(Chest. 2002;122:985-989.)
© 2002
American College of Chest Physicians
Role of Transbronchial Needle Aspiration in Patients Receiving Mechanical Ventilation*
Shekhar Ghamande, MD;
Albert Rafanan, MD;
Raed Dweik, MD, FCCP;
Alejandro C. Arroliga, MD, FCCP and
Atul C. Mehta, MBBS, FCCP
* From the Department of Pulmonary and Critical Care (Drs. Ghamande, Dweik, Arroliga, and Mehta), Cleveland Clinic Foundation, Cleveland, OH; and Department of Pulmonary and Critical Care Medicine (Dr. Rafanan), St. Vincent Mercy Medical Center Hospital, Medical College of Ohio at Toledo, Toledo, OH.
Correspondence to: Atul C. Mehta, MBBS, FCCP, A90/Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195
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Abstract
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Study objectives: To evaluate the diagnostic accuracy and safety of transbronchial needle aspiration (TBNA) in patients receiving mechanical ventilation in the ICU.
Methods: Retrospective review of all patients in the medical and surgical ICUs from February 1999 to July 2001 who underwent TBNA while receiving mechanical ventilation.
Results: A total of eight histology (19 gauge) and eight cytology (22 gauge) TBNAs were performed on eight patients (four men and four women). TBNA yielded a definitive pathologic diagnosis in five of eight patients (62.5%). Diagnoses were posttransplantation lymphoproliferative disorder, large cell carcinoma, poorly differentiated non-small cell carcinoma, squamous cell carcinoma, and adenocarcinoma. Among patients with negative TBNA results (n = 3), two patients underwent mediastinoscopy. Results of mediastinoscopy were non-small cell carcinoma and inflamed tissue. TBNA led to management changes in five of these patients. Excluding one patient in whom a negative TBNA result could not be further confirmed, TBNA yielded a sensitivity of 83%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 50%. The overall accuracy of the procedure was 75%. There were no complications following any of the TBNAs.
Conclusions: In this small group of patients, TBNA was safe and had a high diagnostic accuracy in selected patients receiving mechanical ventilation in the ICU.
Key Words: bronchoscopy • diagnosis • HIV • human • lung cancer • mechanical ventilation • respiratory failure • transbronchial needle aspiration
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Introduction
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In critically ill patients, flexible bronchoscopy (FB) is employed for inspection of airways (eg, hemoptysis), removal of secretions (eg, following lobar atelectasis), collection of microbiological samples, and placement of drugs (eg, surfactant) and devices (eg, stent placement).1
In the ICU, FB is most often performed without the aid of fluoroscopy. Mechanical ventilation with the risk of barotrauma, coagulopathies, and hemodynamic instability limit the invasive procedures that can be performed on these patients. Transbronchial needle aspiration (TBNA) is an underutilized bronchoscopic technique.2
The use of FB for performing TBNA in the ICU has not been described, to the best of our knowledge. We describe our experience of using TBNA in patients receiving mechanical ventilation in the ICU who presented with significant hilar and/or mediastinal lymphadenopathy, in whom a definitive diagnosis was required.
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Materials and Methods
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Medical records of patients receiving mechanical ventilation between February 1999 and July 2001 who underwent TBNA performed during FB were reviewed. Data collected included patient demographics, clinical presentation at the hospital and ICU admissions, radiography, pathology, management changes after the TBNA, complications, and patient outcomes.
All patients received 7.5-mm or 8.5-mm endotracheal tubes. During bronchoscopy, all patients received 100% fraction of inspired oxygen with full ventilatory support. The exact sites for the TBNA were selected based on CT scans. The TBNA needles used were 19 gauge (MW-319) and 22 gauge (MW-222; Mill-Rose Corporation; Mentor, OH). Positive end-expiratory pressure was withdrawn, and two satisfactory specimens were obtained from each target site for histology, cytology, or both examinations using the TBNA according to previously described technique.2
No on-site cytopathologist was available for any of the procedures.
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Results
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Eight patients (four men and four women; age, 59.13 ± 19.36 years [mean ± SD]) who were receiving mechanical ventilation underwent TBNA using FB. Patient characteristics are described in Table 1
. The international normalized ratio (INR) was mildly elevated (< 1.54) in two patients at the time of the TBNA. One of these patients also had a platelet count of 37,000/µL. The INR, activated partial thromboplastin time, and the platelet counts were within normal limits in the rest of the patients. A total of 22 TBNA biopsies were performed (10 biopsies with 19-gauge histology needles, and 12 biopsies with 22-gauge cytology needles), for a mediastinal mass in two patients, a right hilar mass in one patient, right paratracheal lymphadenopathy in one patient, a left hilar mass in one patient, and subcarinal lymphadenopathy in three patients, because establishing the diagnosis of these abnormalities was believed to be imperative for the management of these patients.
