BNA, bronchial needle aspiration.
Bronchial needle aspiration (BNA) is a valuable bronchoscopic procedure in diagnosing and staging patients with lung cancer. 1–10 Complications of BNA are rare events 11–15 and have included pneumothorax, pneumomediastinum, pericarditis, mediastinal hemorrhage, bacteremia, and, in two reported instances, death. 16,17 Technical difficulty with BNA resulting from needle breakage has not been detailed previously in the literature. We describe a patient in whom needle breakage complicated diagnostic BNA, and we review aspects of the prevention and management of this problem.
A 50-year-old man with a 40-pack-year cigarette-smoking history was referred for evaluation of unresolving pneumonia, progressive dyspnea, and a 9 kg weight loss over 2 months. Physical examination showed a pulse of 100 beats/minute and a respiration of 18 breaths/minute. There was no peripheral adenopathy, upper extremity, or facial edema, or digital clubbing. His lungs revealed dullness to percussion and decreased breath sound with few crackles audible at the left base. Serial chest roentgenograms showed a left lower lobe infiltrate, unimproved over a 2-week course of antibiotics. The patient underwent computed tomographic scanning of the chest, which demonstrated a left hilar mass with extensive mediastinal and hilar adenopathy (Fig. 1). The conglomerate mass and associated adenopathy measured 11 × 5 cm and encased the left pulmonary artery. There was a large left pleural effusion, partial collapse of the left upper and lower lobes, and right hilar adenopathy. Multiple densities were present in the liver.
After thorough discussion regarding optional combined diagnostic and staging procedures (including thoracentesis) with the patient, transnasal flexible bronchoscopy was performed. Endobronchial inspection revealed a minimally splayed main carina and apparent tumor mass in the left mainstem bronchus, with a broadened secondary carina on the left. The right lung was patent to the segmental level. BNA of the precarinal lymph nodes was performed with a 22-gauge cytology needle (NW-222; Mill-Rose Laboratories, Mentor, OH, USA). An initial pass was technically unremarkable, but on rapid on-site evaluation by the pathologist present at bronchoscopy, the specimen was nondiagnostic. The cytology needle was assessed for patency and smooth retractibility into the sheath and appeared intact. A second pass was attempted in the first intercartilaginous interspace above the carina anteriorly. There was initial resistance to passing the needle, but a voluntary cough from the patient assisted in embedding the needle to its hub. An aspiration was obtained without difficulty, but some resistance was felt when removing the needle, and the needle separated from the catheter system. On inspection, approximately 8 mm of the 13-mm needle protruded from the anterior tracheal wall (Fig. 2A). The catheter system was removed from the bronchoscope channel. Serrated biopsy forceps (cat. no. FB-15C; Olympus, Melville, New York) were passed into the trachea, and the proximal end of the needle was grasped (Fig. 2B). The needle was extracted without difficulty from the airway wall, and the bronchoscope and forceps were removed as a unit from the trachea, and passed atraumatically through the glottis. The patient was asked to open his mouth and protrude his tongue to enlarge the posterior airspace. An attempt was made to withdraw the bronchoscope orally, but resistance was met and the needle was removed digitally. Reexamination of the patient's upper airway revealed a small laceration in the posterior pharynx but no tracheobronchial or glottic injury. The vocal cords were undamaged, with normal mobility.
A new cytology needle was obtained and two more passes were performed at the same pretracheal site without difficulty. On-site examination by the pathologist of direct smears of BNA specimens demonstrated small cell carcinoma, which was confirmed later in bronchial washings. The patient tolerated the procedure well, with no lasting complications from the incident. He subsequently underwent a bone scan that demonstrated multiple metastases. Cranial computed tomography was unremarkable. The patient was referred to oncology and was started on chemotherapy for his extensive neoplasm.
Examination of the retrieved cytology needle showed that it had separated from its inner catheter (which drives the needle forward through the larger Teflon catheter as it is advanced and locked into position;Fig. 3). There was no apparent crimp or split in the distal tip of the catheter, and the needle hub (which inserts into the distal Teflon catheter) was not damaged. Subsequent appraisal of the entire needle–catheter assembly also revealed that the distal metal hub at the catheter tip was that intended for a histology needle. Its larger lumen had permitted separation of the needle from the entire system.
The videotape of the patient's procedure was reviewed independently by another bronchoscopist experienced with BNA and it was confirmed that there was no obvious kinking of the needle at the needle–catheter junction during any phase of the procedure, and the initial airway puncture and needle removal had appeared to proceed without difficulty. The needle seemed to pass smoothly into the airway wall. Evaluation of other needles from the same lot at our institution identified no defective instruments, and no other such technical difficulties with BNA have been encountered since.
