Introduction

A pleural biopsy is a procedure in which a sample of the pleura (the membrane that surrounds the lungs) is removed with a special biopsy needle to determine if infection, cancer, or another condition is present.

Conventional or closed pleural biopsy

Indications for pleural biopsy are to:

• Evaluate an abnormality of the pleura seen on chest X-ray (Figure 1)

Figure 1. Chest radiograph showing left pleural effusion

• Investigate pleural effusion (fluid collection in the pleural space) (Figure 2a & 2b)
• Diagnose the cause of a pleural infection (caused by bacteria, virus or fungus) or  other condition
• Determine if a pleural mass is malignant (cancerous) or benign
• Obtain further information after pleural fluid analysis suggests the presence of cancer, tuberculosis or other infection

Figure 2a : Right pleural effusion

Figure 2b

Contraindications:

The absolute contraindication is any uncorrectable bleeding condition

Relative contraindications are:

• Inability to drain fluid from the pleural space (dry tap)
• Presence of pus in the pleural cavity
• An uncooperative patient
• High blood urea level

Patient preparation pre-procedure:

• Explanation about the procedure is given by the doctor to the patient.
• The doctor will ask if the patient has  allergy to any medication, latex or tape
• A consent is required
• Generally, fasting is not required before the procedure
• If the patient is taking medications such as aspirin, blood thinning medications or other medications that affect blood clotting, it may be necessary to stop or replace these with other types of medications
• An ultrasound to localize the site of pleural biopsy is done

During the procedure:

The patient will be asked to:

• Remove any jewelry or other objects that may interfere with the procedure.
• Remove clothing, and will be given a gown to wear.
• Sit with arms raised and resting on a table (Figure 3). This position aids in spreading out the spaces between the ribs for needle insertion. If the patient is unable to sit, he/she may be placed in a side-lying position on the edge of the bed on the unaffected side.
• Hold still, exhale deeply, and hold his/her breath when told to during the procedure.

Figure 3. Position during pleural biopsy

The following are done/given:

• Supplemental oxygen as needed, through a face mask or nasal cannula (tube).
• The skin at the puncture site will be cleansed with an antiseptic solution.
• A local anesthetic will be administered at the site where the biopsy is to be performed.
• A needle will be inserted between above the ribs.
• Once the pleural space is entered with the needle, fluid may be withdrawn slowly.
• A biopsy needle (Figure 4) will inserted into the site. One or more samples of pleural tissue will be obtained.
• The biopsy needle will be withdrawn and firm pressure will be applied to the biopsy site for a few minutes until any bleeding has stopped.
• A sterile adhesive bandage or dressing will be applied.
• The tissue sample will be sent to the lab for examination.

Figure 4. Abrams pleural biopsy needle (A – needle, B – stylet)

Post-procedure:

• Dressing over the puncture site will be done
• Dressing will be monitored for bleeding or other drainage.
• A chest X-ray taken is after the biopsy.
• The patient may resume usual diet and activities if there are no complications

Monitoring of:

• Vital signs (heart rate, blood pressure, breathing rate, and oxygen level) are done before, during and after the procedure

Complications

The following may be the complications of a pleural biopsy

• Pneumothorax. Collapse of the lung, causing air to become trapped in the pleural space. 
• Bleeding in the lung
• Infection

References

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