Indications for blind pleural biopsy

This is an automatically translated article.

The article was professionally consulted with MSc.BS Nguyen Huy Nhat - Department of Medical Examination & Internal Medicine - Vinmec Danang International General Hospital.
Blind pleural biopsy is a technique with the aim of removing some pieces of the parietal pleura for histopathological examination. Blind pleural biopsy is indicated in case of exudative pleural effusion or blood red fluid.

1. Blind pleural biopsy

Blind pleural biopsy, also known as closed pleural biopsy, is a technique performed with the aim of taking some pieces of the parietal pleura for histopathological examination.

2. Indications and contraindications

2.1 Designation

Blind pleural biopsy is indicated in cases of exudative pleural effusion or blood red fluid. In which pleural effusion is the phenomenon of appearing more fluid than normal physiological level in the pleural space, due to many causes and changes in clinical and X-ray. The amount of fluid in the pleural space is normally about 10-15ml.

2.2 Contraindications

Coagulation disorder, hemostasis cannot be adjusted, when the test index shows: platelets < 90 G/l, Prothrombin ratio < 60% Hemodynamic disorders Severe cardiac arrhythmias Respiratory failure Chronic renal failure , acute renal failure

3. Implementation steps

3.1 Preparation

Blind pleural biopsies are performed by doctors and nurses trained in pleural biopsies. In addition, some of the equipment needed to perform a blind pleural biopsy include:
2 ampoules of atropine 1/4mg and 5 ampoules of lidocaine 2% 2ml Anti-shock kit. Syringe 5ml, syringe 20ml, needle 20G, needle.. N2 gauze: 2 packs. Transmission line: 1 set. Fork: 1 pc. Scalpel blade: 1 pc. Castelain biopsy needle set includes: cutting needle and specimen collection needle, a trocar set. Sample tubes for testing fluid: 5 tubes Formol container to preserve specimens after biopsies: 1. Petri dishes containing physiological saline for biopsy specimens: 1 pc. Fluid drainage tank: 1 pc. Sterile gloves: 2 pairs, clean gloves: 1 pair. Sterile razor.

To the patient, the doctor explains the purpose and possible complications during the procedure. After that, the patient signed the commitment and prepared some test results that were performed such as:
chest X-ray CT chest Ultrasound pleural blood test, basic coagulation.

3.2 Implementation steps

About 15 minutes before the procedure, the patient was injected subcutaneously with 1 ampule of atropine 1/4 mg. Place the patient in the equestrian position Locate the pleural biopsy. The biopsy site will be on the superior edge of the rib to avoid the intercostal nerve bundle. If this is the second biopsy, avoid the site where the first time was performed. Disinfect the area to be biopsied, and spread the hole. Anesthetize each layer of the chest wall, from the skin to the pleural wall. Avoid intravascular injection of Lidocaine. Then use anesthetic needle to probe the pleural fluid. Mark chest wall thickness. 500ml of 0.9% sodium chloride can be injected into the pleural space before biopsy for cases with little fluid. Place the set screw on the trocar so that the distance from the trocar tip to the screw is equal to the chest wall thickness plus 0.5cm. At the biopsy site, use the scalpel blade to make a small incision in the skin. Insert the trocar through the incision in a direction perpendicular to the chest wall. Withdraw the trocar barrel and attach a 20ml syringe to the trocar's sheath, aspirate, if fluid comes out, the trocar has entered the pleural space.

Remove the 20ml pump, quickly insert the cutting needle into the trocar's sheath, and proceed to cut. Rely on the markers on the cutting needle and on the sheath of the trocar to position the needle so that the cross-section of the needle is facing the parietal leaf. Close the biopsy needle to the chest wall, with the left hand fix the trocar shell tightly, with the right hand pull the cutting needle strongly, if it feels heavy, it's okay. The cutting needle is still in the trocar, slowly bring both needles to a position perpendicular to the chest wall, quickly withdraw the cutting needle from the trocar shell, and immediately replace the 20ml pump. Use a specimen collection needle to remove the pleural piece from the cutting end of the needle and place it in a petri dish with physiological saline available. Conduct biopsies of 3-5 specimens. After the biopsy, the nurse took the specimen and placed it in the formol vial. Avoid biopsies of the area between 11 am and 2 hours to avoid intercostal nerve bundles. In order to prevent pneumothorax, it is necessary to instruct the patient to exhale completely and then hold the breath at each needle or syringe change, or to remove the biopsy needle. After biopsy, if you want to remove the pleural fluid, you need to replace it with a 20G needle or a peripheral venous catheter, which is connected to a set of forks and an infusion line.

4. Monitoring and handling complications

After the biopsy, the patient will be monitored in the ward. Some clinical symptoms such as fatigue, chest pain, sweating, subcutaneous emphysema, aspiration of a lot of air after biopsy, change in color of fluid if pleural bleeding is red, ..
Some complications may occur during and after blind pleural biopsy such as:
Elevated vagal: the patient will feel tired, dizzy, slow pulse, low blood pressure. Need to stop the procedure, have the patient lie down, inject 2 ampoules of Atropin 1/4 mg intramuscularly and breathe oxygen through the nose. Continue to monitor pulse rate, blood pressure, and blood oxygen saturation. When blood pressure is <90/60mmHg, it is necessary to place a peripheral intravenous line immediately. Pneumothorax: there are symptoms such as chest pain, cough, shortness of breath,... The patient needs to have a straight chest X-ray. If the case of pneumothorax is less, give oxygen and monitor, or aspirate with a needle. If pneumothorax is large, pleural drainage is indicated. Hemothorax: the patient has symptoms of fatigue, chest pain, shortness of breath, blue skin, pale mucous membranes, rapid pulse, low blood pressure,... Perform pleural effusion to drain blood, transfuse red blood cells, Consult a specialist surgeon, monitor the amount of drainage > 300ml/hour for surgery.

Infection of the pleural cavity: The patient may have a fever, pleural effusion reveals purulent fluid or the fluid has many degenerated neutrophils, pleural fluid culture looks for bacteria. Need treatment: antibiotics, pleural lavage if the fluid is small and localized, open the pleura to drain and pump out daily if the purulent fluid is clear or the fluid is abundant. Other complications are less common such as: tearing of the diaphragm, spleen, liver and embolism due to gas. In summary, blind pleural biopsy is a technique performed with the aim of removing some pieces of parietal pleura for histopathological examination for diagnostic purposes. Blind pleural biopsy is indicated in case of exudative pleural effusion or blood red fluid. Once performed, the patient should be monitored. If there are any abnormal signs, it is necessary to notify medical staff for timely treatment.
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