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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 2  |  Page : 246-251

Evaluation of risk factors in pneumothorax development after computerized tomography-guided transthoracic biopsy and management of complications


1 Department of Radiology, Harran University, Faculty of Medicine, Şanliurfa, Turkey
2 Department of Radiology, İnonu Universty, Faculty of Medicine, Malatya, Turkey

Date of Submission31-Oct-2018
Date of Acceptance11-Nov-2019
Date of Web Publication7-Feb-2020

Correspondence Address:
Dr. M Kolu
Department of Radiology, Harran University, Medical Faculty, Sanliurfa 63100
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_541_18

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   Abstract 


Aims: This study aims to discuss the relationship between complications and patient characteristics and lesion properties in the transthoracic fine needle aspiration biopsy (TTFNAB) procedures performed for lung lesions and the treatment applied in our clinic to eliminate these complications. Methods: In this retrospective study conducted from July 2014 to August 2017, the CT-guided TTFNAB was performed on 186 patients (145 males, 41 females) who were considered to have malignancies on their clinical evaluation, CT, and PET CT results. Results: After 186 CT-guided TTFNAB interventions, a total of 24 (12.9%) patients developed procedure-related pneumothorax. Of these patients, 7 had a limited and minimal pneumothorax and no treatment was required for them, while 17 had a large and increasing pneumothorax and manual air aspiration was performed with coaxial needle during the procedure. The number pleural transitions (OR 6.513; 95%, 2,529-16,771 P < 0.001), emphysematous lungs (OR 4.612; 95%, 1,852-11.487 P < 0.001), and the presence of a lesion unrelated to the pleura (OR 8.205; 95%, 3,162-21,291 P < 0.001) can form the basis for the development of a pneumothorax. Conclusion: The chances of developing pneumothorax after TTFNAB depend on number of pleural transition, emphysematous lungs, and non-pleural lesions. However, it is considered that procedures such as manual air aspiration and autologous blood patch may reduce the need for chest tube following the development of pneumothorax.

Keywords: Lung nodules, pneumothorax, transthoracic fine needle biopsy


How to cite this article:
Kolu M, Yildirim I O. Evaluation of risk factors in pneumothorax development after computerized tomography-guided transthoracic biopsy and management of complications. Niger J Clin Pract 2020;23:246-51

How to cite this URL:
Kolu M, Yildirim I O. Evaluation of risk factors in pneumothorax development after computerized tomography-guided transthoracic biopsy and management of complications. Niger J Clin Pract [serial online] 2020 [cited 2020 Oct 1];23:246-51. Available from: http://www.njcponline.com/text.asp?2020/23/2/246/277871




   Introduction Top


There has been a significant increase in the number of lesions detected in lungs with the increasing use of computed tomography (CT) devices. While this increases the early diagnosis chance in patients, and the transthoracic biopsy (TTB) numbers increase in daily practice with each passing day. However, the number of difficult lesions increases in terms of TTB because of the lesion sizes and localizations. From this respect, the management of complication of TTB procedures performed along with CT becomes important. The CT-guided transthoracic fine needle aspiration biopsy (TTFNAB) procedures are still being widely used as the most efficient method for cytological evaluation of the pulmonary nodules.[1],[2] Pneumothorax is the most common complication seen with the CT and its incidence rate is approximately 17% – 26.6%, requirement for chest tubes is reported to be approximately between 1%-14.2%.[3] In this study, it was aimed to discuss the relationship between complications and patient characteristics and lesion properties in the transthoracic fine needle aspiration biopsy (TTFNAB) procedures performed for lung lesions and the treatment applied in our clinic to eliminate these complications.


   Methods Top


Patients

In this retrospective study conducted from July 2014 to August 2017, the CT-guided TTFNAB was performed on 186 patients (145 males, 41 females) who were considered to have malignancies on their clinical evaluation, CT, and PET CT results. After informing the patients about the complications related to the procedure, a consent form was received from each patient. Patients with normal platelet count and activated thromboplastin time within one week prior to the procedure were taken to the procedure. Patients using aspirin, clopidogrel and warfarin stopped taking their medications 1 week before the procedure. Patients requiring continued anticoagulation were administered IV heparin instead of warfarin, and low-molecular weighted heparin was administered subcutaneously instead of aspirin and clopidogrel.

