Percutaneous Lung Lesion Biopsy

Anatomy and Physiology

Anatomical Structures

In the typical configuration, the lung parenchyma is divided into lobes by serous connective tissue, with 3 complete or partial lobes on the right and 2 on the left. The connective tissue lining the lobes is known as the visceral pleura. The thoracic wall's inner lining is termed parietal pleura. Between the 2 pleural surfaces exists a potential space or cavity called the pleural space, which in a normal state contains minimal fluid. Pleural fluid helps create surface tension and contact between the 2 pleural surfaces, which keeps the lungs inflated as air passing bidirectionally through the trachea causes the lungs to expand and contract.

Bloody Supply

The lungs receive a dual blood supply through bronchial and pulmonary arteries. The bronchial arteries branch off the aorta from the left ventricle, with the most common configuration being 2 arteries to the left lung and 1 to the right. These bronchial arteries bifurcate and travel alongside the bronchi and bronchioles. In contrast, pulmonary arteries are supplied by the right ventricle, with the typical configuration consisting of 1 pulmonary trunk, 1 primary pulmonary artery per lung, and 1 secondary pulmonary artery per pulmonary lobe.

Indications

Percutaneous Lung Lesion Biopsy Guidelines

In the United States, the National Comprehensive Cancer Network (NCCN), American College of Chest Physicians (ACCP), American Society of Clinical Oncology (ASCO), College of American Pathologists (CAP), and Society of Interventional Radiology (SIR) have created clinical guidelines for when PLLB is indicated versus performing other types of biopsies.[3][4][5][6][7] 

These guidelines include the following recommendations, organized according to the type of cancer suspected. However, in general, once a decision has been made that biopsy is critical for guiding management, if initially obtained specimens are inadequate for histologic and molecular characterization, pursuing a second biopsy is acceptable before moving to attempts at therapy.

Nonmetastasized primary non-small cell lung cancer

For patients suspected of having primary non-small cell lung cancer that has not metastasized, the following recommendations have been established:

• Performing PLLB can add unnecessary time, costs, and risks. For patients in whom stage 1 or 2 lung cancer is strongly clinically suspected based on risk factors and radiologic appearance, a biopsy is not required before surgical excision. When the lesion is moderately to highly suspicious for lung cancer and a reason to suspect metastasis is not present, surgical excision via thoracoscopy without preoperative biopsy is preferred.
• In nodules with an indeterminate likelihood of malignancy or when wedge resection appears difficult or risky, lesion sampling via PLLB or bronchoscopy with or without guidance technology, eg, radial endobronchial ultrasound (EBUS) or electromagnetic navigation, may be considered.
• Histologic assessment via preoperative biopsy or wedge resection should be the standard before performing a lobectomy or pneumonectomy.
• Invasive imaging (eg, thoracoscopy) of the mediastinum combined with thoracoscopy biopsy of any lesions identified is recommended before resection of lung lesions for most patients with suspected clinical stage 1 or 2 lung cancer.
• Rapid onsite evaluation (ROSE) of the samples obtained by PLLB or other forms of non-wedge resection biopsy should be offered.
• Decisions regarding the optimal method for tissue diagnosis for suspected stage 1, 2, or 3 cancer should be made on a patient-by-patient basis via discussion between radiologists, pulmonologists, and surgeons specializing in diagnostic and invasive management of thoracic cancer. The initial tissue sampling approach should be the least invasive method expected to achieve an adequate tissue yield.
• When tissue diagnosis is required due to diagnostic uncertainty or poor surgical candidacy in the setting of a peripheral lung nodule, radial EBUS is recommended as the first-line image-guided approach to achieve a diagnosis. Electromagnetic navigation guidance is recommended if the equipment and expertise are available. Otherwise, PLLB is recommended.
• Regardless of biopsy approach, when targeted therapy or immunotherapy is considered to be a relevant treatment option, enough tissue should be obtained to test for mutations, eg, BRAF and EGFR mutations (for patients with cancer that appears invasive, as well as in the setting of suspected metastatic cancer).

Metastasized primary non-small cell lung cancer

For patients suspected of having primary non-small lung cancer that has metastasized, clinicians should obtain histologic confirmation from suspected metastatic sites, not the suspected primary lesion. However, if biopsy of a metastatic site is technically difficult or hazardous, biopsying the primary lung lesion or mediastinal lymph nodes should be performed using the least invasive method.