The TBNA results and patient outcomes are described in Table 2 . TBNA was diagnostic in five of eight patients (62.5%). In one patient, a benign cytopathology was confirmed by a subsequent mediastinoscopy. The diagnoses obtained by TBNA were posttransplantation lymphoproliferative disorder (PTLD), large cell carcinoma, poorly differentiated non-small cell carcinoma, squamous cell carcinoma, and adenocarcinoma. In patient 2, the negative TBNA finding could not be confirmed by mediastinoscopy due to coagulopathy, and an autopsy could not be performed. In patient 4, the TBNA finding was negative; mediastinoscopy with biopsy revealed non-small cell lung cancer. Excluding patient 2 in whom a definite diagnosis was not made in the absence of an autopsy study, the TBNA yielded a sensitivity of 83%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 50%.
The management was altered in patients with diagnostic TBNA: patient 1 received anticytomegalovirus immune globulin and gancyclovir for PTLD with further plans for anti–CD-20 antibody therapy. Patient 3 was extubated, and a decision was made not to reintubate due to the metastatic nature of the disease; she underwent palliative radiation and chemotherapy. In patient 5, the malignancy workup was stopped following a negative mediastinoscopic biopsy result. Patient 6 deteriorated, and the family decided to withdraw life support based on the diagnosis provided by TBNA. Patient 7 underwent palliative radiation therapy and was successfully extubated 10 days later. He opted for comfort care at that point. Patient 8 could not be weaned off the ventilator. The family chose not to treat her malignancy, and she was moved to a long-term ventilator weaning facility. All the patients tolerated the procedure well. There were no complications.
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Discussion
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Lung cancer remains an important diagnostic problem in critically ill patients. In a study3
of 348 medical oncology patients admitted to the ICU, lung cancer was present in 16% of patients, and 48% of these patients died in the ICU. Respiratory failure in nonsurgical lung cancer patients carries a poor prognosis.4
An early diagnosis of malignancy in patients receiving mechanical ventilation may optimize the future care of these patients. CT scan of the chest has a low sensitivity (63%) and specificity (57%) compared with mediastinoscopy (89% and 100%, respectively) in staging of mediastinal lymph nodes.5
However, mediastinoscopy is an invasive procedure that involves dissection along the retrovascular pretracheal plane in close proximity to the great vessels. The overall morbidity of mediastinoscopy is 1.4 to 3.7%, and the mortality is 0.05 to 0.5%.6
Furthermore, cutaneous tracheostomies, coagulopathies, superior vena cava syndrome, and severe cardiovascular disease, which are relative contraindications for mediastinoscopy,7
limit the use of mediastinoscopy in critically ill patients.
In our group of ICU patients, TBNA yielded a diagnosis of malignancy in five patients. These results helped institute management changes in all five patients. One of the needle aspiration findings was a true-negative. The low negative predictive value of TBNA mandates a mediastinoscopy for negative results, especially if the suspicion for nodal involvement is high.8
This holds true for TBNA performed in patients receiving mechanical ventilation. A high suspicion of malignancy prompted two of our patients to undergo mediastinoscopy after a negative TBNA finding. One of these patients yielded a diagnosis of non-small cell carcinoma, and the other one patient confirmed the absence of infection or malignancy. TBNA did not contribute to management changes in these two patients.
The utilization of TBNA has increased over the last 10 years. However, most of the respondents in the American Association of Bronchology survey who responded positively about TBNA performed < 10 TBNAs in a year.9
In our study, only eight TBNAs were performed over a period of 2 years in busy ICUs. We contend that mediastinal pathology in the ICU may be underrecognized because CT scans of the chest are not frequently performed in the ICU. Besides, the clinicians may not have believed that performing TBNA would add substantial information to change short-term management in their critically ill patients, thereby leading to an underutilization of the TBNA.
Use of on-site cytopathology during TBNA, endobronchial brushing, or transbronchial biopsy increased the diagnostic yield from 50% to 81% in a prospective cohort study.10
Perhaps the availability of an on-site cytopathologist might have further augmented our yield and obviated the need for mediastinoscopy in our patients with a negative result, such as in patient 4. However, the procedural time constraints during bronchoscopy in patients receiving mechanical ventilation and the limited availability of an on-site cytopathologist decreases the utility of this technique in the ICU.
