of PPLs. While much remains for exploration using the TBLC technique for diagnosing PPLs, it can be envisaged that the emergence of additional studies with larger data accrual will hopefully add to the body of evidence in this field.

Role of Transbronchial Lung Cryobiopsy in the Diagnosis of Interstitial Lung Disease: A Meta-analysis of 68 Studies and 6300 Patients

BACKGROUND

Diagnosis of interstitial lung disease (ILD) is based on multidisciplinary team discussion (MDD) with the incorporation of clinical, radiographical, and histopathologic information if available. We aim to evaluate the diagnostic yield and safety outcomes of transbronchial lung cryobiopsy (TBLC) in the diagnosis of ILD.

METHODS

We conducted a meta-analysis by comprehensive literature search to include all studies that evaluated the diagnostic yields and/or adverse events with TBLC in patients with ILD. We calculated the pooled event rates and their 95% confidence intervals (CIs) for the diagnostic yield by MDD, histopathologic diagnostic yield, and various clinical adverse events.

RESULTS

We included 68 articles (44 full texts and 24 abstracts) totaling 6386 patients with a mean age of 60.7±14.1 years and 56% men. The overall diagnostic yield of TBLC to achieve a definite or high-confidence diagnosis based on MDD was 82.3% (95% CI: 78.9%-85.2%) and histopathologic diagnosis of 72.5% (95% CI: 67.7%-76.9%). The overall rate of pneumothorax was 9.6% (95% CI: 7.9%-11%), while the rate of pneumothorax requiring drainage by a thoracostomy tube was 5.3% (95% CI: 4.1%-6.9%). The rate of moderate bleeding was 11.7% (95% CI: 9.1%-14.9%), while the rate of severe bleeding was 1.9% (95% CI: 1.4%-2.6%). The risk of mortality attributed to the procedure was 0.9% (95% CI: 0.7%-1.3%).

CONCLUSION

Among patients with undiagnosed or unclassified ILD requiring tissue biopsy for diagnosis, transbronchial cryobiopsy represents a reliable alternative to surgical lung biopsy with decreased incidence of various clinical adverse events.

Transbronchial lung cr onchial lung cryobiopsy for the diagnosis of diffuse obiopsy for the diagnosis of diffuse parenchymal lung disease: Pitfalls and challenges, a single center experience

BACKGROUND

: Transbronchial lung cryobiopsy (TBLC) is a minimally invasive technique of the diagnosis of diffuse parenchymal lung diseases (DPLD). The aim of this study is to determine the clinical-radiological and histopathological characteristics of patients in whom cryobiopsy contributes to the diagnosis.

METHODS

: In this retrospective study, we searched for the medical records of patients who underwent TBLC from July 2015 to March 2020 at the pulmonology department of our university hospital clinic. Radiological images were evaluated by a chest radiologist experienced in DPLD. Prediagnosis was indicated by clinical-radiological findings. The final diagnosis was determined by the contribution of histopathological diagnosis. The agreement of pretest/posttest diagnosis and the diagnostic yield of TBLC were calculated.

RESULTS

Sixty-one patients with female predominance (59.0%) and current or ex-smoker (49.2%) made up the study population. We found the diagnostic yield of TBLC 88.5%. The most common radiological and clinical-radiological diagnosis was idiopathic pulmonary fibrosis (IPF) (n = 12, 19.6%) while the most common multidisciplinary final diagnosis was cryptogenic organizing pneumonia (COP) (n = 14, %22.9). The concordance of pre/posttests was significant (p < 0.001) with a kappa agreement = 0.485. The usual interstitial pneumonia (UIP) diagnosis was detected in six patients among 12 who were prediagnosed as IPF having also a suspicion of other DPLD by clinical-radiological evaluation (p < 0.001). After the contribution of TBLC, the multidisciplinary final diagnosis of 22(36.1) patients changed. The histopathological diagnosis in which the clinical-radiological diagnosis changed the most was nonspecific interstitial pneumonia (NSIP).

DISCUSSION

We found the overall diagnostic yield of TBLC high. The pretest clinical-radiological diagnosis was often compatible with the multidisciplinary final diagnosis. However, TBLC is useful for the confirmation of clinical radiological diagnosis as well as clinical entities such as NSIP which is difficult to diagnose clinical-radiological. We also suggest that TBLC should be considered in patients whose clinicopathological IPF diagnosis is not precise.

Anesthesia for interventional pulmonology

PURPOSE OF REVIEW

Anesthesia for pulmonological interventions is a demanding challenge. This article discusses recent innovations and the implications for periinterventional anesthetic management.

RECENT FINDINGS

Interventional pulmonology is a rapidly expanding specialty with very complex diagnostic and therapeutic approaches that include oncological staging, treatment of obstructive and restrictive lung diseases, recanalization of endobronchial obstructions, and retrieval of foreign bodies. With the development of advanced diagnostic and therapeutic interventions, the application is extended to critically ill patients. Current evidence focusing on the anesthetic techniques is presented here.

SUMMARY

The development of new pulmonological methods requires a tailored anesthesiological approach. Their specific impact must be taken into account to ensure patient safety, goal-oriented outcome diagnostics and -quality, successful interventions, and patient comfort.