[Case Report] 62yo undergoing procedure for a lung nodule

A 62‐year-old man is undergoing a CT‐guided core biopsy of a lung nodule when he develops an iatrogenic pneumothorax. After admission to the Royal Adelaide hospital he has ongoing dyspnoea, oxygen desaturation, and chest pain not helped by a preexisting Chronic Obstructive Pulmonary Disease. The treatment for the patient’s symptoms doesn’t immediately go to plan but his care team apply a combination of recent technologies to bring the condition under control. Pomegranate [Case Reports] have been developed to help Trainees rehearse diagnostic problem solving and case presentation.

Guests
Associate Professor Arash Badiei FRACP (Royal Adelaide Hospital; Adelaide University)

Hosts
Associate Professor Stephen Bacchi FRACP (Northern Adelaide Local Health Network; Adelaide University)
Dr Brandon Stretton (Central Adelaide Local Health Network;)

Production
Produced by Dr Stephen Bacchi and Mic Cavazzini DPhil. Music licenced from Epidemic Sound includes ‘Desert Whispers’ by Tellsonic and ‘Brighton Breakdown’ by BDBs. Image created and copyrighted by RACP. Editorial feedback kindly provided by RACP physicians Aidan Tan and med students Srishti Sharma, Prakriti Sharma and Cindy Shi. 

Key Reference (Spoiler Alert)

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Persistent air leak successfully treated with endobronchial valves and digital drainage system [Altree, Respirol Case Rep. 2018]

Please visit the Pomegranate Health web page for a transcript and supporting references. Login to MyCPD to record listening and reading as a prefilled learning activity. Subscribe to new episode email alerts or search for ‘Pomegranate Health’ in Apple Podcasts, Spotify, Castbox or any podcasting app. 

Transcript

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SPEAKER_02 0:04

A 62-year-old man is undergoing a CT guided core biopsy of a lung nodule when he develops an iatrogenic pneumothorax. After admission to the Royal Adelaide Hospital, he has ongoing dyspnea, oxygen desaturation, and chest pain not helped by a pre-existing chronic obstructive pulmonary disease. The treatment for the patient's symptoms doesn't immediately go to plan, but his care team apply a combination of recent technologies to bring the condition under control. Welcome to Pomegranate Case Report from the Royal Australasian College of Physicians. I'm Mika Kabazzini, but this series of podcasts has been prepared by Associate Professor Stephen Bucky to help trainees of the RACP work through diagnostic problem solving and case management. Today's case was reported in the journal Respirology Case Reports in 2018. And I'll put a link in the show notes. But I encourage you to listen along and test your thinking as Stephen and his guests drip feed the evolution of the case. Let's get started.

SPEAKER_00 1:06

Hi, I'm Stephen. I'm a neurologist at the Northern Adelaide Local Health Network and Adelaide University. And today with us we have Prof. Arash Badiyi, who's a respiratory physician and interventional pulmonologist with a national and international reputation in plural medicine and advanced thoracic procedures. He serves as plural lead and interventional pulmonologist at the Royal Adelaide Hospital and holds a clinical associate professor appointment at the Adelaide University. And we have Dr. Brandon Stratton, who is a respiratory advanced trainee and is currently a PhD student at the Adelaide University. Thank you both for joining us.

SPEAKER_03 1:41

Thank you very much. I appreciate you having me on and really looking forward to discussing this case.

SPEAKER_00 1:48

So as usual, we'll be discussing a previously published case report in a step-by-step manner with a focus on content that is relevant to trainees and a generalist audience. Today we have a 65-year-old male who's had a learning nodule identified on imaging in the left upper lobe. He has no clearly attributable symptoms. He's a past medical history of severe chronic obstructive pulmonary disease or COPD and rheumatoid arthritis on top of synid. Now I know that ideally we'd like a lot more information than this, but just to start off with, could you please outline the pieces of information that are particularly important to you when evaluating a patient with a lung nodule?

