Steps of the Procedure

  1. Accurately localize the lesion and plan the approach.
  2. Screen for contraindications.
  3. Premedication is not necessary for this procedure. Start the patient on 3-5 liters of oxygen by nasal cannula. Start an IV to keep the line open.
  4. Position the patient. If feasible, keep the side to biopsy higher. This will enable you to take advantage of gravity in order to minimize bleeding.
  5. Prepare the selected site with iodine and alcohol.
  6. Anesthetize the skin, subcutaneous tissue and pleura with 2% xylocaine. For fear of inducing pre-biopsy pneumothorax, be careful not to go too deep.
  7. Make a small dermatotomy using a size 11 scalpel blade. This avoids resistance of skin and bending of the needle.
  8. Select a size 22 spinal needle. Attempt to insert the needle into the lesion.
  9. Ensure placement of the needle into the lesion. Intermittent fluoroscopy is performed to guide the advancement of the needle towards the lesion. Assess in both planes to be sure that the needle is in the lesion. Do not bend the needle.I insert the needle during quiet breathing. Many prefer to insert the needle during breath holding. This usually confuses the beginner and the patient may sometimes take a deep breath increasing the likelihood of a tear of the lung.
  10. Remove the stylet and connect the needle to a 10 cc syringe. Jab the lesion a few times with suction. The maneuver increases the change of retrieval of tissue.
  11. Stay in the chest with the needle for only the length of time necessary. Withdraw the needle without suction. The suction is stopped during withdrawal to avoid picking up blood from the soft tissue.
  12. Expel the aspirate onto frosted and plain slides for bacteriology. Make the smears quickly. A cytologist stains and review the slides immediately for adequacy of the specimen.
  13. Repeat the procedure with a new needle if the aspirate is unsatisfactory and non-diagnostic. This quick read technique optimizes the number of needle passes.
  14. Apply a band aid.
  15. Fluoroscope to evaluate for pneumothorax.