Metastatic lung cancer

For patients suspected of having cancer metastatic to the lung, adequate tissue should be obtained to allow for molecular testing to guide chemotherapy options.

Small cell lung cancer

For patients suspected of having small cell lung cancer, clinicians should confirm the diagnosis histologically using the least invasive method available, eg, sputum cytology, thoracentesis, fine needle aspiration, or transbronchial aspiration.

Contraindications

General Contraindications

PLLB has numerous relative contraindications, including:

• Uncooperative patients [8] 
• Recurrent cough (cough suppressants should be prescribed)
• Pulmonary hypertension (as determined by computed tomography or, more accurately, by right heart catheterization)
• Respiratory failure requiring positive-pressure ventilation (invasive or noninvasive ventilation)
• Severe hypoxic respiratory failure requiring oxygen supplementation
• Severe impairment of diffusion capacity of the lungs for carbon monoxide (diffusing capacity of the lungs for carbon monoxide) <35% of predicted [9]
• Severe interstitial lung disease [10] 
• Severe/bullous emphysema
• End-stage pulmonary fibrosis
• Small lesions (<8 mm, or <1 cm located near the diaphragm)
• Central lesions adjacent to a large vessel
• Contralateral pneumonectomy
• Coagulation abnormalities (platelet count <100,000/mL, international normalized ratio (INR) >1.5) [11]
• Uncorrectable coagulopathy [12]

These factors are considered contraindications because they increase the risk of the following:

• Failure to obtain an adequate specimen is unlikely
• Severely injuring the patient in an environment where appropriate treatment cannot be quickly provided
• Inability to extend the patient's survival or improve quality of life

(Refer to "Bleeding Risks" and "Noncooperative, Nontrained, or Over-Sedated Patients" for more detailed information on these various risks)

Bleeding Risks

SIR practice standards for procedures depend on procedure-related hemorrhage risk. PLLB is classified as a high bleeding risk procedure.[6] When the INR exceeds 1.5, measures should be taken to correct it, eg, by administering fresh frozen plasma or vitamin K. Platelet transfusion is recommended when platelet counts fall below 50,000/μL. The guidelines offer specific criteria for which antiplatelet and anticoagulant medications should be held and for how long. 

The Johns Hopkins Surgical Risk Classification System categorizes PLLB as a category 2 procedure on a scale of 1 to 4 regarding overall morbidity risk, where category 2 procedures involve a blood loss of up to 500 cc, which is comparable to laparoscopic cholecystectomy and inguinal hernia repair. In most institutions, the latter 2 procedures are performed with an anesthesiologist or certified registered nurse anesthetist who can support hemodynamic correction, airway maintenance, and analgesia as standard of care; such precautions should be considered for PLLB. Specific lung lesions, eg, a metastasis to the lung from a renal cell carcinoma or melanoma, may be anticipated to have higher than usual bleeding risk due to their vascularity.[13]

Noncooperative, Nontrained, or Over-Sedated Patients

Lung tumors exhibit significant mobility in various directions, regardless of their anatomical location.[14] PLLBs are still performed without real-time imaging guidance in hospitals lacking CT-fluoroscopy technology. A person who cannot remain still or who is not trained to breathe in a controlled fashion for the time needed to perform the biopsy reduces the odds of successful tissue retrieval and increases the odds of complications.[15] 

Patients often prefer to have some sedation, which can facilitate calm breathing and reduce patient self-repositioning, eg, in persons who have arthritic discomfort and find it challenging to remain still on a surface that lacks adequate cushioning. However, sedation to the point where the patient loses their ability to precisely control breathing throughout the respiratory cycle can allow for target lesion hypermobility and increase the likelihood of PLLB diagnostic failure and unnecessary complications.

Equipment

Imaging Guidance

Imaging guidance for PLLB can be performed using conventional fluoroscopy, ultrasound, "non-dynamic" or "spot" CT, or "dynamic" CT (CT fluoroscopy). CT fluoroscopy is the modality that usually best visualizes the target abnormality and its surrounding anatomic structures as they move in real time, providing the most information about the safest route for obtaining the sample.

