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Vascular and Interventional Radiology |
1 Department of Radiology, Hospital of Saint Raphael, 1450 Chapel St, New Haven, CT 06511.
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Abstract |
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 TOP Abstract IntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: Four hundred twenty-three needle biopsies of the lung were performed in 390 patients from October 1991 to August 1994 with computed tomographic guidance, fluoroscopic guidance, or both. Two hundred forty-two biopsies were performed from the posterior approach, 166 from the anterior approach, and 15 from the lateral approach. The patients were assigned on an alternating basis to either the puncture-site–dependent recumbent position (210 biopsies) or the puncture-site–nondependent recumbent position (213 biopsies) for at least 1
hours after biopsy.
RESULTS: No significant differences were found in either the incidence of pneumothorax (dependent position, 62 of 210 biopsies [30%], vs nondependent position, 57 of 213 biopsies [27%]; P = .60) or the incidence of pneumothorax that required chest tube placement (dependent position, 10 of 210 biopsies [5%], vs nondependent position, six of 213 biopsies [3%]; P = .43).
CONCLUSION: The results suggest that the puncture-site–down postbiopsy position may not affect either the incidence of postbiopsy pneumothorax or the incidence of pneumothorax that requires chest tube placement.
Index terms: Biopsies, complications, 60.458 • Lung, biopsy, 60.126 • Pneumothorax, 60.732
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Introduction |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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The average number of passes per procedure was 1.7 (range, one to six). The need for immediate additional passes was based on the relative confidence level of the operator that the lesion had been sampled and on the gross appearance and size of the specimen. With large necrotic lesions, two specimens were usually obtained: one from the center of the lesion and one from the periphery. Immediate preliminary cytologic analysis was not available at our hospital during the course of this study; however, a preliminary report was usually rendered within 20–30 minutes. When additional passes were required because of inadequate material, they were usually repeated on the same day; that is, the patient was brought back from the nursing holding area to the procedure room, usually within 2 hours after the original procedure. Additional passes performed on the same day were classified as a single biopsy procedure; biopsies performed on another day were classified as a repeat (additional) procedure.
After the procedure (usually consisting of one or two passes), the patient was immediately transferred from the CT or fluoroscopic table to a stretcher while the recumbent position was maintained, with the puncture site either down (dependent) or up (nondependent). Patients were sequentially assigned to either the dependent or nondependent postbiopsy position on an alternating basis. Thirty-nine patients were unable to tolerate the prone position and were placed in the supine position; the next two patients were placed so as to maintain equal numbers of patients in the dependent and nondependent groups. Fifteen patients who underwent biopsy from the lateral approach were placed in either the dependent or nondependent lateral decubitus position.
After the biopsy, the condition of each patient was monitored (including periodic evaluation of vital signs and arterial oxygen saturation) by nursing staff in the patient holding area of the radiology department. If the patient developed pain, dyspnea, or hypoxemia, a chest radiograph was obtained immediately after biopsy. Supplemental nasal oxygen therapy was administered only to patients who developed dyspnea, decreasing arterial oxygen saturation, or both. Asymptomatic patients were maintained in the assigned recumbent position for 1 hours, at which time a chest radiograph was obtained with the patient in the upright (erect) position. If no pneumothorax was found, the patient was discharged. Patients with an asymptomatic pneumothorax on the 1-hour radiograph were maintained in the same dependent or nondependent position and were monitored clinically for an additional 1–2 hours, at which time a repeat chest radiograph was obtained. Most asymptomatic patients whose pneumothorax stabilized (no increase in pneumothorax size for at least 1 hours) and was less than an estimated 35%–40% and who had good cardiopulmonary function and normal arterial oxygen saturation were discharged with instructions to call and return if symptoms developed.
Estimation of the percentage of pneumothorax was performed by simple visual assessment by the radiologist who had performed the lung biopsy. The assessment was based on an estimate of the percentage area occupied by the pneumothorax compared with the area occupied by the entire hemithorax on a single posteroanterior upright chest radiograph at expiration. The size of the pneumothorax was only one factor affecting the decision to treat or not treat with chest tube placement, and greater emphasis was placed on the condition of the patient, that is, the presence of dyspnea or pain, the oxygen saturation, and underlying cardiopulmonary disease.
