Part 3B: Endobronchial Brushing volume 1

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Part 3B Endobronchial Brushingvolume 1
Strategy and Planning Execution

• Bronchoscopy International

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When to perform endobronchial brushing

• Visible airway mucosal abnormalities
• Visible airway nodules or masses
• In case of suspected sarcoidosis (even if airway
  mucosa appears normal)
• In case of abnormal autofluorescence to diagnose
  intraepithelial lesions (dysplasia, metaplasia,
  carcinoma in-situ)

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Training is essential in order to

• Learn proper techniques and indications
• Avoid procedure-related complications.
• Learn to protect the equipment and the patient
• To obtain adequate tissue for diagnosis
• To avoid damaging the working channel
• To avoid excess patient discomfort (cough,
  anxiety, shortness of breath).
• To avoid bleeding, that might also prompt cough
  and patient agitation.

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Q1 Optimal endobronchial brushing samples
requires correct processing
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Q8 Optimal endobronchial brushing samples
requires correct processing
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TRUE. Brushing samples must be processed
correctly and according to the needs and
preferences of your institutions cytology and
microbiology laboratories.

• Other ways to potentially increase diagnostic
  yield include
• Using brushes with longer bristles
• Brushing vigorously and for a longer period of
  time.
• Making sure that all parts of the brush are in
  contact with the mucosal abnormality.
• Using the pirouette technique (rotation) in
  combination with long-axis motion.

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Bronchial brushing

• Originally done under fluoroscopy without
  bronchoscopy
• Common indications
• Visible endobronchial tumors or mucosal
  abnormality
• Peripheral tumors (/- fluoroscopy)
• Peripheral infection pneumonia, abscess, cavity
• Brush samples larger surface area of lesion

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Bronchial brushing

• Different size brushes
• Standard 3 mm cytology
• 7 mm brush (rarely used)
• No sheath
• For visible lesions only
• Cannot be retracted into scope
• Collects more cells but yield and bleeding
  equivalent to 3 mm1
• Protected specimen brush
• Avoid upper airway contamination
• For diagnosis of infection/ quantitative cultures
  

From Flexible Bronchoscopy Wang and Mehta
1Cleve Clin J Med 198754195-203
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Bronchial brushing

• Technique
• Advance catheter into desired segment then
  extend brush (up to 5 cm)
• Make sure brush extension doesnt push back the
  scope or catheter
• Move back and forth over the visible lesion or
  blindly in distal airway (5-10 times) /-
  rotation
• Cells collected in brush bristles

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Bronchial brushing

• Yield
• 94 endoscopically visible/peripheral 781
• 92 central and peripheral with fluoro2
• 77 endoscopically visible/20 peripheral with
  fluoro3

1CHEST 197363889-892 1Am Rev Respir Dis
197410963-66 2CHEST 197465616-619 3CHEST
197669752-757
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Bronchial brushing

• Complications
• Bleeding
• Pneumothorax

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Biopsy vs cytology

• 154 patients with malignant pulmonary lesions
• Each patient had (EBB or TBB) AND (TBNA or
  brushing)
• EBB/TBB sensitivity 62.8
• TBNA/brush (cyto) sensitivity 69.2
• Combined sensitivity 87.2

J Bronchol 200411154-159
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Additional literature
J Bronchol 200411154-159
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Endobronchial Brushing

• Brush samples large area of mucosal abnormality
• May be done under direct visualization, or with
  fluoroscopic guidance
• Brushes may be bare of within a covering sheath

Brush Video
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Indications and brushing techniques

• Indications
• Visible airway mucosal abnormality
• Peripheral lesion (lung nodule, abcess etc)
• Peripheral lung infiltrate
• Techniques
• Extend catheter into target segment
• Extend brush Brush out. Be certain extended
  brush does not cause pain or pneumothorax, nor
  push bronchoscope proximally.
• Brush forcefully and gently and frequently (5-10
  times) with and without brush rotation so that
  all parts of brush touch the lesion.
• Retract brush Brush in.
• Remove the catheter-brush from the working
  channel.

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Brushing Yield

• Greatest when cancer is present
• 94 in case of central lesion, 78 in case of
  peripheral lesions. But yields can also be as low
  as 20 for peripheral lesions.

Chest 197363889, Chest 197669752, J Bronchol
200411154
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Brushing-related Complications

• Bleeding
• Pneumothorax
• Perforation of lung abscess

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Bleeding risk if Thrombocytopenia lt50,000

• Risk of bleeding 0-26 (TBBx, post transfusion)
  (1)
• Brushing with mean platelet count of
  30,000Bleed 16 , Death 4 (2)
• What to do? Transfuse 6 packs before during
  bronchoscopy, no need to recheck platelets (3)
• Platelet half-life 6 hours!
• (1) Weiss S, Chest, 19931041025
• (2) Papin T, Chest, 1985 8854
• (3)Wahidi M, Respiration 200572285

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Combined procedures have greatest yield for
malignancy

• Arch Bronchoneumol. 200642(6)278-82
• 75 patients underwent bronchial washing before
  (pre) and after (post) endobronchial biopsy and
  brushing

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This presentation is part of a comprehensive
curriculum for Flexible Bronchoscopy. Our goals
are to help health care workers become better at
what they do, and to decrease the burden of
procedure-related training on patients.

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Bronchoscopy.org
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International to maintain currency of online
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shows, streaming videos, and essays can be cited
for reference as

• Bronchoscopy International Art of Bronchoscopy,
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  Date Accessed).

Thank you
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Prepared with the expert assistance of Udaya
Prakash M.D. (Mayo Clinic, USA), and Atul Mehta
M.D. (Cleveland Clinic, USA), and Wes Shepherd
M.D. (Virginia Commonwealth University, USA)
www.bronchoscopy.org