TRANSBRONCHIAL NEEDLE ASPIRATION: An Underused Diagnostic Technique
Section snippets
INDICATIONS
The indications for using TBNA are summarized as follows:
Major To establish the diagnosis in patients with,
Mediastinal or hilar adenopathy Extrinsic compression of the airway by peribronchial process Submucosal disease Peripheral nodules
To stage known or suspected lung carcinoma in patients with,
Mediastinal or hilar adenopathy
In the diagnosis of endobronchial lesions with,
Necrotic tumor
Hemorrhagic tumor
Predicting line of surgical resection
Follow-up of small-cell
INSTRUMENTS
A variety of needles are now available and selection of the appropriate needle depends on the indication: (1) For staging central lesions, it is best to use a needle that is at least 12 mm long with a catheter stiff enough to allow exertion of sufficient force to push the needle through the tracheobronchial wall into the lymph node. Catheter stiffness is enhanced by a metal stylet; (2) for peripheral lesions, a more flexible catheter is desirable; (3) to obtain a histology specimen, at least a
TECHNIQUE
The chest radiograph (CXR) and CT scan should be thoroughly reviewed to locate lymph nodes and lung lesions before any elective procedure is recommended. Reviewing the images helps select the proper site for needle insertion and also increases the diagnostic yield. If a submucosal/peribronchial or endobronchial lesion is detected during routine FB, TBNA can be performed even without imaging studies. A routine coagulation profile is not required unless the patient is at increased risk for
Staging of Carcinoma
The clinical usefulness of TBNA lies in its ability to sample lymph nodes situated beyond the confines of but in close proximity to the airways, enabling presurgical staging. Thus, it is essential to know the anatomy of the tracheobronchial tree, the location of the lymph nodes, and specifically, the location of the major vessels that interface with the airways so that these structures can be avoided for needle puncture.37, 95
TBNA can sample lymph nodes on either side of the airways that are
SUMMARY
Despite its proven usefulness, TBNA is not widely used. An American College of Chest Physicians (ACCP) survey showed that only 11.8% of pulmonologists use TBNA.56 Most pulmonologists in the 1980s were not formally trained in TBNA. This lack of training has unfortunately translated to minimal emphasis on TBNA in current training programs in a large number of institutions.27 Technical problems with the procedure (faulty site selection, incomplete needle penetration, catheter kinking that prevents
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Address reprint requests to Atul C. Mehta, MD, FCCP, FACP, Department of Pulmonary and Critical Care Medicine, Desk A-90, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195