Patients with a pneumothorax that was increasing were monitored longer until the pneumothorax (a) stabilized or exceeded an estimated 35%–40% or (b) became symptomatic or was accompanied by diminishing oxygen saturation. Patients whose pneumothorax exceeded 35%–40%, who became dyspneic, or who developed diminishing oxygen saturation were treated with a 10.3-F chest tube (APD All-Purpose Drain; Medi-tech/Boston Scientific, Watertown, Mass) attached to a Heimlich valve (Becton Dickinson) placed by the radiologist. On the basis of their overall cardiopulmonary status, general condition, and accessibility to the hospital, patients either were discharged with arrangements for follow-up or were admitted overnight. Patients with postbiopsy pneumothorax who were not treated with chest tube placement but were sent home were instructed to maintain a recumbent or nearly recumbent position as much as possible at home until the next day. All such patients were contacted by telephone several hours after the procedure and again on the next day. Patients were carefully instructed to return if symptoms developed.
A record was kept regarding the approach (anterior, posterior, or lateral), whether the puncture site was placed dependent or nondependent, and whether the patient was placed in the supine, prone, or lateral decubitus position after biopsy. The numbers and incidences of pneumothoraces and of pneumothoraces requiring treatment were calculated for each postbiopsy position (dependent vs nondependent; and supine, prone, or lateral decubitus), as well as for each approach (anterior, posterior, or lateral). We also recorded and correlated the number of passes, the number of pleural surfaces traversed, the depth of the lesion from the pleural surface, mean age, sex, the presence of emphysema, the use of CT or fluoroscopic guidance for biopsy, the presence of pneumothorax and of pneumothorax requiring treatment, and the postbiopsy position (dependent or nondependent) (Tables 1–3). The assessment of emphysema was qualitative and was based on the criteria defined by Sanders et al (18). They defined emphysema on the CT scan as hypovascular areas of pulmonary parenchyma with decreased attenuation that were not associated with a fissure and usually lacked well-defined walls (18).
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2, t (Student t test), odds ratios, and 95% CIs were calculated with the SYSTAT statistical software package, version 5.2 (Systat, Evanston, Ill) (Tables 1–3). Statistical significance was specified at P = .05. |
RESULTS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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In the dependent group, pneumothorax occurred in 62 of 210 biopsies (30%); in the nondependent group, pneumothorax occurred in 57 of 213 biopsies (27%). Treatment with small chest tubes was required in 10 patients (5%) in the dependent group and in six patients (3%) in the nondependent group (Table 3). No significant differences were demonstrated at 2 analysis between the puncture-site–dependent and puncture-site–nondependent groups for either the incidence of pneumothorax (P = .60) or the incidence of pneumothorax that required treatment (P = .43) (Tables 1, 3).
Of the 166 biopsies performed with the anterior approach, 55 (33%) resulted in pneumothorax; the pneumothorax required chest tube placement after five biopsies (3%). Of the 242 biopsies performed with the posterior approach, 60 (25%) resulted in pneumothorax; the pneumothorax required chest tube placement after 10 biopsies (4%). Of the 15 biopsies performed with the lateral approach, four (27%) resulted in pneumothorax; the pneumothorax required chest tube placement after one biopsy (7%) (Table 1–3). No significant differences were revealed with 2 analysis on the basis of the approach (Tables 1–3).
We also analyzed the effect of prone versus supine position on the incidence of pneumothorax and the incidence of pneumothorax that required chest tube placement. The incidences of pneumothorax and of pneumothorax that required treatment were 31% and 3%, respectively, in the supine group and were 25% and 4%, respectively, in the prone group. These differences were not statistically significant (Tables 1, 3).
No statistically significant differences were found between the dependent and nondependent groups for the mean number of passes made, the mean number of pleural surfaces traversed, the mean depth to the lesion, the incidence of emphysema, the age and sex of the patients, and the percentage of biopsies with fluoroscopic guidance versus CT guidance (Table 2). No statistically significant differences were seen in the incidence of pneumothorax or of pneumothorax that required treatment between biopsies performed with CT guidance and those performed with fluoroscopic guidance. Two hundred seventy-five procedures were performed with CT guidance alone; in this group, the incidences of pneumothorax and of pneumothorax that required treatment were 27% and 4%, respectively. For the 135 procedures performed with fluoroscopic guidance alone, the incidences of pneumothorax and of pneumothorax that required treatment were 30% and 4%, respectively. Thirteen biopsies were performed with both fluoroscopic and CT guidance; these were excluded from the analysis.
