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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 4 – Practical procedures > Chapter 66 – Abrams’ pleural biopsy Chapter 66 Abrams’ pleural biopsy P.682

  • Diagnosis of tuberculous pleural effusion
  • Abrams’ biopsy is used for the diagnosis of malignant pleural disease in many centres, although a recent randomized-controlled trial has shown that CT-guided cutting-needle biopsy has a greater sensitivity (sensitivity 87% in CT-guided biopsy group vs. 47% in Abrams’ group).

Technique An assistant is required.

  • Discuss procedure with patient and obtain written consent.
  • Insert IV cannula.
  • Consider sedation (e.g. midazolam 2–5 mg IV, with oxygen saturations monitoring).
  • Position patient sitting forward, leaning on a pillow over a table with their arms folded in front of them.
  • Double-check correct side from chest examination and CXR.
  • Choose biopsy site: 1–2 intercostal spaces below upper level of effusion on percussion. Use posterior or lateral approach (although avoid very posterior approaches close to spine, as intercostal artery drops medially to lie in mid-intercostal space).
  • Sterile skin preparation. Wear sterile gloves and gown.
  • Infiltrate skin, intercostal muscle, and parietal pleura with 10 ml of 1% lidocaine. Aim just above the upper border of the appropriate rib, avoiding the neurovascular bundle that runs below each rib. Anaesthetize area behind rib below the insertion point.
  • Whilst waiting for anaesthetic to work, assemble Abrams’ reverse bevel biopsy needle. The needle consists of an outer sheath with a triangular opening (biopsy port) that can be opened or closed by rotating an inner sheath.
  • Verify that the insertion site is correct by aspirating pleural fluid with a green (21G) needle. If unable to aspirate fluid, do not proceed.
  • Make small (5 mm) skin incision; dissect intercostal muscles with blunt forceps (e.g. Spencer–Wells).
  • Insert biopsy needle gently with biopsy port closed. Do not apply force; the needle should slip into the pleural space without resistance. When in the pleural cavity, fluid can be withdrawn by attaching a syringe to the needle and opening the biopsy port.
  • To take a biopsy, attach a syringe to the needle. Open the biopsy port and angle it downwards, and then pull the biopsy port firmly against the parietal pleura on the rib beneath the entry point (6 o’clock position relative to entry point). Close the biopsy port, thereby pulling a sample of parietal pleura into the needle.
  • Remove the biopsy needle, open the biopsy port, and remove biopsy sample.
  • Repeat procedure four–six times in positions 4–8 o’clock, always sampling below the insertion point (to avoid the neurovascular bundle beneath the rib above).
  • Send biopsy samples in saline for analysis for tuberculosis and in formalin if malignancy is suspected.
  • Apply dressing to biopsy site. May require a single stitch.
  • CXR to exclude pneumothorax.

Complications include pain, pneumothorax, haemothorax, and empyema. Haemorrhage from trauma to an intercostal artery may necessitate emergency thoracotomy. Fatalities are well-documented but rare. Further information Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Maskell NA, et al. Lancet 2003; 361: 1326–31

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