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(Chest. 2002;121:1521-1526.)
© 2002 American College of Chest Physicians

The Incidence and the Risk of Pneumothorax and Chest Tube Placement After Percutaneous CT-Guided Lung Biopsy*

The Angle of the Needle Trajectory Is a Novel Predictor

Hisashi Saji, MD; Haruhiko Nakamura, MD; Takaaki Tsuchida, MD; Masahiro Tsuboi, MD; Norihiko Kawate, MD, FCCP; Chimori Konaka, MD, FCCP and Harubumi Kato, MD, FCCP

* From the Department of Surgery, Tokyo Medical University, Tokyo, Japan.

Correspondence to: Hisashi Saji, MD, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan; e-mail: saji-q{at}ya2.so-net.ne.jp


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objective: Pneumothorax remains the most common complication of percutaneous CT-guided lung biopsy, despite improved techniques. The rate of pneumothorax reported in the literature ranges from 19 to 60%. The aims of this study were to estimate the risk of pneumothorax in patients undergoing CT-guided lung biopsy, and to determine which factors affect its occurrence.

Design: Retrospective study.

Patients and methods: This study involved 289 consecutive patients who underwent biopsy in our hospital under consistent methods, using only one type of needle, the 19-gauge Tokyo Medical College (TMC) Needle (Takei; Tokyo, Japan), under CT guidance.

Result: Seventy-seven patients (26.6%) had pneumothorax after percutaneous CT-guided lung biopsy. Forty-one of the 77 patients (53.2%) who had pneumothorax (14.2% of the entire series) required placement of a chest tube. Our present study, using multivariate logistic regression analysis, confirmed that greater lesion depth, wider trajectory angle, and increasing FVC percent predicted are independent risk factors of pneumothorax, and that two former factors are independent risk factors of chest tube placement following percutaneous CT-guided lung biopsy.

Conclusions: The angle of needle route is a novel predictor of this complication. Our findings suggest that low pneumothorax rates are achieved by combining several techniques to reduce the risk of pneumothorax.

Key Words: chest tube placement • percutaneous CT-guided lung biopsy • multivariate logistic regression analysis • pneumothorax • risk factor • Tokyo Medical College Needle


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Percutaneous needle aspiration of the lung has been described as a successful means of diagnosing chest abnormalities for > 100 years.1 The popularity of needle aspirations has varied over time. Despite its accuracy and safety, one major limitation to its use is the associated high pneumothorax rate. Studies2 3 4 5 6 7 8 9 have reported that pneumothorax rates were between 19% and 60%. There are several reports4 5 10 11 12 13 suggesting that various technical factors affect the risk of pneumothorax, such as needle size, number of needle insertions, procedure duration, guidance by fluoroscopy or CT scan, and depth from pleura to lesion. In addition, according to functional factors, lung disease with obstruction or hyperinflation has been suggested to increase the risk of pneumothorax.3 7 8 12 14

Among the numerous reports investigating factors that influence the occurrence of pneumothorax, many have yielded ambiguous results, because of various technical means and inappropriate methods of statistical analysis. Moreover, these results were based on a limited number of patients. The aims of the present study were to evaluate the risk of pneumothorax in patients undergoing CT-guided lung biopsy, and to determine which factors affect its occurrence. This study involved 289 consecutive patients who underwent biopsy by the same method, using the simple, 19-gauge, Tokyo Medical College (TMC) Needle (Takei; Tokyo, Japan), under CT guidance.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Eligibility
This study included 289 consecutive lung biopsies under CT guidance performed in our institution from January 1998 to December 1999. Patients in this series had a pulmonary mass or nodule and negative bronchofiberscopic examination results, including transbronchial lung biopsy and transbronchial aspiration cytology with fluoroscopic guidance. Informed consent was obtained before the procedure in all cases.

Methods
All patients underwent chest CT before CT-guided lung biopsy at the time of the biopsy to measure the size and the depth of the lesion, to accurately localize it, and to plan the approach. CT was chosen for guidance in all cases instead of fluoroscopy for reasons of access and safety. The procedure was performed by senior surgeons in our department, who were experienced in CT-guided biopsies.

Patients were placed in prone, spine, or lateral decubitus positions, depending on the location of the lesion, to provide the most direct route for biopsy. Selected slices were obtained within the area of interest with 2- to 8-mm slices. Localization was performed using CT imaging with laser light and a grid system. Biopsies were planned to avoid ribs, bullae, vessels, and fissures. Each needle path was planned to provide the shortest route and as vertical an approach for the pleura as possible.

The biopsy was routinely performed without any premedication or fasting. Premedication or neuroleptic anesthesia was reserved for extremely anxious patients. Local anesthesia consisting of subcutaneous injection of 1% lidocaine was administered to all patients. All biopsies were performed using the 19-gauge TMC Needle. Breath holding was limited to when the needle was crossing the pleura. The biopsy needle was introduced to the edge of the lesion and was checked using CT as a guide for proper advancement of the needle. The number of needle insertion attempts never exceeded three.