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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More recently, other investigators have examined the effects of the recumbent position and of the puncture-site–dependent versus nondependent position in patients; however, not all results have been in complete agreement. In a study by Berger and Smith (14), published in 1988, patients were placed puncture site down in the lateral decubitus position for 10 minutes after transthoracic needle biopsy. No statistically significant differences were found in the incidences of pneumothorax and of pneumothorax that required treatment, compared with results previously obtained in patients in whom no positional restrictions were used. In 1990, Cassel and Birnberg (15) reported that their incidence of postbiopsy pneumothorax decreased from approximately 20% to 5% (four of 80 patients) and that their incidence of pneumothorax that required treatment decreased from approximately 10% to 0% (zero of 80 patients) after they instituted the "rollover" technique; that is, after the procedure, the patient was maintained recumbent with the puncture site dependent for 3 hours.
In the same year, Moore et al (5) published results from a series of 308 needle biopsies in which patients were placed recumbent for 1 hour after biopsy. In addition, their activity (coughing, talking, and moving) was restricted (5). Compared with the results from several other reported series, Moore et al (5) found no apparent decrease in the incidence of postbiopsy pneumothorax, but the incidence of pneumothorax that required chest tube placement was reduced. Their incidences of pneumothorax and of pneumothorax that required treatment were 25% (77 of 308 biopsies) and 1.6% (five of 308 biopsies), respectively (5). Dependent versus nondependent position was not evaluated in that study.
In a second study, the results of which were published in 1991, Moore et al (10) reported that the incidence of postbiopsy pneumothorax that required treatment was reduced by positioning patients with the puncture site dependent (vs nondependent). In this study, 55 patients underwent transthoracic needle biopsy and were then positioned recumbent (with activity restrictions), with the puncture site either dependent or nondependent, for at least 1 hour after the procedure. As in their previous study, Moore et al (10) found no reduction in the overall incidence of postbiopsy pneumothorax (20 of 55 patients [36%]). Also, no statistically significant difference was found in the incidence of pneumothorax in the dependent group (14 of 36 patients [39%]) versus the nondependent group (six of 19 patients [32%]); however, chest tubes were required in only one of 36 patients (3%) in the dependent group versus four of 19 patients (21%) in the nondependent group. On the basis of these results, Moore et al (10) concluded that patients should be placed with the puncture site down after transthoracic needle biopsy.
In 1990, after publication of the initial study by Moore et al (5), we changed our practice of allowing patients to remain upright and mobile after transthoracic needle biopsy and thereafter maintained patients recumbent after the procedure until their postbiopsy chest radiograph was obtained 1 hours later. We performed an informal retrospective review of the records of more than 100 such patients and found no apparent differences in either the incidence of pneumothorax or the incidence of pneumothorax that required treatment between patients placed puncture site down versus puncture site up. In addition, some patients found that the prone position was uncomfortable or unpleasant, and a few were unable or unwilling to remain prone for 1 hours or more.
This experience, combined with the discordant results and varying protocols of previous studies, prompted us to perform a prospective study of the effects of the dependent versus nondependent postbiopsy position. The major findings of our study can be summarized as follows: No significant differences were found in either the incidence of pneumothorax or the incidence of pneumothorax that required treatment with a chest tube between patients placed with the puncture site dependent (down) after biopsy and those placed with the puncture site nondependent (up). The incidence of pneumothorax was 30% in the dependent group and 27% in the nondependent group. The incidence of pneumothorax that required chest tube placement was 5% in the dependent group and 3% in the nondependent group. None of these differences were statistically significant (Tables 1, 3). Although the anterior approach was associated with a slightly higher incidence of pneumothorax than the posterior approach (33% vs 25%), this difference was also not statistically significant (P = .08) (Table 1).
To our knowledge, no prospective controlled studies have evaluated the effects of the recumbent versus the nonrecumbent position on the incidences of pneumothorax or of pneumothorax that requires treatment, and our study did not directly address this issue; however, we compared the results of our current series with those of a previous series (in which fluoroscopic guidance was used) by Westcott (9) published in 1980. In that study, the biopsy techniques and needles were similar to those of the current study, but no postbiopsy positional restrictions were used (ie, patients were allowed to sit and, to a limited extent, move about). Comparison of the two series demonstrated no difference in the incidence of pneumothorax (27% [118 of 432 biopsies] then vs 28% now), but a significant reduction was seen in the incidence of pneumothorax that required treatment when postbiopsy recumbency was used (10% [45 of 432 biopsies] in the previous series [9] vs 4% in the current series; P < .001).