Use of Intravenous Contrast

Nonenhanced CT usually offers enough contrast to differentiate the structures of concern. Occasionally, intravenous (IV) contrast agent administration for contrast-enhanced CT may be prudent, such as in cases to define vascular or non-target mediastinal structures in the anticipated needle path.[16]

Room Setup

Equipment and supplies should be readily available to address potential complications and emergencies during a PLLB. General equipment required includes:

• An oxygen supply for augmenting oxygenation
• Suction equipment for airway clearance
• Artificial airway and intubation equipment for maintaining a patent airway
• A bag valve mask for manual ventilation
• A resuscitation cart containing essential emergency medications and other equipment for performing advanced cardiac life support
• Cushions for preventing patient neuropathy or the desire for patient self-repositioning

Additional equipment that should be available due to the possible need for immediate intervention or sedation administration during the procedure includes:

• A monitor capable of detecting blood pressure, cardiac rhythm, oxygen saturation, and carbon dioxide waveforms
• A functioning IV line for administration of medications and fluids as needed

When pneumothorax is considered at all likely, the following supplies should be available:

• One or more needles for the Seldinger or trocar technique for introducing a chest tube
• Chest tubes with or without accompanying guidewires
• A valved tube or stopcock for controlling the flow of air into the pleural space
• A Heimlich valve for preventing reentry of air into the pleural space
• Wall suction for rapidly decompressing air escaping into the pleural space
• A chest drainage device for long-term management of pneumothorax, hydrothorax, or hemothorax
• Connecting stopcocks and tubing necessary for connecting the items used for pleural pressure monitoring

Preparation

Patient Engagement

PLLB education and performance depend on specific aspects unique to each patient. Persons undergoing lung biopsies often have comorbidities, including cardiopulmonary debilitation, arthritis, hearing impairments, and sleep apnea. Practice is required to learn to perform consistent breath sizes and breath-hold durations.

Clinical trials have not proven the superiority of a specific technique for training patients to perform consistent breath holds versus PLLB without patient training. The author's experience has been that training the patient to produce consistent inspiratory amounts and durations while lying in the planned biopsy position increases the procedural success rate. If the patient is unable to hold their breath on command in the setting of lesions near the diaphragm, then performing a unilateral phrenic nerve block may enable a safer PLLB attempt.

Overall Procedural Risk Assessment, Including Sedation Planning

The patient's ability to withstand the procedure should be evaluated using clinical risk predictors recommended by the ACCP, plus or minus other organizations like the American Society of Anesthesiology (ASA). This can help determine whether the patient is an appropriate candidate for PLLB, endobronchial biopsy, or proceeding straight to surgery, as well as what kind of anesthesia to use.

PLLB does not require anesthesia or sedation if adequate preparation is made for analgesia during the biopsy and rescue of pneumothorax. However, if sedation is planned or a reason to believe sedation may be needed during the procedure is present, then pre-PLLB patient assessment should include the elements recommended by the ASA (published on the ASA website) to obtain an objectively derived preprocedure risk score. 

A thorough assessment includes the following elements:

• Clinical history including:
  • Disease of the heart, blood vessels, blood cells, liver, kidneys, pancreas, and central nervous system
  • Lung and airway disease, sleep apnea, and risk factors for intubation
  • Ongoing or recent infections
  • Active medicines and recreational substance use
  • Allergies
  • Prior surgeries and implants
• Physical examination including:
  • Body mass index
  • Cardiovascular and respiratory systems
  • Patient's ability to tolerate lying in the planned position for PLLB
• Laboratory analysis including:
  • INR and platelet count
  • pulmonary function testing and diffusion capacity of the lungs for carbon monoxide (DLCO)
• Imaging studies to assess the following:
  • Which site for biopsy is most appropriate if there are multiple sites
  • A route for needle placement based on depth and distance away from dangerous structures

The SIR has made additional recommendations for preparing for PLLB and other aspects of patient care in PLLB.[17]

Patient Positioning

PLLB performed with the patient in the predominantly prone position has advantages over the supine and lateral decubitus positions. The rib posterior aspects move less than the anterior aspects, the posterior intercostal spaces are wider, the patient cannot visualize the needle during the procedure, and the patient can recover in a more comfortable puncture-site down supine position. The target hemithorax's degree of wall motion increases from prone to supine to lateral decubitus position (assuming the nondependent side is biopsied).

