Pneumothorax rates in CT-Guided lung biopsies: a comprehensive systematic review and meta-analysis of risk factors

Abstract

Objective: This systematic review and meta-analysis investigated risk factors for pneumothorax following CT-guided percutaneous transthoracic lung biopsy. Methods: A systematic search of nine literature databases between inception to September 2019 for eligible studies was performed. Results: 36 articles were included with 23,104 patients. The overall pooled incidence for pneumothorax was 25.9% and chest drain insertion was 6.9%. Pneumothorax risk was significantly reduced in the lateral decubitus position where the biopsied lung was dependent compared to a prone or supine position [odds ratio (OR):3.15]. In contrast, pneumothorax rates were significantly increased in the lateral decubitus position where the biopsied lung was non-dependent compared to supine (OR:2.28) or prone position (OR:3.20). Other risk factors for pneumothorax included puncture site up compared to down through a purpose-built biopsy window in the CT table (OR:4.79), larger calibre guide/needles (≤18G vs >18G: OR 1.55), fissure crossed (OR:3.75), bulla crossed (OR:6.13), multiple pleural punctures (>1 vs 1: OR:2.43), multiple non-coaxial tissue sample (>1 vs 1: OR 1.99), emphysematous lungs (OR:3.33), smaller lesions (<4 cm vs 4 cm: OR:2.09), lesions without pleural contact (OR:1.73) and deeper lesions (≥3 cm vs <3cm: OR:2.38). Conclusion: This meta-analysis quantifies factors that alter pneumothorax rates, particularly with patient positioning, when planning and performing a CT-guided lung biopsy to reduce pneumothorax rates. Advances in knowledge: Positioning patients in lateral decubitus with the biopsied lung dependent, puncture site down with a biopsy window in the CT table, using smaller calibre needles and using coaxial technique if multiple samples are needed are associated with a reduced incidence of pneumothorax.

Pneumothorax after CT-guided transthoracic lung biopsy: A comparison between immediate and delayed occurrence

“…In the present study, pneumothorax developed in 30% of CTLB procedures, comparable to previous studies [9,20]. Of all cases of pneumothorax, 16.1% was delayed occurrence.…”

“…Among variables contributing to the risk of pneumothorax, factors other than small lesion size remain controversial [ 9 , 19 , 21 – 24 ]. Our study showed small lesion size as the only consistent factor related to both immediate and delayed pneumothorax.…”

“…Risk factors for pneumothorax after transthoracic lung biopsy have been examined widely. Among the known risk factors, some are consistent whereas others are inconsistent or even contradictory across published studies, probably owing to various baseline characteristics, biopsy techniques, and analytic methods [8][9][10][11][12]. Although biopsy related pneumothorax frequently occurs during or immediately after procedure, pneumothorax can be identified in the follow-up chest radiographs or even after discharge due to chest pain or dyspnea (delayed pneumothorax) [13,14].…”

Management of screen-detected lung nodules: A Canadian partnership against cancer guidance document

“…209 Other studies including a meta-analysis of 36 studies with 23,104 patients identified several risk factors for pneumothorax: lateral decubitus position where the biopsied lung was nondependent compared to supine (OR: 2.28) or prone position (OR: 3.20), larger caliber guide/needles ( 18 G vs. >18 G: OR 1.55), fissure crossed (OR: 3.75), bulla crossed (OR: 6.13), multiple pleural punctures (>1 vs. 1: OR: 2.43), multiple noncoaxial tissue sample (>1 vs. 1: OR 1.99), emphysematous lungs (OR: 3.33), smaller lesions (<4 cm vs. 4 cm: OR: 2.09), lesions without pleural contact (OR: 1.73), deeper lesions (!3 cm vs. <3 cm: OR: 2.38) and operator experience. [209][210][211] Severe COPD, previous pneumonectomy, use of home oxygen and moderate to severe pulmonary hypertension are relative contraindications to PTNB. 207 Preoperative PTNB to confirm malignancy in patients with suspicious moderate-risk to high-risk lung nodules may lead to decreased costs and a lower probability of resecting nonmalignant lesions.…”

Efficacy and Safety of Ultrasound-guided Percutaneous Transthoracic Needle Biopsy for Peripheral Pulmonary Lesions: Comparison Between 16-gauge and 18-gauge Core Biopsy Needle- a Propensity Score Matching Analysis

“…However, in addition to radiation exposure, it could not access real-time monitoring [13]. Besides, previous studies reported that the rate of post-procedure complications was high, including pneumothorax, hemorrhage and vasovagal reaction, which lengthened the period of hospitalization [14]. On the other hand, US-guided percutaneous needle biopsy for PPLs was more advantageous than CT-guided procedure, such as radiation-free, convenient and cost-effective, real-time and dynamic [15][16][17].…”