These results partly agree and partly disagree with the results of previous studies. These results agree with two of the findings of Moore et al (5,10): (a) The overall incidence of postbiopsy pneumothorax does not appear to be significantly influenced by positional restrictions, and (b) patients who are maintained in a recumbent position after biopsy appear to have a reduced incidence of pneumothorax that requires treatment. (Neither the findings of Moore et al [5,10] nor our findings were able to confirm the findings of Cassel and Birnberg [15] that the incidence of postbiopsy pneumothorax was reduced by using the dependent position). However, contrary to the findings of Moore et al (10), we found no significant difference in the incidence of pneumothorax that required treatment between patients who were positioned with the puncture site dependent versus those positioned with the puncture site nondependent. Our findings are similar to those reported by Shepard and McLoud (16), who, after the implementation of recumbent positioning, found no reduction in the incidence of postbiopsy pneumothorax but did observe a substantial reduction in the incidence of pneumothorax that required treatment (from 9.1% [eight of 88 biopsies] to 2.5% [six of 242 biopsies]). We are not certain why our results differ from those of several of the previous studies with regard to the effects of the puncture-site–dependent position on the incidences of pneumothorax and of pneumothorax that required treatment. We considered the possibility that our dependent and nondependent groups may not have been comparable with respect to factors known to affect biopsy-associated pneumothorax. These factors include the number of passes made, the number of pleural surfaces traversed, the depth to the lesion, the presence or absence of emphysema, the patient's age and sex, and whether the biopsies were performed with fluoroscopic versus CT guidance. However, statistical analysis revealed no significant differences in any of these factors between the dependent and nondependent groups (Tables 1–3). Differences in biopsy techniques and postbiopsy protocols do exist among different investigators, and unknown differences may exist in patient populations and types of lesions. In our series, we used a noncoaxial single-needle technique in the majority of cases, whereas Moore et al (5,10) used the coaxial technique. In addition, in their series, an upright chest radiograph was obtained immediately after the procedure, whereas our patients remained recumbent for 1 hours before the first upright chest radiograph was obtained. We also did not emphasize restriction of the patient's activity (coughing, talking). Berger and Smith (14) kept patients with the lung that had the biopsy site in the dependent lateral decubitus position for 10 minutes; Moore et al (10) placed the puncture site dependent for 1 hour; we used a period of 1 hours; Cassel and Birnberg (15) used 3 hours. Some of the previous series were based on relatively small numbers: Berger and Smith (14) studied 50 cases; Cassel and Birnberg (15) studied 80 cases. The recommendation by Moore et al (10) to maintain patients in the dependent position after biopsy was based on findings in a series of only 55 patients (20 developed pneumothorax, and five required treatment).
In summary, our study demonstrated no significant differences in the incidences of pneumothorax and of pneumothorax that required treatment between patients placed puncture site up and those placed puncture site down after biopsy. This finding was of some practical importance because a large majority of our patients preferred to lie supine, rather than prone, and 39 patients could not or would not remain prone for 1 hours or more after lung biopsy. Although the hypotheses and rationale for the puncture-site–dependent position make intuitive sense, we were unable to show that the dependent position made any difference, at least in our population and with our biopsy methods and postbiopsy protocol. A comparison of the results of our current study with previous results suggests that the decrease in the incidence of pneumothorax that requires treatment that has been observed with postbiopsy positional restrictions may be secondary to recumbency rather than to puncture site dependency; however, enough differences exist in lung biopsy methods and postbiopsy care protocols that we encourage further study by others. For now, we continue to maintain our patients recumbent after transthoracic needle biopsy but allow patients to lie prone, supine, or lateral decubitus on the basis of their personal preferences.
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Acknowledgments |
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Footnotes |
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Current address: Department of Radiology, Medical Center of Central Georgia, Mercer University School of Medicine, Macon.
Current address: Department of Radiology, Rhode Island Hospital, Providence.
Current address: Department of Radiology, Medical Center of Central Georgia, Mercer University School of Medicine, Macon.
Current address: Department of Radiology, Rhode Island Hospital, Providence.
Current address: Department of Diagnostic Imaging, Yale-New Haven Hospital, Conn.
Address reprint requests to J.L.W.
From the 1995 RSNA scientific assembly.
Author contributions: Guarantor of integrity of entire study, J.L.W.; study concepts, J.L.W.; study design, C.L.C., J.L.W.; definition of intellectual content, C.L.C., J.L.W.; literature research, C.L.C., N.L.B., J.L.W.; clinical studies, C.L.C., J.L.W.; data acquisition, C.L.C., N.L.B., J.L.W.; data analysis, C.L.C., J.L.W.; statistical analysis, R.C.L.; manuscript preparation, C.L.C., J.L.W.; manuscript editing and review, J.L.W.
Received February 23, 1998;
revision requested March 30, 1998; revision received May 6, 1998;
accepted August 3, 1998.
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References |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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