The association between patient position (lateral decubitus versus supine) and overall complication rates has been shown to have statistical significance for hemorrhage and pneumothorax.[18][19] A prone oblique position allows the patient's face to be unobstructed with the head still in line or mostly in line with the spine and positioning the arms below the level of the shoulders in their normal resting configuration. Adjusting the arm to reposition the scapula may be necessary. Any maneuvers necessary should be taken to remove or reduce the following:

• Strain on joints (particularly the neck, back, shoulders, and hips),
• Pressure on "pressure points"
• Dyspnea

Choice of Biopsy Target Lesion in Cases of Multiple Lesions

While nodules as small as 4 mm have yielded enough tissue to enable a confident diagnosis of non-small-cell lung cancer, relying solely on lesion size is not a reliable predictor of success.[20] For example, a lesion measuring 1 cm along an upper lobe's pleura may be targeted accurately due to minimal respiratory movement in that region. However, the same-sized lesion in a lower lobe moves more with respirations and could require multiple pleural punctures via a direct needle approach, causing a pneumothorax and procedure failure before tissue sampling.[21] 

An ideal target for PLLB is a lesion that has the following features:

• Abuts the parietal pleura: Avoiding aerated lung tissue upon entry decreases the likelihood of pneumothorax.
• Large in the craniocaudal dimension: The craniocaudal dimension is more important than other lesion dimensions, particularly when using a machine for image guidance that lacks real-time imaging. This dimension dictates the lesion's visibility on the imaging monitor throughout the procedure.
• Located in the upper lobe posterior aspect: The upper lobe is less mobile than the lower lobe, and a posterior approach has advantages as discussed above.
• Signs of malignancy: Exhibits visual signs distinctive for cancer, including peripheral hypermetabolism on positron emission tomography-CT. Higher metabolic activity increases the probability of obtaining viable abnormal tissue.

Morphological characteristics suggesting true malignancy trump lesion size. Benign conditions like round atelectasis can meet all the criteria for an optimal "lesion" described above. The decision to biopsy an abnormality should be made only when the likelihood that a cancer mimic is present is low. Ground glass or predominantly necrotic lesions often yield insufficient viable cellular material for diagnosis through needle sampling. 

Small, immediately subpleural lesions pose challenges in timing needle entry to successfully puncture them on the first attempt. Given the choice between a small lesion positioned against the pleura or a slightly deeper lesion, often the more central lesion should be preferred because of the following:

• A direct route perpendicular to the pleura can still be utilized, allowing room for redirection without withdrawing the needle back through the pleura after an inadvertently directed initial pleural puncture.
• The introducer needle is more likely to remain within the lesion when multiple samples need to be obtained.

A peripheral, nonperimediastinal thoracic location reduces the risk of encountering larger vessels and minimizes the potential for inadvertent direction (needle drift) during insertion. Cardiac motion can make targeting pericardiac lesions challenging. Across all patients undergoing PLLB, bleeding is a much more likely risk of death than pneumothorax.

Nodules located along fissures and the diaphragm can present difficulties even when using an angled CT gantry. Unintended punctures in this scenario lead to unnecessary pleural punctures and pneumothorax. Puncturing the diaphragm causes considerable pain, even without perforation of caudal structures such as the liver or spleen.

Additionally, if a patient has a history of prior invasive thoracic procedures, selecting the side on which the previous surgery was performed is advisable as pleural adhesions may have formed on that side, which may reduce the risk of pneumothorax.[22]

Technique or Treatment

Needle Access

The coaxial technique for lesion sampling involves inserting a thinner sampling needle through a larger place-holding needle positioned at the edge of the lesion. Compared to tandem punctures, coaxial sampling offers several advantages, including:

• Multiple samples via only 1 pleural puncture allowing for improved procedure speed, reduced pain, and lowered risk of puncture-related complications
• This technique can work unless and until the introducer needle develops significant friction due to the inflow of coagulated blood.
• Better control of needle penetration/depth (ie, sufficient tissue retrieval without inadvertent injury to non-target lung)
• Larger needles are stiffer and more likely to track in a straight line than thin needles. Unlike aspiration needles, biopsy gun needles can be set to retrieve predetermined tissue core lengths. 
• More options for managing complications (ie, further sampling after a complication starts and aid in managing pneumothorax)
• If pneumothorax occurs during the procedure, the introducer needle used in the coaxial technique often remains lodged in the lesion and tethers the lung somewhat to the chest wall. A second chest wall puncture with small-bore chest tube insertion can then be performed without the lung collapsing as rapidly as it otherwise would. 
• Versatile applications (multiple functions via only 1 puncture) 
• The coaxial needle allows obtaining a specimen via the biopsy gun needle, inserting a marker into the lesion for thoracoscopic resection or radiation therapy planning, or delivering a substance to seal the tract created during the procedure.