After the procedure, a chest radiograph was obtained to verify the appearance of the lung and to check for pneumothorax. Small asymptomatic pneumothoraces were treated conservatively with monitoring of vital signs and follow-up chest radiographs to confirm stability. Patients with stable pneumothorax were returned to the ward for further observation. A chest tube was inserted for drainage in patients who had pneumothorax with signs of respiratory distress or shortness of breath.

Lung function tests were performed within 1 month before or after the procedure. All lung function tests were performed using a calibrated pneumotachograph in accordance with the guidelines of the American Thoracic Society. Pulmonary function testing included FVC, FEV1, FVC percent predicted, and FEV1 percent predicted.

Variables analyzed in relation to the occurrence of pneumothorax included those dependent on the patient and the biopsied lesion. The patient-dependent data considered were age, sex, and lung function findings. Lesion variables were size, location, depth of the lesion from the pleural point of entry of the needle, and the needle insertion angle (Fig 1 ).



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  		Figure 1.. Line A is the tangent at the point of pleural entry of the needle. Line B is drawn perpendicular to it. The needle trajectory angle is that between the actual needle route and line B.

 
TMC Needle
The TMC Needle has a 1-mm (19-gauge) outer sheath and a 0.8-mm inner needle. The needle is introduced to the edge of the lesion. We removed the inner needle and inserted another inner needle with many thorn-like protrusions at the tip to harvest the cell specimens (Fig 2 ). The inner needle is then removed, and its contents are smeared on a glass slide. This procedure is repeated four or five times with new inner needles in order to gather many cells. Moreover, we can prevent implantation of malignant cells along the needle by this technique, because the inner needle with protrusions is inserted into the tumor and is removed from the tumor through the outer needle.



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  		Figure 2.. The TMC Needle. Shown are (A) the outer needle, 1.0 mm in diameter; (B) the inner core, 0.8 mm in diameter; and (C) the sampling inner needle, which has many thorn-like protrusions at its tip. It is 15 mm in length.

 
Needle Tract Angle of Deviation
In order to determine whether the angle of penetration of the needle had any significance with regard to postprocedural complications, we established the concept of angle of deviation. The tangential line to the point of contact between the needle and the pleura is designated A. The line perpendicular to A at the point of contact is designated B, and the angle of deviation of the needle tract is that between the longitudinal axis of the needle and line B (Fig 1) .

Statistical Analysis
Patients were classified into two groups according to the occurrence of pneumothorax and that of chest tube placement after CT-guided lung biopsy. Comparison of variables was performed between both groups. Univariate statistical analysis was performed using Student’s t test for independent data in the case of quantitative variables. For qualitative variables, the Pearson {chi}2 coefficient was calculated. In both analyses, a p < 0.05 was taken as indicating statistical significance. Multivariate logistic regression analysis was performed to evaluate possible associations between different variables and the incidence of pneumothorax and of chest tube placement. Only variables significant by univariate analysis were included in the logistic regression model. This analysis was performed with specific software (StatView 5.0; SAS Institute; Cary, NC).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The study included 169 men (58.5%) and 120 women (41.5%). The mean age (± SD) of the population was 64.0 ± 11.4 years (range, 25 to 93 years). The lesion was in the upper lung field in 111 patients (38.4%) and lower lung field in 178 patients (61.6%). The mean lesion size was 21.0 ± 14.2 mm (range, 3.0 to 90.0 mm). The average depth from the pleura to the lesion was 16.1 ± 14.9 mm (range, 1.0 to 65.0 mm). The mean angle of the needle path was 23.5 ± 15.9° (range, 1.0 to 65.0°). Among the patients who underwent complete lung function tests, mean values were as follows: FVC percent predicted, 101.4 ± 19.9% (range, 51.4 to 169.2%); FEV1 percent predicted, 75.6 ± 11.8% (range, 27.7 to 100.4%).

Seventy-seven patients (26.6%) had pneumothorax after percutaneous CT-guided lung biopsy; of those, 41 patients (53.2%) required placement of a chest tube. Table 1 shows variables in the 289 patients classified into two groups: those with and those without pneumothorax. In univariate analysis, variables associated with a significantly higher rate of pneumothorax were sex (p = 0.0071), lesion size (p = 0.0448), pleura-to-lesion distance (p < 0.0001), angle of the needle path (p = 0.0003), and pulmonary function, including FVC percent predicted and FEV1 percent predicted (p = 0.0018 and p = 0.0285, respectively). Sex significantly correlated with FVC percent predicted (p = 0.0074). Therefore, we performed multivariate logistic regression analysis using the factors of lesion size, lesion depth, angle of the needle trajectory, and pulmonary function, including FVC percent predicted and FEV1 percent predicted. In multiple regression analysis, the independent risk factors were pleura-to-lesion distance (p = 0.0012), angle of the needle trajectory (p = 0.0411), and FVC percent predicted (p = 0.0044). Odds calculation ratios and confidence intervals for variables considered in the multivariate regression analysis were 1.038 (range, 1.015 to 1.061), 1.023 (range, 1.001 to 1.046), and 1.028 (range, 1.009 to 1.048), respectively (Table 2 ).


