Elizabeth Jo-Anne

H. Moore, 0. Shepard,

MD MD

#{149} Johanne #{149} Theresa

LeBlanc, MD2 #{149} Scott C. McLoud, MD

A. Montesi,

Effect ofPatient Positioning after Needle Aspiration Lung Fifty-five

patients

who

fluoroscopically

ration

lung

assigned

biopsy

to one

treatment placed

U

underwent

guided

needle

ish

were

randomly postbiopsy Patients were

of two

groups: recumbent down (n

with

puncture

site

either = 36) or up (n = 19) for at least 1 hour. No significant dliference in pneumothorax rate was seen

between

two groups.

the

Chest

tube placement, however, was required in 21% (four of 19) of the puncture-site-up

group

versus

3%

(one of 36) of the puncture-site-down group, which was a significant difference (P = .04). Puncture-site-down postbiopsy positioning reduces the proportion of patients requiring chest tube placement after lung biopsy. Biopsies, 66.732 #{149} Lung, biopsy, neoplasms, 60.31, 60.32 Index

terms:

Radiology

NTIL

aspi-

complications, 60.458, 66.732

60.458, #{149} Lung #{149} Pneumothorax, 66.732

1991; 181:385-387

recently, the

requiring study

and

used

by

a different

tube

placement.

retrospective,

control

addition,

the

sitioning,

activity

The

however,

biopsies

group

performed

of radiologists.

effects

In

of recumbent restriction,

po-

and

puncture site positioning were not separately examined. We therefore believed that a prospective controlled trial to isolate the variable of patient positioning would further clarifying this technique.

MATERIALS

be of interest the usefulness

AND

in of

METHODS

Three radiologists (T.C.M., J.L., S.A.M.) who had no previous experience with the technique of dependent positioning of the biopsy site were recruited to perform the biopsies. Biopsy technique and choice of needle were left to the discretion of the individual ,

From the Department

of Radiology,

chusetts General Hospital, S.A.M.,J.O.S., T.C.M.), and

Massa-

Boston (E.H.M., the Department

Radiology, University of Washington Center, Seattle (M.L.R.). From the

J.L., of

Medical 1990

RSNA

scientific assembly. Received February 21, 1991; revision requested April 4; revision received June 24; accepted July 1. Address reprint requests to E.H.M., Department of Radiology, University of California, Davis, Ticon II Bldg. 2516 Stockton Blvd, Sacramento, CA 95817. 2

Current

address:

H#{244}pitalLaval, 3

Current

Nashville, © RSNA,

Ste.-Foy,

address: Tenn. 1991

Department Quebec,

Radiology

of Radiology, Canada.

Consultants

Inc.

Greene

radiologist.

needles

(Cook,

Twenty-two-gauge Bloomington,

hid) were used for biopsies performed with a single-needle technique. For biopsies obtamed with coaxial needles, 19-gauge Greene outer needles and 22-gauge Greene or 21-gauge Cut biopsy needle inserts (E-Z-Em, Westbury, NY) were used. Immediate

cytologic

evaluation

material

sufficient

for diagno-

in the case of suspected

lesions, multiple samples and adequate culture material were acquired. The “blood patch” technique was not employed in this group of patients. All fluoroscopically guided biopsies performed by the three radiologists during their participation in the study were randomized by hospital unit number into two

of pneumothorax

chest was

MD

benign

of “positional precaucompletion of lung bi-

prevalence

until

sis was obtained;

after

included recumbent positioning with the biopsy site dependent and prohibition of coughing or talking (1). When compared with histoncal control subjects from our institution, this led to a 25-fold diminution in the

L. Richardson,

formed

to diminrate

needle aspiration lung biopsy have concentrated on maneuvers performed during the biopsy procedure itself. Recently, however, we described a series of patients subjected to a program tions” after opsy, which

#{149} Michael

Biopsy’

attempts

complication

MD3

treatment

groups.

Patients

with

odd

unit

numbers were placed recumbent with puncture site down immediately after completion of the biopsy procedure; patients with even unit numbers were placed recumbent with puncture site up. Coughing

and

talking

were

strongly

dis-

couraged. Chest radiographs with patients in the upright position were obtained immediately after the procedure and then hourly or as indicated by clinical circumstances; the presence and size of any

pneumothorax

were

recorded.