TTFNAB method

All TTFNAB procedures were performed by 2 interventional radiologists with 2 and 6 years of experience, respectively, in the thoracic biopsy. The FNAB procedure was performed with the CT (Aquillion 64 MDCT Toshiba Japan, 256 MDCT Somatom Siemens Germany) with placement of radio-opaque grid on the skin and lesion intended thorax CT images were obtained to find a suitable entry point for the lesion. Then the laser marker was automatically directed to the section where the selected image was located. It was reached to the lesion from the suitable point on the skin. The technical parameters in the CT procedure were 120 mAs, 100 KV, with the section thicknesses being set at 5 mm.

Patients were prepared in lateral, prone, supine positions according to lesion localization. The entry point for the biopsy was chosen with a steep angle to the lesion as much as possible and the shortest route was selected while avoiding less aerated lung tissue, bullous and emphysematous areas, interlobar fissures, and visible bronchia. No sedatization was performed on any patient. Following sterilization of the entry point, 1% lidocaine 5-10 cc subcutaneous local anesthetic agent was administered. All biopsy procedures were performed with the coaxial method, using 5 and 10 cm long 17-gauge outer coaxial needles and 10, 15, 20 cm long 22-gauge inner Chiba aspiration needles. After the FNAB procedure (on site), taking specimens was repeated until it was considered to be enough by the operator, since there was no pathologist.

Lesion characterization

All pulmonary lesions were measured according to their maximal diameters. The distance between the pleura-lesion and the skin-lesion was calculated. Patient position during puncture, lung lobe containing the lesion, relation of the lesion with the pleura, the number of pleural transitions, and the condition of lungs (emphysematous – non-emphysematous) were recorded.

Evaluation of the complications

After the biopsy, it was re-entered to the pleural space with coaxial needle because of the medium-serious pneumothorax. Attempts to aspirate the pleural space were made with an interconnection and triple tap connected to the needle end, and this was followed by the pleural patch pleurodesis procedure performed by injecting 5-10 cc autologous blood to the pleural space without removing the coaxial needle [Figure 1]. Immediately afterwards, the patients were taken to the puncture-site-down position. These patients were then given 2 L/s O2 via nasal cannula and were monitored for heart rate, respiratory count, blood pressure, and O2 saturation level for 3 hours. The control chest radiographs were taken at the end of the 3rd hour. If the pneumothorax is small and stable in control lung radiographs, the patients were discharged after being advised to apply to the emergency department in case symptoms, such as severe chest pain and difficulty in breathing are seen. Chest tubes were inserted in patients with a progressive and symptomatic pneumothorax. The hemogram follow-up was performed and the next day once control CT was taken in patients who were detected to have severe parenchymal hemorrhagic areas after the CT.
Figure 1: A pneumothorax is seen during the single pleural transition in the lateral position in a 65-year-old male patient with the diagnosis of adenocarcinoma

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Statistical analysis

The statistical evaluation of the data was carried out using the SPSS 15 (Statistical Package for Social sciences) program. The Student's T-test was used to assess quantitative data in addition to descriptive statistical methods (mean, standard deviation) when evaluating the study data. The relationships of all quantitative data with each other were examined using the Pearson correlation coefficient. The results were evaluated at a confidence level of 95%, and the significance was assessed at the P < 0.05 level.

Evaluation of independent risk factors associated with pneumothorax

Patient characteristics were determined as age and gender, lesion characteristics as the lesion size, its localization in lungs, and lung parenchymal properties (emphysematous – non-emphysematous). The method-related properties were the distance between the pleura-lesion and the skin-lesion, and the number of pleural transitions. The parameters in patients with or without a pneumothorax were analyzed to determine the risk factors in the formation of a pneumothorax. Then, the multivariate logistic regression analysis was performed to determine the independent risk factors of the parameters which were statistically significantly different in both groups. The low-risk category associated with the pneumothorax determined the univariate-analysis was taken as a reference. The odds ratio (OR) of > 1.00 probability of a diagnostic failure was accepted to be high. The P value of < 0.05 was accepted to be statistically significant.