SPEAKER_04 2:27

Thanks, Lee. And so I guess the the first thing to do is to start right at the basics with the definition of what a nodule actually is. So a nodule, by definition radiologically, is an opacity that's less than or equal to 30 millimeters. Above that cutoff, we call them a mass. So that's the first definition that we need to get right. And then really, when it comes to us assessing this, it's about assessing it in terms of attributing some risk in terms of whether this is likely to be a lung cancer or not. And so that's where our decision making comes from. So these nodules can be incidentally detected, as we've got in this case, or more recently, they can be detected via the National Lung Cancer Screening Program. So that's a screening detected nodule. And they obviously have slightly different risk profiles because we're targeting different patients. And I am going to use this as a bit of a plug for the National Lung Cancer Screening Program because that just kicked off last year and we're really trying to promote people to get on board. So that screening program is for people that are aged 50 to 70 years of age, they're asymptomatic because this is a screening population. And then you have to have some smoking history. So you either have to be an active smoker or have quit in the last 10 years and have at least 30-pac-year history of smoking. So if that if you meet that criteria, then you'll be eligible for a lung cancer screening CT, a low dose CT. But we'll now go back to this case because this was an incidentally detected nodule. So again, when it comes to these nodules, what we really do is break it down into the risk of the patient. So we're talking things like the patient's age, gender, whether they've got a smoking history, whether they've got a history of themselves or a family history of lung cancer. All those things increase the risk from a patient perspective. And then we've got the nodule risks. So what size is the nodule? And then is the nodule solid? Is it subsolid? Is it part solid? Or is it a um like a ground glass capacity? The other really useful bit of information is if we have some historical imaging that shows whether that nodule is either growing in size or whether it's stable or if it's new. So if we have historical CTs that, for example, show the nodule's been there for 10 years, that risk profile drops dramatically. So that is likely to be a benign nodule. Whereas if that's a new nodule that's grown in say the last three months and a patient's got a smoking history, then our risk kind of profile changes quite a bit and we treat that nodule quite suspiciously. So all of these things come into the mix when we're looking at these nodules. With incidentally detected nodules, there are a number of different guidelines that are available to try and help us in determining what we should do next. The most well-known are probably the Fleishness Society guidelines for the incidentally detected nodules. So these give us some guidance in terms of taking the patient history, so if they've got a high or low risk in terms of smoking history, lung cancer history, etc. And then really it's based on size of the nodule. And for the Fleishness Society guidelines, they have at the moment, these are the 2017 guidelines, so they're probably due for renew, but the six to eight millimeters was around the cutoff. So less than six millimeters, usually considered low risk. Once it gets into that six to eight, it's a bit of an intermediate risk where we have to really assess the patient risk factors. And once it gets above that eight millimeters, then really we're we're treating that nodule as suspicious and we'll probably go on to the next uh steps in the investigation. So again, this comes down to other things. So if we have prior imaging that shows that a millimeter nodule has been stable for 10 years, then we won't be really treating that as a suspicious nodule. But if we have uh an incidentally detected nodule with no prior um imaging available and there's uh appropriate risk factors, then that nodule will be treated as suspicious. And then we go through some routine steps in terms of investigation. So the first would be to obviously see the patient history and examination, uh the routine things that we we would do normally. Um, lung function testing is essential, and usually that's spirometry and diffusion capacity, because they're the minimum that we need to determine if a nodule, if it's proven to be malignant, is operable or not. And then the other thing that's important is in terms of staging is an FDG PET scan. Um so that tells us about staging, if there's any mediastinal node involvement that we need to think about in terms of the overall staging when we are working that patient up.

SPEAKER_01 6:50

Thanks for that overview, prof. And so now in this case, we don't have all the details, but we know the patient is proceeding to have uh tissue obtained, or I guess in other words, the treating teams decided that a biopsy is required. In general terms, could you give us a bit of an outline for the different methods that you could pursue when looking at uh a lung biopsy and what maybe factors might influence one decision over the other?

SPEAKER_04 7:16

Yeah, absolutely. Um so look, broadly speaking, um, in most of the centres and most of the tertiary centres that deal with these nodules, um, you have two approaches. One is a percutaneous or transthoracic technique, which would be using a CT guided um uh approach, for example. Um, and then the other big one for us is obviously endobronchial or bronchoscopic approach. Um, I'll just mention because I think this is changing, this paradigm is changing a little bit with the advent of robotic-assisted bronchoscopy that we're seeing come through now. Um so some of the nodules that would traditionally have been CT guided biopsies may change in the future to robotic assisted. But for now, the majority of centers have the two either CT guided or bronchoscopic approaches. Um, again, very generally speaking, if a nodule is more peripheral, closer to the skin and chest wall, a CT guided approach may be the more preferred approach. Um and if there's an airway leading to that, or if it's more central, um then usually we would uh elect for a bronchoscopic approach. So that can either be using bronchoscopy with linear rebus um guidance, or more commonly for the peripheral nodules, it's a radial and a bronchial ultrasound guided biopsy. Um so they're the the broad uh splits. The reason we prefer bronchoscopic approaches is because the risk profile or the complications are much lower. So again, broadly speaking, um, using a bronchoscopic approach, the risk and the main risk we talk about is pneumothorax. So primary hemorrhage and pneumothorax are the two big ones, but pneumothorax is by far the most common one. Um so using a bronchoscopic approach, the risk of pneumothorax is usually less than 3% in patients, and of those, less than 1% need to come into hospital and have an intervention like thoracostomy, uh, compared to CT guided, where the risk goes up to about 30%. And of those, around 10 to 15% will need thyrocostomy or hospital admission. So for that reason, um, a bronchoscopic endobronchial approach is preferred if if the anatomy and the nodule is is in the right position.