The risk of pneumothorax increases with the number of pleural punctures, each puncture disrupting the normal pressure difference between internal lung alveoli and the pleural space needed to keep the lung inflated. When the visceral pleura has a visible tear, air leakage into the pleural space can occur at pressures as low as 1 to 2 mm Hg.[23] Coughing can generate pressures exceeding 100 mm Hg and easily force air through any nonpatched pleural hole into the pleural space. 

The CAP-SIR guidelines approve needles that range between 19 and 25 gauge.[3] Using larger needles is controversial; no randomized trials have been performed to determine risks based on needle size, and retrospective studies have found conflicting evidence that larger needles may unnecessarily increase complications without improving diagnostic yield. 

Additional Procedural Considerations

Additional precautions to consider to reduce the risk of complications include:

• Time management: The time the needle lies across the pleural space is indirectly proportional to the risk of complications. Streamline the procedure to avoid unnecessary interruptions, including prolonged duration of ROSE, improper imaging techniques, and unnecessary additional imaging. Ensure personnel know their roles and that anyone entering the CT room is already equipped with the proper radiation safety equipment.
• Breath holding: During PLLB, the patient's ability to maintain respiratory volume within their normal range ("quiet" breathing) is important. Puncturing the lung during a deep inhale or exhale will result in tension on the needle (and therefore the pleura) once the lung returns to its normal state of expansion, and increase the likelihood of a pleural tear.
• Cough suppression: Forceful coughing poses a risk for pleural tears and air embolism. Needle manipulation should be halted during coughing. Administer a cough suppressant (prophylactically if necessary) or address the underlying cause of irritation. If coughing persists, premature procedure termination may be necessary.
• Lung/pleural patch technique: Patching the lung/pleural needle defect can prevent alveolar gas leakage into the pleural space. Various materials can be used. The traditional approach involves using the patient's blood, but other materials are commercially available. The effectiveness of a pleural patch may be reduced if multiple punctures have been made or pneumothorax has already developed. Randomized trials comparing different patch techniques are lacking.[23] 

Following pleural patch placement and needle removal, some physicians desire the patient to be rolled so that the puncture site is downward against the bed, a concept initially proposed by Zidulka in 1982. This position, which is the same position used when a patient is known to have a pneumothorax already, creates more overall pressure on and less air exchange within the downward lung.[24] This initial repositioning should involve as many assistants as needed to ensure the patient remains passive, avoiding any straining or Valsalva maneuver. Rolling the patient as they exhale can mitigate the likelihood of a reflex Valsalva maneuver. The combination of needle removal and repositioning should be swift, typically taking only a few seconds.

In cases where a pneumothorax is known to be present, administering oxygen can facilitate the resorption of the existing pneumothorax. The underlying premise is that a higher partial pressure of oxygen accelerates the diffusive resorption of trapped pleural air that is primarily composed of nitrogen (and carbon dioxide).

Surveillance Imaging

After the patient has been relocated from the procedure table following a PLLB, imaging is typically performed before discharge to confirm that no significant pneumothorax is present. However, oxygen saturation levels and clinical monitoring provide sufficient clinical information to allow for nonimmediate post-biopsy image acquisition. Acquiring radiographs involves some degree of patient straining or Valsalva maneuver, which can increase the risk of developing an immediate post-biopsy pneumothorax. An alternative approach is to take precautionary measures against pneumothorax and perform imaging when clinically indicated or closer to the time planned for discharge.

The most sensitive method for detecting intrapleural air via plain film radiography involves upright expiratory images in at least 2 views (eg, frontal and oblique). If pneumothorax is detected, serial images should be performed to distinguish a new or ongoing leakage from a stable, resolved leak.

Post-Biopsy Management and Discharge

A "delayed" pneumothorax is one that is discovered after the PLLB itself has concluded. Post-biopsy management includes mitigation strategies to prevent this condition from occurring. A common preventative protocol is to request the patient to spend 2 hours in a relatively immobile state, usually in a puncture-site-down position.[25][26] Once time has been allowed for pleural healing or significant bleeding to manifest, the patient is encouraged to attempt activities they are likely to perform at home the next day (eg, using the restroom, bending over, light lifting), followed by a chest x-ray. 