   Results Top


Data about patients, lesions and methods are shown on [Table 1]. After 186 CT-guided FNAB interventions, a total of 24 (12.9%) patients developed procedure-related pneumothorax. Of these patients, 7 had a limited and minimal pneumothorax, and no treatment was required for them, while 17 had a large and increasing pneumothorax and manual air aspiration was performed with coaxial needle during the procedure. In 12 patients who underwent aspiration, the pleural patch procedure was performed with the autologous blood of the patients, and a chest tube was placed in 6 (3.2%) of these patients upon the continuation and increasing of the pneumothorax. Hemoptysis was detected in a total of 9 patients. No patient was required to be treated for hemorrhage. No systemic air embolism was detected in any of these patients.
Table 1: The patient, lesion and procedure characteristics

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According to the univariate analysis for CT-guided FNAB [Table 2], the significant risk factors in the development of a pneumothorax were determined as small nodules, distance of a lesion from the pleura, the number of pleural transitions, the presence of a lesion unrelated to the pleura, and the pulmonary emphysema. According to the multivariate logistic regression analysis, the number of pleural transitions (OR 6.513; 95%, 2,529-16,771 P < 0.001), the presence of a lesion unrelated to the pleura (OR 8.205; 95%, 3,162-21,291 P < 0.001), and pulmonary emphysema (OR 4.612; 95%, 1,852-11.487 P < 0.001) were found to be significant independent risk factors. There were no statistically significant differences between the groups with and without pneumothorax in terms of age, gender, lobar localization, and procedure position.
Table 2: The univariate analysis of risk factors in development of pneumothorax

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   Discussion Top


CT-guided transthoracic biopsy is a safe procedure that substantially provides an accurate diagnosis. Complications related to the procedure are largely tolerable, and the most frequent complications are pneumothorax and pulmonary hemorrhage. There are also less frequent complications such as air embolism, tumor spread, and infection.[3]

In the literature, there are different rates for the pneumothorax complications, while the pneumothorax rate was 15%, the chest tube requirement was 6.6% and the rate of pulmonary hemorrhage was 1% after 15860 procedures in a multicenter study by Wiener et al. conducted in North America.[4] In this study, there was no separation between the core or fine needle biopsy procedures. In another large-series study by Tomiyama et al., it was reported that their pneumothorax rates were 35% at the end of 9783 biopsy procedures.[5]

However, the procedure method, lesion characteristics, and patient-related factors were effective in the development of a pneumothorax. SIR and ACR (In Quality improvement Guidelines for Percutaneous Needle Biopsy) stated that the estimated pneumothorax ratio could be between 12-45% and the chest tube requirement between 2-15% in the transthoracic biopsy procedures.[6]

The difference in pneumothorax ratios has been an object of interest in many studies and the factors affecting the development of a pneumothorax during biopsy procedures were investigated. In these studies, the risk factors associated with a pneumothorax ranging from patient characteristics to lesion, procedure method, and the biopsy needle thickness have been identified [Table 3].[7],[8],[9],[10],[11],[12],[13],[14],[15]
Table 3: Post transthoracic biopsy related pneumothorax, important studies looking at the risk factors for placement of a chest tube

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In the present study, the number of pleural transitions, pulmonary emphysema, and the presence of a lesion unrelated to the pleura were found to be independent risk factors in the development of a pneumothorax. These were among the risk factors previously described in the literature.[10],[11],[12],[13],[14] In this study, the rate of pneumothorax was 12.9%, which was tolerable when compared with the literature.[8],[10],[12],[14] However, in our patients the requirement for a chest tube was 3.2% and this rate was distinctly low compared to many other studies. It is considered that the low rate of chest tube requirement after the TTFNAB procedure in our clinic is associated with the procedures that we applied in the complication management. It is considered that the chest tube requirement was minimalized as a result of the manual air aspiration followed by the autologous blood patch and the procedure performed on the pleural space for each patient with progressive and severe pneumothorax. Studies showing that the rates of chest tube placement decrease only after manual aspiration following a pneumothorax also support this.[16],[17],[18] Moreover, there are also many studies which emphasize that the autologous blood patch applied to the parenchymal and pleural space may be a mitigating factor for the requirement of a chest tube after pneumothorax.[19],[20],[21]

In our clinic, the manual air aspiration and autologous blood patching in the pleural space were applied together in rapidly progressive and serious symptomatic patients. It is considered that the simultaneous implementation of these two procedures is a preventive factor in chest tube placement in patients with a pneumothorax.

In conclusion, the number of pleural transitions, pulmonary emphysema, and the presence of a lesion unrelated to the pleura may form the basis for the development of a pneumothorax. However, it is considered that procedures such as manual air aspiration and autologous blood patch performed after the development of a pneumothorax may reduce the patient's need for a chest tube afterwards.

Acknowledgements

The authors would like to thank all of the participants involved in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Tomiyama N, Yasuhara Y, Nakajima Y, Adachi S, Arai Y, Kusumoto M, et al. CT-guided needle biopsy of lung lesions: A survey of severe complication based on 9783 biopsies in Japan. Eur J Radiol 2006;59:60-4.  Back to cited text no. 5
    
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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