Patients were kept in the assigned position for at least 1 hour, or until any air leakage had stopped for 1 hour, or until a chest tube was required. Percutaneously placed 9-F Teflon chest catheters (Cook, Bloomington, hid) were used if a pneumothorax

was

estimated

to exceed

30%

or

showed progressive enlargement over several successive radiographs, or if the patient became symptomatic from a pneumothorax. If no chest tube was required, patients were placed in an upright seated position, without activity restrictions, for 1 hour prior to discharge. A final chest radiograph Patients

was were

obtained discharged

after this period. if no further air

leakage had occurred. Patients were instructed to return if symptoms occurred. Results were analyzed by using an exact permutation test with a software package (StatXact;

CyTel

Software,

Cambridge,

Mass). All P values were two-sided. The common odds ratio was estimated with the same software package by using the conditional

maximum

likelihood

method.

of sped-

mens was performed with the patient in the puncture-site-up position and required approximately 10-20 minutes. Whether an outer needle was left in place depended on choice of coaxial or singleneedle technique. Repeat punctures or further coaxial aspirations were per-

RESULTS

Fifty-five patients were entered into the protocol between March 1989 and October 1990. Thirty-six patients had odd

down

unit

numbers

postbiopsy

(puncture-site-

positioning)

and

19 385

patients had even unit numbers (puncture-site-up postbiopsy positioning). Because patients are assigned sequential unit numbers by the hospital at the time of their first visit, the preponderance of odd unit numbers in this study was attributed to chance. A total

of 20 pneumothoraces

Table 1 Postbiopsy

Patient

placed

site

races progressing tube placement

Table

of patients developed,

18 involved

punctures. difference

There between

mothorax

or chest

singleand or between singleand sies

in the

two

or more

placement

treatment

the

of

development of a usually has little effect who undergo needle aspi-

hospital admission is an unpleasant and expensive occurrence. The technique of placing the patient puncture down

after

biopsy

was

experi-

mentally developed in dogs by Zidulka et al (2). We have demonstrated that the technique provides a method of substantially diminishing the proportion of patients who will eventu386

#{149} Radiology

Review

.77

67% (4 of 6)

7% (1 of 14)

.01

.04

pneumotho-

to require chest

of Postbiopsy

Complications

Pneumothorax (%)

Study Moore et al (I) (1990) Single pleural punctures

Jereb (3)

(1980)

Westcott Jackson

(4) (1980)

Stevens

andJackman

Chest

30.1 41 19.8 23.8 29

Khouri et al (8) (1985) Perlmutt et al (9) (1986) Stanley et al (10) (1987)

Require

(%)

to Chest

Tube Placement

1.6 0.4 5 10 12 14.3 10 5 11.5 10

44 (7) (1984)

Tube

Placement

25 17.9 19 27

et al (5) (1980) Gibney et al (6) (1981)

ally

require

chest

tube

placement

and

thus hospital admission. A low rate of chest tube placement was achieved in this series despite a rather high over-

all pneumothorax rate. This low rate of chest tube placement is reflected by estimates of the common odds ratio. Patients placed puncture site up were 8.9 times as likely to require a chest tube as those placed puncture site down. For the subgroup of 20 patients who develpneumothoraces,

puncture

as likely

groups.

ration lung biopsy, a pneumothorax requiring chest tube drainage and

site

39% (14 of 36) 3% (1 of 36)

Progressing

placed

DISCUSSION Although pneumothorax on patients

32% (6 of 19) 21% (4 of 19)

test)

Percentage of Existing Pneumothoraces

oped

in

multiple-puncture cases the relative proportions multiple-puncture bioptwo

P (exact permutation

6.4 2.2 26.3 37.0 27.3 47.5 24.4 25.3 48.3 34.5

in

was no significant the rates of pneutube

Site

Down

up

chest tube drainage was required in 7% (one of 14) of the puncture-sitedown group and 67% (four of 6) of the puncture-site-up group (Table 1). These rates are statistically significantly different (P = .01). The estimate of the common odds ratio of these rates is 20.0. In this series, biopsy procedures required only one pleural puncture in 37 cases;

Site Up

2

Literature

was 32% (six of 19) (Table 1). These rates are not statistically significantly different (P = .77). Five of the 55 patients in our study required chest tube placement (9%). The rate for chest tube placement in the patients placed puncture site down was 3% (one of 36), while the rate for patients placed puncture site up was 21 % (four of 19) (Table 1). These rates are statistically significantly different (P = .04). The estimate of the common odds ratio of these rates is 8.9. Of the subgroup whom pneumothorax

Puncture

Pneumothorax Chest tube placement Percentage of existing

oc-

puncture

Position Puncture

Development

curred. Size ranged from minute (0.5 mm from the apex) to a large tension pneumothorax. None of the patients had late complications that necessitated a return to the hospital. The pneumothorax rate for patients placed puncture site down was 39% (14 of 36), and the pneumothorax rate for patients