Pleural drainage is indicated for the following:

• Persistent symptoms despite attempting biopsy-site down positioning
• A pneumothorax exceeding approximately 30% or extending along the lateral aspect of the chest (typically necessitates evacuation)
• A pattern of pneumothorax worsening despite 2 or more cycles of site-down positioning [23]

Visual-only estimates of the percentage of pneumothorax tend to be unreliable. Calipers and an evidence-based formula are recommended for a more accurate assessment.[27] 

The decision to discharge a patient from the hospital, rather than admitting them for observation or treatment, is based on several factors, including the patient's condition, ability to be observed at home, and home location. Patients with a pneumothorax should be admitted or observed unless pneumothorax stability despite light activity is demonstrated, in which case the patient is only discharged if the following are present:

• The patient's prebiopsy testing parameters indicate that they are likely to survive subsequent pneumothorax growth while awaiting emergency responders to provide chest decompression.
• A responsible individual is willing to stay the night with the patient.
• The patient lives within 20 minutes of the medical facility or for ambulance arrival after a 911 call.

Delayed pneumothorax necessitating chest tube insertion has occurred as late as 2 weeks after PLLB.[28] 

Complications

PLLB is a procedure with a high complication rate. The SIR recommended benchmark threshold for pneumothorax and chest tube insertion rates is 45% and 20%, respectively. Surpassing these benchmarks should prompt a comprehensive review to formulate strategies to mitigate and decrease the incidence of these complications.[29] Following PLLB, deaths can occur due to hemorrhage (rate about 1%), air embolism (rate <1%), cardiac event, or tension pneumothorax.[30] 

Pneumothorax

The most common risk factors associated with a higher incidence of biopsy-related pneumothorax include:

• Long lesion depth (≥3 cm)
• Small lesion size (≤4 cm)
• Lesions without pleural contact
• Emphysema
• Using a large needle gauge (≥18)
• Crossing fissures or bulla
• Multiple pleural punctures
• Clinicians with limited experience [28]

Pain from pneumothorax is not a consistent phenomenon in all patients. While some patients may experience pleuritic chest pain even with a small pneumothorax, others remain asymptomatic until a more substantial pneumothorax develops. Furthermore, the size of pneumothorax necessary to cause dyspnea is highly variable and depends on the underlying cardiopulmonary condition. 

If a pneumothorax occurs before completing tissue retrieval, reinflating the lung before resuming attempts at tissue retrieval should be considered. Once a patient experiences clinical deterioration and the lung loses its fixed position, anticipating the target lesion's future position during subsequent needle advancements becomes difficult. Moreover, the lung may only be able to be balloted rather than punctured by needle thrusts.

In some instances, aspiration alone may obviate the need for chest tube placement, especially in patients without substantial pneumothorax. Small-gauge catheters, as fine as 4 French, can be employed via the Seldinger or trocar technique. Alternatively, a large-gauge needle, such as a Hawkins-Akins needle (a non-sharp needle with a sharp trocar), can be used. The most expeditious method for pneumothorax evacuation involves wall suction. 

Hemoptysis and Pulmonary Hemorrhage 

Pulmonary hemorrhage from PLLB has been estimated to occur at a rate as high as 60%.[31] Hemoptysis is less frequent, occurring in approximately 10% of cases. The risk of hemoptysis increases in the following cases:

• Individuals receiving dual antiplatelet therapy [32]
• When puncturing a pulmonary cavity or an enlarged bronchus, both of which are associated with bronchial artery hypertrophy

Unusually bloody specimens and ground-glass attenuation developing in the lung indicate the possible development of clinically significant hemoptysis, which may need to be addressed with one or more of the following strategies:

• Administer oxygen.
• Position the patient biopsy side down to prevent blood from seeping through the bronchi into the contralateral lung.
• Intubate with a dual-lumen tube.
• Perform bronchoscopic tamponade of the lobar bronchus.
• Perform bronchial or pulmonary artery embolization or surgery.

Air Embolism

Air embolism affects <1% of patients undergoing PLLB. This complication can arise from patient inhalation after trocar removal from a needle tip in a pulmonary vein or from the iatrogenic creation of a broncho-venous fistula. Manifestations of an air embolism include unconsciousness, stroke-like symptoms, or seizures. However, only one-third of these cases result in substantial morbidity or mortality.[33] 

The following treatments for air embolism are recommended:

• The patient should be positioned in the left lateral decubitus Trendelenburg position to prevent air from exiting the left atrium before having the opportunity to dissolve.
• Oxygen should be administered to aid the absorption of nitrogen in the bubbles.
• While most hospitals do not have decompression/hyperbaric chambers, air embolism cases are an appropriate time to use these chambers, if available.

