1. Part 3B: Endobronchial Brushing volume 1
Strategy and Planning
Execution
Bronchoscopy International BI

2. When to perform endobronchial brushing
Visible airway mucosal abnormalities
Visible airway nodules or masses
In case of suspected sarcoidosis (even if airway mucosa appears normal)
In case of abnormal autofluorescence to diagnose intraepithelial lesions (dysplasia, metaplasia, carcinoma in-situ) BI

3. Training is essential in order to
Learn proper techniques and indications
Avoid procedure-related complications.
Learn to protect the equipment and the patient
To obtain adequate tissue for diagnosis
To avoid damaging the working channel
To avoid excess patient discomfort (cough, anxiety, shortness of breath).
To avoid bleeding, that might also prompt cough and patient agitation. BI

4. Q1: Optimal endobronchial brushing samples requires correct processingBI

5. Q8: Optimal endobronchial brushing samples requires correct processingBI

6. Other ways to potentially increase diagnostic yield include
TRUE. Brushing samples must be processed correctly and according to the needs and preferences of your institution’s cytology and microbiology laboratories.
Other ways to potentially increase diagnostic yield include
Using brushes with longer bristles
Brushing vigorously and for a longer period of time.
Making sure that all parts of the brush are in contact with the mucosal abnormality.
Using the pirouette technique (rotation) in combination with long-axis motion. BI

7. Bronchial brushing:
Originally done under fluoroscopy without bronchoscopy
Common indications:
Visible endobronchial tumors or mucosal abnormality
Peripheral tumors (+/- fluoroscopy)
Peripheral infection – pneumonia, abscess, cavity
Brush samples larger surface area of lesion BI

8. Bronchial brushing: Different size brushes Protected specimen brush
Standard 3 mm cytology
7 mm brush (rarely used)
No sheath
For visible lesions only
Cannot be retracted into scope
Collects more cells but yield and bleeding equivalent to 3 mm1
Protected specimen brush
Avoid upper airway contamination
For diagnosis of infection/ quantitative cultures
From Flexible Bronchoscopy Wang and Mehta BI
1Cleve Clin J Med 1987;54:

9. Bronchial brushing: Technique:
Advance catheter into desired segment – then extend brush (up to 5 cm)
Make sure brush extension doesn’t push back the scope or catheter
Move back and forth over the visible lesion or blindly in distal airway (5-10 times) +/- rotation
Cells collected in brush bristles BI

10. Bronchial brushing: Yield: 94% endoscopically visible/peripheral 78%1
92% central and peripheral with fluoro2
77% endoscopically visible/20% peripheral with fluoro3
1CHEST 1973;63:
1Am Rev Respir Dis 1974;109:63-66
2CHEST 1974;65:
3CHEST 1976;69: BI

11. Bronchial brushing:
Complications:
Bleeding
Pneumothorax BI

12. Biopsy vs cytology: 154 patients with malignant pulmonary lesions
Each patient had (EBB or TBB) AND (TBNA or brushing)
EBB/TBB sensitivity 62.8%
TBNA/brush (cyto) sensitivity 69.2%
Combined sensitivity 87.2% BI
J Bronchol 2004;11:

13. Additional literature:BI
J Bronchol 2004;11:

14. Endobronchial Brushing
Brush samples large area of mucosal abnormality
May be done under direct visualization, or with fluoroscopic guidance
Brushes may be bare of within a covering sheath
Brush Video BI

15. Indications and brushing techniques
Visible airway mucosal abnormality
Peripheral lesion (lung nodule, abcess etc)
Peripheral lung infiltrate
Techniques
Extend catheter into target segment
Extend brush “Brush out”. Be certain extended brush does not cause pain or pneumothorax, nor push bronchoscope proximally.
Brush forcefully and gently and frequently (5-10 times) with and without brush rotation so that all parts of brush touch the lesion.
Retract brush “Brush in”.
Remove the catheter-brush from the working channel. BI

16. Brushing Yield * Greatest when cancer is present
94% in case of central lesion, 78% in case of peripheral lesions. But yields can also be as low as 20 % for peripheral lesions. *
Chest 1973;63:889, Chest 1976;69:752, J Bronchol 2004;11:154* BI

17. Brushing-related Complications
Bleeding
Pneumothorax
Perforation of lung abscess BI

18. Bleeding risk if Thrombocytopenia: <50,000
Risk of bleeding: 0-26% (TBBx, post transfusion) (1)
Brushing with mean platelet count of 30,000: Bleed: 16% , Death: 4% (2)
What to do? Transfuse 6 packs before & during bronchoscopy, no need to recheck platelets (3)
Platelet half-life 6 hours!
(1) Weiss S, Chest, 1993;104:1025
(2) Papin T, Chest, 1985; 88:54
(3)Wahidi M, Respiration 2005;72:285 BI

19. Combined procedures have greatest yield for malignancy
Arch Bronchoneumol. 2006;42(6):278-82
75 patients underwent bronchial washing before (pre) and after (post) endobronchial biopsy and brushing BI

20. This presentation is part of a comprehensive curriculum for Flexible Bronchoscopy. Our goals are to help health care workers become better at what they do, and to decrease the burden of procedure-related training on patients. BI

21. Step by Step©
Bronchoscopy.org
BRONCHATLAS© BI

22. All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as:
Bronchoscopy International: Art of Bronchoscopy, an Electronic On-Line Multimedia Slide Presentation. of Bronchoscopy/htm. Published 2007 (Please add “Date Accessed”).
Thank you BI

23. Prepared with the expert assistance of Udaya Prakash M. D
Prepared with the expert assistance of Udaya Prakash M.D. (Mayo Clinic, USA), and Atul Mehta M.D. (Cleveland Clinic, USA), and Wes Shepherd M.D. (Virginia Commonwealth University, USA) BI