SPEAKER_00 9:16

Thanks, Prof. Eddie. One question that historically I found tends to arise not infrequently is what to do with anti-thrombotics or anticoagulants and antiploylets in the setting of invasive pulmonary procedures, such as bronchoscopies, plural procedures, and the TT guided biopsies. I know that it's not possible to discuss all eventualities, but could you please go through some principles with us around this common question? And are there any particular guidelines people should look at?

SPEAKER_04 9:43

Yep, no, absolutely. And I think that's a great question because this is something you know we we all do on a daily basis, because uh more and more patients are on antiplatelet agents, on anticoagulation, and we're detecting these nodules uh much earlier because we've got more imaging happening. So this is a very relevant and um question and something we're dealing with every day. So, look, the uh from a bronchoscopy and interventional pulmonology point of view, um, there are guidelines from the American College of Chest Physicians and British Thoracic Guidelines. Um, but actually, like the there is an Australian guideline which is from the Clinical Excellence Commission, which is a guideline on peri-procedural management of anticoagulation and antiplatels. And I think they um they risk stratify things quite well and it aligns with um what we use from the British Thoracic Society as well as the um ACCC, so the A American College of Chest Physicians. Um the uh what they do is basically break down um the risk into procedural risk. So what's the bleeding risk from the procedure? Uh and then we have the alternative risk, what is the risk for clotting and a thrombotic uh event in a patient when you stop the anticoagulation or the anticoagulate? So using that kind of two uh two kind of risks, um, we then determine what we do. So, in terms of bronchoscopy, anything that involves biopsy, so this is bronchoscopy with trans bronchial biopsies or a linear rebus with needle aspiration or radial e-bus guided biopsy, all of those are considered to be moderate to high risk of bleeding. So, in that setting, um we would uh usually hold dual antiplatelets and have a plan for anticoagulation, which I'll go through in just a second. Um, and with plural procedures, usually just uh thorosantesis, a needle thoroughcentesis is considered low risk. But anything that involves a tube being inserted or a biopsy is again considered moderate to high risk. So, in that situation, we would also think about the antiplatelet agents and the anticoagulation. So, generally speaking, aspirin, we are happy to perform most procedures on aspirin alone, but the other antiplatelet agents such as clepidigal, ticagarol, we would hold. And our advice generally is to hold for at least five days prior to the procedure. Obviously, that risk changes if the patients recently had an event. Um, so uh these discussions are common with cardiology, with neurology, uh, if the patients have had uh cardiac event or stroke about and when is the appropriate time that we may be able to hold digital antiplateless for a short window to be able to do a biopsy if it's necessary to do so. Um, when it comes to anticoagulation, then the the question is about do we need bridging or not? Um so generally, if they're a low risk, um, so you know if they've just got AF with a Chavs VAS score that's less than six, um then in that setting we would probably not bridge and we would hold the anticoagulants. So if they're on a warfront, again, we would hold for or ask the patient to hold it for five days and then test the INR the day before, and ideally a point of care INR before the procedure. Um, with the direct acting anticoagulants, we would usually hold for 48 hours prior to the procedure. Um, the bigger trend we don't see that often, renal function comes into that one, so usually we don't have to deal with that nowadays. But with river oxaban, a pixaban is usually 48 hours prior to the procedure. And then on restarting, which is the other one that's really important. I think the one key point for people who remember with plural procedures in particular is if a drain has been put in, the bleeding risk you have to think about on the removal of the drain as well, um, so not only on the insertion. So don't start their anticoagulation, remove the drain, because sometimes that's the thing that causes the bleeding. Um, and for us, usually, if the procedure is uncomplicated, anticoagulation can restart the next day. But if it's a complicated procedure for any reason, um then we may delay that depending on the risk for bleeding.