Intubation and positive pressure ventilation may worsen the introduction of venous air in a bronchopleural fistula and should be avoided.

Clinical Significance

Depending on the study being used, PLLB accounts for one-third to one-half of lung lesion biopsies in the United States. The Dartmouth Institute for Health Policy and Clinical Practice in 2022 reported that around 65,000 PLLBs are performed annually in the United States.

Most experienced interventional radiologists can reach a target of at least 5 mm in diameter and <15 mm in depth, which for nonobese patients includes the majority of the lung parenchyma. The commonly asked question, "Can a percutaneous approach biopsy the lesion?" is generally not the question that should be asked. Medical research does not clearly address all conditions where a biopsy approach offers superior results to another. Recognizing this, as well as the fact that patients are not solely medical cases but are individuals, the various medical societies that make guidelines for performing lung lesion biopsies leave many patient-dependent factors for clinicians to consider. 

When determining whether PLLB should be the first-line option or is even an option at all, clinicians must consider whether a patient will be able to do what is necessary to enable the healthcare practitioner performing the PLLB to target the lesion successfully. They must consider the limitations of a hospital's equipment and what healthcare personnel are available to provide safe prebiopsy, intrabiopsy, and postbiopsy services. Specific questions to ask in each case should include:

• Has the lesion reached a size allowing a reasonable chance at a tissue yield, or is it more reasonable to wait to allow the lesion to grow in anticipation that a diagnosis will still likely be achieved before potential metastasis?
• Assuming that biopsy is now appropriate, how should the clinician and patient work together to optimize the patient medically and psychologically to improve the likelihood of a safe and successful biopsy?
• Anticipating that the biopsy may not yield adequate tissue, what will be the alternative plan?

Such considerations may prevent prolonged hospitalization or severe permanent injury to the patient.

Enhancing Healthcare Team Outcomes

Successful PLLBs rely on seamless interprofessional collaboration, where each team member plays a critical role in enhancing patient-centered care, optimizing outcomes, ensuring safety, and improving overall team performance. Physicians—including radiologists, pulmonologists, and referring clinicians—must lead efforts to align individual patient preferences with current clinical evidence and guideline-based practice. This includes transparent communication with patients about the risks, benefits, and alternatives to PLLB, enabling informed consent and preserving patient autonomy. Advanced practitioners contribute meaningfully by conducting comprehensive assessments, assisting during the procedure, and supporting follow-up care. Imaging technologists are essential to the procedural planning phase, ensuring that all required equipment is available and functioning, and guiding optimal patient positioning and imaging to facilitate accurate biopsy and reduce complications.

Nurses are vital to the continuum of care, providing preprocedural education, preparing patients physically and emotionally, and leading initiatives to ensure patient comfort during and after the procedure. Pharmacists also play a key role, especially in managing sedation or analgesia tailored to patient-specific needs, contributing to both safety and comfort. Effective communication among all these professionals is paramount—not only to prevent errors, but to ensure that the plan of care is clearly understood and aligned with the patient's values and goals. Coordinated teamwork helps prevent complications such as pneumothorax or bleeding and ensures timely recognition and management of adverse events. Through mutual respect, clearly defined responsibilities, and a shared commitment to high-quality care, the interprofessional team can deliver PLLB services that are not only technically successful but also deeply aligned with the principles of person-centered medicine.[34]

Nursing, Allied Health, and Interprofessional Team Interventions

PLLB is often a stressful experience for a patient to undergo; it requires concentration and effort to lie motionless for as much as an hour while actively undergoing a medical procedure. The nurse assisting the procedure can hold as much responsibility/credit as anyone for the procedure's success by helping the patient maintain controlled breathing, focus, calm, and patience.

A pneumothorax or hemothorax may manifest or worsen in the recovery room or after a patient has been admitted for observation. Nurses responsible for monitoring patients who have had pneumothoraces should be trained in managing the chest tube apparatus used to apply suction to the pleural space, including keeping the drainage tubing clear, knowing how to assess and replace the Heimlich valve, and knowing what clinical signs indicate internal hemorrhage and worsening or tension pneumothorax.