BNA is, perhaps, the safest of the bronchoscopic sampling modalities, and complications are uncommon. 11–17 As in our patient, in whom multiple approaches may have simultaneously established his diagnosis and unresectability, BNA offers a minimally invasive option. Even in patients with potentially increased risks, 18,19 BNA complications are unusual. To our knowledge, this is the first detailed report of BNA needle breakage within a patient's airway, and it provides a number of worthy insights. BNA has been performed in our medical center in more than 1,000 procedures without such a complication. Moreover, discussion with bronchoscopists with extensive BNA experience show that in their pooled experiences encompassing an estimated several thousand procedures, only three such episodes could be recalled. One of these occurred in a canine laboratory preparation when, after multiple passes using the same needle in a “hands-on” bronchoscopy training session, the needle separated from its plastic catheter. It was removed safely by means of forceps, without airway injury.
Another bronchoscopist with extensive BNA experience recalled one instance among more than 1,000 procedures in which a needle had separated from its catheter, lying flat on the airway wall. This needle was retrieved uneventfully using forceps. Another episode of marked difficulty removing the needle from a site was described, but the needle assembly remained intact. Communications with representatives of the manufacturer have also confirmed that no previous episodes of such needle breakage have been reported to them in a cumulative use of more than 200,000 needles (personal communication with Alan Poje, 1998). During a hands-on BNA demonstration at a national course, an experienced bronchoscopist described an instance of separation of the distal hub from the tip of the Teflon catheter, without separation of the needle or harm to the patient (personal communication with Warren S. Goff, 1998). The hub was in the distal channel, and was not lost in the airway.
Two simultaneous factors were necessary for the problem encountered in our patient to occur. The metal hub affixed to the distal end of the catheter assembly (Fig. 3) ordinarily provides added assurance that even if a needle were to separate from its driving catheter (as in our patient), it would still be contained within the outer catheter assembly. However, careful examination revealed that a slightly larger hub (21 gauge) than the one routinely present for this cytology needle allowed separation of the metal needle from the catheter system.
Separation of the needle from the inner driving catheter would be expected to be even less likely to occur with current models, in which the needle is affixed to a metal stylet, rather than attached to the tip of a catheter. The mechanical problem with the needle we encountered most likely occurred at the time of needle system assembly and, on follow-up by the manufacturer, appeared to represent an isolated event. As with any instrument introduced into the working channel of the bronchoscope, we believe that the bronchoscopist's inspection of needles before insertion is a routine precautionary measure.
The rarity of the complication encountered in our patient is consistent with the very well-documented safety of BNA, 1 but the possibility of this technical problem also underscores the importance of appropriately observing guidelines for needle use by bronchoscopists and their technicians. Thorough familiarity with the needle–catheter assembly is essential to its proper (and safe) application. All needles must be inspected carefully before their use. In particular, before passing the needle into the instrument channel, one must be certain that the base of the needle is affixed firmly, and that the needle passes smoothly within its Teflon external catheter from the unlocked into the locked position, without any resistance. During airway puncture, kinking of the catheter–needle assembly must be avoided to lessen the likelihood of airway injury or needle damage (as well as to enhance BNA success). After each aspirate has been obtained, the needle should be reinspected to ensure that there has been no damage to it during puncture of the airway. This appraisal is particularly important in patients in whom passage of the needle into hard tumor masses or neoplastic nodes has been met with resistance, when coughing has been necessary to facilitate passing the needle, or when the needle has been forced inadvertently through tracheobronchial cartilaginous rings rather than through the intercartilaginous space. If, on needle inspection, any crimping of its stylet and/or Teflon catheter is noted, the needle should be discarded and another new needle should be used for any subsequent passes.
Clearly, the very low frequency of problems encountered during the routine performance of BNA should not lead to complacency with the procedure. The bronchoscopist must always be prepared for any unpredictable consequences of airway puncture, including familiarity with principles of foreign body retrieval. In this instance, the dislodged needle was removed with forceps and brought up slowly to the proximal trachea. Early prototypes of BNA needles were designed to be grasped by the conventional forceps used in fiberoptic instruments, should such retrieval from the airway ever become necessary (personal communication with K. P. Wang, 1999). This feature proved key in the current case. Without this timely response, immediate availability of rigid bronchoscopy, with its broader capability for safe foreign body removal, would have been necessary. Because fewer current bronchoscopists are skilled with the rigid instrument, institutional provisions for this backup procedure remains another essential advance preparation should complications occur during flexible bronchoscopy.
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