Methodology in Transbronchial Lung Biopsy

Abstract

To the Editor: We feel compelled to comment on Zavala's1Zavala DC Pulmonary hemorrhage in fiberoptic transbronchial biopsy.Chest. 1976; 70: 584-588Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar article entitled “Pulmonary Hemorrhage in Fiberoptic Transbronchial Biopsy.” While we share his concern over the problem of hemorrhage following transbronchial lung biopsy, our beliefs regarding methodology differ significantly. There should be no question that the patient's safety is of paramount importance. On the other hand, methods required to ensure safety are, and should be, open to critical appraisal. It is with Zavala's1Zavala DC Pulmonary hemorrhage in fiberoptic transbronchial biopsy.Chest. 1976; 70: 584-588Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar rigid methodology that we disagree. His comments regarding methods were stated very dogmatically, but we know of no evidence that his method is safer than others used around the country. At our institution, transbronchial lung biopsies are performed transnasally with no premedication unless specifically indicated. Our current experience includes 175 patients who underwent two to four biopsies each. Some of these cases have previously been reported.2Scheinhorn DJ Joyner LR Whitcomb ME Transbronchial forceps lung biopsy through the fiberoptic bronchoscope in Pneumocystis carinii pneumonia.Chest. 1974; 66: 294-295Crossref PubMed Scopus (38) Google Scholar, 3Joyner LR Scheinhorn DJ Transbronchial forceps lung biopsy through the fiberoptic bronchoscope: Diagnosis of diffuse pulmonary disease.Chest. 1975; 67: 532-535Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4Koontz CH Joyner LR Nelson RA Transbronchial lung biopsy via the fiberoptic bronchoscope in sarcoidosis.Ann Intern Med. 1976; 85: 64-66Crossref PubMed Scopus (103) Google Scholar, 5Beechler CR Enquist RW Kneisner MR et al.Linear immunofluorescence of transbronchial lung biopsies in patients with Goodpasture's syndrome.Am Rev Respir Dis. 1976; 113: 112Google Scholar While significant bleeding has occurred in several patients, only one patient has required intubation for respiratory support, and she had significant respiratory insufficiency prior to the procedure. There have been no deaths associated with the procedure. In our hands, it appears that the use of an endotracheal tube for all patients undergoing transbronchial biopsy is unwarranted; however, the use of such a tube in selected individuals, particularly those with respiratory insufficiency or bleeding tendencies (or both), may be indicated. Our experience also differs from Zavala's1Zavala DC Pulmonary hemorrhage in fiberoptic transbronchial biopsy.Chest. 1976; 70: 584-588Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar in the routine use of fluoroscopy. Physical limitations at our institution make the routine use of fluoroscopic techniques difficult; thus, most of our procedures are done without fluoroscopic guidance unless the patient has localized disease (less than lobar). Our complications include only two pneumothoraces in the 175 patients, which we believe is an acceptable rate. While the patient's safety and comfort should remain the first priority in the performance of any procedure, our experience with transbronchial lung biopsy indicates a more critical appraisal of the methodology is indicated.