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  		Table 1.. Relationship Between Occurrence of Pneumothorax and Clinical Factors Evaluated by Univariate Analysis*

 

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  		Table 2.. Relationship Between Occurrence of Pneumothorax and Clinical Factors Evaluated by Multivariate Logistic Regression Analysis

 
Table 3 shows variables in the 289 patients classified into two groups: those with and those without chest tube placement. On regression analysis, location of the lesion, lesion size, lesion depth, and angle were significantly correlated with the need for chest tube placement for pneumothorax; p values were 0.0068, 0.0282, < 0.0001, and 0.0001, respectively. None of the lung function test variables were associated with occurrence of chest tube placement. On multiple regression analysis, pleura-to-lesion distance and needle tract angle of deviation were independent risk factors of chest tube placement. Odds calculation ratios and confidence intervals for variables considered in the multivariate regression analysis were 1.048 (range, 1.024 to 1.073) and 1.031 (range, 1.007 to 1.055), respectively (Table 4 ).


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  		Table 3.. Relationship Between Occurrence of Chest Tube Placement and Clinical Factors Evaluated by Univariate Analysis*

 

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  		Table 4.. Relationship Between Occurrence of Chest Tube Placement and Clinical Factors Evaluated by Multivariate Logistic Regression Analysis

 
In the univariate analysis among 77 patients with pneumothorax, patients with chest tube placement had significantly lower location, greater depth of lesion, and wider angle of needle route than those without chest tube placement. The p values were 0.0142, 0.0095, and 0.0900, respectively. (Table 5 ).


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  		Table 5.. Pneumothorax With and Without Chest Tube Placement, Univariate Analysis*

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Pneumothorax remains the most common complication of CT-guided lung biopsy, despite improved techniques. The rate of pneumothorax following lung biopsy with CT guidance reported in the literature ranges from 19 to 60%.2 3 4 5 6 7 8 9 In our study, the rate of pneumothorax was 26.6%, and that of chest tube placement was 14.2%, which were similar to rates observed in other studies.15 16 17 18 19 20 21 22 Many authors reported that various items influence this rate, including patient factors (age, sex, lung function, and presence of emphysema), lesion variables (size, depth, location, and pleural contact), and procedure-related factors (experience of the operator, degree of difficulty, imaging method used for guidance, and type of needle used).

Among patient factors, male gender, increased FVC percent predicted, and decreased FEV1 percent predicted significantly correlated with pneumothorax following CT-guided lung biopsy on univariate analysis. Multivariate analysis shows FVC percent predicted to be one of independent risk factors. Studies9 13 14 involving multivariate logistic regression analysis noted that neither decreasing FEV1 percent predicted nor none of the lung function test variables were significantly associated with occurrence of pneumothorax. The result in our report that increasing FVC percent predicted reduces the risk of pneumothorax differs from previous reports. We speculated that the greater the movement of the lung while the needle is in the lung, the greater the risk of pneumothorax, but the mechanism remains unclear. Therefore, further studies are needed to identify it.

Concerning procedure-related factors, in our study, all patients underwent biopsy by a single type of needle, the 19-gauge TMC Needle, under CT guidance. Experienced operators in our department perform all biopsies. Therefore, consistent methods were employed in all procedures.

According to lesion variables, a long pleura-to-lesion distance is a major predictive factor of pneumothorax following CT-guided lung biopsy in this present study, which agrees with multivariate studies.3 7 8 12 13 19 In addition, we emphasize that the angle of the needle path is a novel predictor of pneumothorax after CT-guided lung biopsy. As in previous studies, the number of needle passes was important for the occurrence of pneumothorax. We noticed that the greater the angulation the less the success in hitting the nodules by a single insertion, and concluded that the angulation might have some correlation with the number of attempts. Thus, the number of needle insertion attempts never exceeded three in our department.

The depth of the lesion and the angle of needle route are also independent predictors of chest tube placement for pneumothorax. Therefore, we speculate that using the shortest route and keeping the needle as vertical to the pleura as possible might be more important predictors of pneumothorax than pulmonary function in percutaneous CT-guided lung biopsy.

Multivariate logistic regression analysis in this series confirmed that greater lesion depth, wider insertion angle, and increased FVC percent predicted are independent risk factors of pneumothorax after percutaneous CT-guided lung biopsy, and that distance and angle of deviation are independent risk factors for the necessity of chest tube placement. The angle of the needle route is a novel predictor of this complication. Although the importance of age, lesion site, lesion size, and FEV1 percent predicted were previously considered to be important factors of pneumothorax, these were not found to be predictors in this study. Our findings suggest that low pneumothorax rates are achieved by combining several techniques to reduce the risk of pneumothorax.


   Acknowledgements
 
We thank Toshiya Onoda, Tatsuo Ohira, Kiyoshi Ogata, and Masaharu Nomura for assistance and comments. The authors thank Professor J. Patrick Barron of the International Medical Communications Center of Tokyo Medical University for his review of this article.


   Footnotes
 
Abbreviation: TMC = Tokyo Medical College

Received for publication February 15, 2001. Accepted for publication December 12, 2001.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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