Developments

those

patients

site up were

to require

placed

Thus, the particularly

puncture

technique useful

chest

tubes

20 times as

site down. appears in patients

to be with

existing air leaks. The percentage of patients with a pneumothorax who progress to require chest tube placement after use of this technique may be compared with standards in the literature. Table 2 lists the data from all series of lung biopsies that have included at least 100 patients and that have been published in the past 10 years (1,3-10). Our rate of progression to chest tube placement in patients with pneumothorax and positioned puncture site down (7%) is similar to the rate encountered in our previous study (1) (6.4% overall, 2.2% for single punctures), but is substantially better than the rates reported in the litera-

ture (24.4%-48.3%). puncture-site-up cessively

high

membered is most

Although our number seems exat 67%,

that commonly

be

of lung

performed

posterior approach. who lie in a supine opsy

it must

biopsy

therefore

from

Many position

are

bi-

inadvertently

to chest

a

patients after

sub-

jected to positional precautions. may explain the intermediate progression

re-

lesions

tube

This rates of

placement

reported in the literature. Puncture-site-down positioning causes dependent atelectasis, which results

in diminished

air

delivery

to

the puncture site. In the presence of a pneumothorax, the lung falls to the bottom of the chest cavity, maintaining close contact between the punctured visceral pleura and the parietal pleura. This inhibits further air leakage

and

may

provide

a template

fibrin deposition. Although mothoraces appeared after this small study, of pneumothorax

ter patients lowing

were

we have seen that developed

seated

puncture-site-down

for

no pneu1 hour in cases af-

upright

fol-

position-

ing. Observation of patients in the erect seated position before discharge cannot be overemphasized, because puncture-site-down positioning may sometimes leakage.

Further

mask

unsealed

improvements

sites

of air

in postbiNovember

1991

opsy study,

management radiographs

with

the

after

the

longer salva

patient

are possible. were obtained

upright

procedure,

advocate. maneuver

formed upright;

In this

immediately

which

we

when patients attempt obtaining radiographs

no

Valper-

to sit imme-

diately may cause air leakage at a critical time before the puncture seals. Currently, unless the patient shows evidence of respiratory distress or experiences chest pain, we maintain puncture-site-down positioning and delay radiography until at least 1-2

hours after the procedure, depending on assessed risk of complication; even longer delays have been advocated (11).

Similarly,

periods

in which

On the basis of this small, prospective randomized study and our previous larger series with historical controls, we continue to advocate dependent positioning of the puncture site

site is left upward and unduring delays necessited by

cytologic nated by

examination use of a single

as a method

of pneumothorax

chest biopsy.

tube

6.

EH,

Shepard

JO, McLoud

2.

of localized

pulmonary

1980;

137:

needle biopsy of pulmonary lesions. Am Surg 1980; 139:586-589. Gibney RTN, Man GCW, King EG, leRiche

Aspiration

in the diagnosis of Chest 1981; 80:300-303. Stevens GM, Jackman J. Outpatient needle biopsy of the lung: its safety and utility. Radiology 1984; 151:301-304. Khouri NF, Stitik FP, Erozan YS, et al. Transthoracic needle aspiration biopsy of benign and malignant lung lesions. AJR pulmonary

7.

TC, Tem-

Position may stop pneumothorax progression in dogs. Am Rev Respir Dis 1982; 126: 51-53. Jereb M. The usefulness of needle biopsy in chest lesions of different sizes and locations. Radiology 1980; 134:13-15. Westcott JL. Direct percutaneous needle

Radiology

Jackson R, Coffin LH, DeMeules JE, Miller DB, Dietrich P. Fairbank J. Percutaneous

J.

9.

pleton PA, KosiukJP. Positional precautions in needle aspiration lung biopsy. Radiology 1990; 175:733-735. Zidulka A, Braidy TF, Rizzi MC, Shiner RJ.

3.

5.

8.

lung

patients.

31-35.

U

Moore

can be elimipuncture

2

requiring after

in 422

results

preva-

1.

aspiration

#{149} Number

drainage

the

References

4.

181

to reduce

lence

a

puncture protected

Volume

leakage oc-

curs.

An inadvertent is frequenfly

with a coaxial needle, because around the outer needle rarely

1985; 144:281-288. Perlmutt LM, Braun SD, Newman GE, et al. Timing of chest film follow-up after trans-

thoracic 1986;

10.

11.

biopsy

disease.

needle

aspiration

biopsy.

AJR

146:1049-1050.

Stanley JH, Fish GD, AndrioleJG, et al. Lung lesions: cytologic diagnosis by fine needle biopsy. Radiology 1987; 162:389391. Cassel DM, Birnberg FA. Preventing

pneumothorax over technique

after lung biopsy: (letter). Radiology

the roll1990;

174:282.

lesions:

Radiology

#{149} 387