One report11
described the use of endosonography-guided fine-needle aspiration (EUS-FNA) in three critically ill patients. It was used to aspirate a mediastinal abscess in one patient, a paratracheal hematoma in another patient, and to sample mediastinal lymph nodes in the remaining patient with an apical lung lesion.11
EUS-FNA may have an important role in sampling posterior mediastinal lymph nodes and in patients with a negative TBNA finding in the ICU. EUS-FNA was shown to have a sensitivity of 96% and specificity of 100% in a prospective study of 35 ambulatory patients with negative bronchoscopy findings in the diagnosis of mediastinal involvement with lung cancer.12
However, a recent prospective study13
with sequential TBNA followed by EUS-FNA revealed equal sensitivity, specificity, and accuracy for diagnosis of patients with lung cancer and mediastinal lymphadenopathy.
Besides malignancy, TBNA may also be useful in diagnosing infections in immunocompromised patients in the ICU, which was a consideration in patients 1 and 3. Patient 1 was a lung transplant recipient who was receiving broad-spectrum antimicrobials for pneumonia and sepsis. BAL failed to identify the specific organism. TBNA yielded PTLD on his cytopathology as well as histology (Fig 1 , 2
). Patient 3 had AIDS with an undiagnosed mediastinal mass despite an earlier mediastinoscopic biopsy at an outside hospital. TBNA revealed a poorly differentiated non-small cell carcinoma. He received right and left mainstem bronchus Ultraflex stents (Boston Scientific; Boston, MA) along with radiation therapy, which facilitated his extubation. Harkin et al14
demonstrated the usefulness of TBNA with a 19-gauge needle in HIV-infected patients with mediastinal and hilar lymph node sampling.
Excluding patient 2 with no definite diagnosis, TBNA demonstrated a high sensitivity and specificity in our group of patients. Although this should be interpreted with caution due to the small sample size, our results may be explained by the advanced presentation in these patients with larger targets for TBNA. There is a positive linear correlation of diagnostic yield obtained by a TBNA with the lymph node size.15
In our opinion, this is valid for patients receiving mechanical ventilation. The smallest lesion sampled in our study was 2 cm in size. Attempting a smaller-sized pathology is less likely to be fruitful due to the additional technical difficulties imposed by performing bronchoscopy in patients receiving mechanical ventilation.
TBNA was not associated with any complications in our study. All of our patients were critically ill, and there was no selection bias to explain the lack of complications. TBNA has been found to be safe in outpatients, with an overall morbidity of 0.1%.8
Major complications are infrequent and include bleeding, pneumothorax, pneumomediastinum, pyopericardium, hemomediastinum, and delayed bleeding 5 days after TBNA.16
17
18
19
20
Overall, we believe that TBNA is a safe procedure even in the challenging ICU environment in patients receiving mechanical ventilation.
In summary, mediastinal masses or lymphadenopathy > 2 cm in size confirmed by a CT scan can be safely sampled via a bronchoscopic needle aspiration in patients receiving mechanical ventilation, especially when obtaining such a diagnosis is going to substantially impact on the immediate management of these patients. Severe hypoxia on a ventilator, significant uncorrected coagulopathy (INR > 2), shock, recent myocardial infarction, or ongoing ischemia would be contraindications for such a procedure. A negative yield by TBNA in the setting of a strong clinical suspicion should prompt a more invasive procedure like mediastinoscopy for a definitive diagnosis.
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Conclusion
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In our small study, TBNA was found to be a safe and useful minimally invasive technique in the ICU in selected patients receiving mechanical ventilation. TBNA has a high sensitivity, specificity, and positive predictive values in this setting. Additional diagnosis obtained by the TBNA helps in the management of these critically ill patients. CT scan confirmed mediastinal masses or lymphadenopathy > 2 cm in size are suitable targets for performing TBNA in selected patients receiving mechanical ventilation.
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Figure 2. Top: Cytology obtained by TBNA demonstrating PTLD in patient 1 (methylene blue stain, original x 400). Bottom: Histology obtained by TBNA demonstrating PTLD in patient 1 (hematoxylin-eosin, original x 200).
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Footnotes
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Abbreviations: EUS-FNA = endosonography-guided fine-needle aspiration; FB = flexible bronchoscopy; INR = international normalized ratio; PTLD = posttransplant lymphoproliferative disorder; TBNA = transbronchial needle aspiration
Received for publication October 12, 2001.
Accepted for publication February 7, 2002.
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References
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Abstract
Introduction
