In this episode, host Dr. Chris Beck interviews chest and interventional radiologist Dr. Robert Suh about his lung biopsy technique, including how he approaches pain management, and his take on the best way to seal the biopsy tract to prevent air leaks.

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SHOW NOTES

Dr. Suh begins by telling us about his background and current practice at UCLA. He was trained in interventional radiology but did a second fellowship in chest radiology due to the job market at the time. At UCLA they have a very organ-specific practice, and Dr. Suh has spent his whole career on chest and lung imaging and procedures. He splits his time between procedures, triage and planning, clinic and administrative days.

Before a lung biopsy, Dr. Suh sees the patient when they arrive and reviews their procedure. He ends the patient meeting by putting the ball back into their court by coaching them on their breathing. He tells them to take a small breath in and hold it. He has them concentrate on this while on the table which gives them more control in an unfamiliar environment. He uses mild or moderate sedation, and feels that the most important part of pain management is properly numbing the parietal pleura as it is somatically innervated. To do this, he brings a 19 gauge coaxial needle up to the extrapleural space, which looks like a black band of fat, and administers at least 10cc of lidocaine or bupivacaine. Once the parietal pleura is numb, the procedure goes much better because the needle is not tugging on the pleura with each breath. For subpleural lesions, he prefers a tangential approach, which crosses more lung parenchyma but yields a better sample than the shorter perpendicular approach. If a target is inaccessible, he first tries to reposition the patient and does not hesitate to consult interventional pulmonology to discuss alternative approaches.

Dr. Suh discusses how he previously used blood patches at the end of the biopsy to seal the tract, and why he changed his technique. He now exclusively uses BioSentry, a hydrogel polymer that functions similarly to a blood patch. After deploying the BioSentry through the introducer needle he waits 3-5 minutes, checks for pneumothorax development, and if there is no pneumothorax he sends patients home within 30 minutes without doing a post-biopsy chest x-ray.

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RESOURCES

MD Anderson Study:
https://pubmed.ncbi.nlm.nih.gov/15673500/

Memorial Sloan Study:
https://pubmed.ncbi.nlm.nih.gov/30480487/

AngioDynamics BioSentry:
https://www.angiodynamics.com/product/biosentry-tract-sealant-system/