SPEAKER_01 13:35

Thank you. And in this case, the patient underwent a C2 guided core biopsy. And post-procedure they were noted to be hemodynamically stable, but had some reports of chest pain and then accrued some dyspnea and uh eventually uh oxygen saturations. And so pneumothorax was eventually diagnosed, and a eight and a half French intercostal catheter was placed uh with an underwater seal drain and with some uh reassuringly improvements in their symptoms. However, over the following two days, a large air leak did persist and an X-ray showed a persistent apical pneumothorax. With eventually on day three, the patient had progressive worsening and subcutaneous emphysema. Um, and so could you talk us through kind of your thought processes um at this stage of the game?

SPEAKER_04 14:21

So, yeah, so this is um as we discussed, so the risk with CT guy biopsy. Obviously, there's a relatively high risk of pneumothorax, so not unexpected. Um, so in this case, the fact that um they have had an 8.5 French drain put in, and what we're seeing is a clinical deterioration with subcutaneous emphysema immediately tells me this is a bit of a flow issue with the air leak. So either the tube, because it's quite small, has blocked, uh, and now air, which like any liquid will follow a path of minimum resistance, the air is following the subcutaneous tissue as its path of exit. Um so that's why the patients develop this. If the air leak is large, the subcutaneous emphysema will be quite significant, will develop rapidly. Um, so by the sounds of this case, something may have changed, the leak may have gotten a bit bigger, the tubing may have been blocked, and the tube is just not able to cope with the air flow at the moment. So that air is leaking out under the skin. So the appropriate thing to do at this stage is to um you can temporize it with using some suction because that will improve the flow through the tubing. Um, but really the thing that needs to happen is this patient needs to have a large boar chest drain inserted. And you might remember from from kind of physics days that you know the the flow of fluid through a tube is directly proportional to the internal radius or internal diameter of the tube to the power of four. So that's where it really makes a difference that you put in a large bore or chest tube in these patients. Um so um that's the the main uh thing that we would look at in that initial um deterioration with a subca and the semema.

SPEAKER_00 16:02

Well, thank you. In this case, the patient had quite a complicated course with a subsequent attention pneumothorax and then 20 days with an underwater seal drain and no improvement. And he was subsequently treated with an endobronchial valve. And I imagine our listeners may not be seeing patients with endobronchial valves very frequently. Could you please remind us of what the role of an endobronchial valve is usually in specific considerations for these patients?

SPEAKER_04 16:28

Yeah, absolutely. So um this patient had a very protracted course. So um by definition, if you have a pneumothorax and that pneumothorax is still leaking at five days, we term that a persistent air leak. Um persistent air leak has a fairly uh clear guideline in terms of how to proceed. If the patient is a surgical candidate, um then still to date, based on the available evidence, going to surgery and trying to close that hole, um, the air leak surgically is um the best way to go. But in patients that are not surgical candidates, um then we turn to medical management. Um, and one of the um, I guess, non-invasive reversible techniques that's become available for us is the use of these endobronchial valves. Um, so an endobronchial valve was designed for uh lung volume reduction in the setting of patients with bad emphysema and gas trapping. Um, so they're little valves that sit in the airways and block the airway. Um they're usually a well, they are a one-way valve, they allow air to escape out but not back in. Um, so there's some of them are a duct bill shape, others are more of an umbrella shape. Um, so these valves intentionally are initially intended for lung volume reduction, um, but uh have an off-label use for um use in uh air leak with pneumothorax. So what would typically happen is a patient like this would go to bronchoscopy and we would do an air leak isolation study where we basically systematically block off the airways with a balloon while we look at the drain and see how much uh the bubbling reduces. So you're trying to isolate which segment or which airway is causing that leak there. And if you can isolate it, then you can deploy these valves in either one or multiple airways to try and block the air leak. Um, so that's basically what these valves are used for. And on the plus side, they're reversible and so they can be removed when the air leak resolves. And typically we would look at removing them around six to eight weeks post-insertion.

SPEAKER_01 18:30

Excellent. And so in this case, the patient had a 46-day admission, but ultimately was able to have their chest tube removed and eventually discharged home. So great outcome all around. And so to wrap up the case for our listeners, do you think you could potentially outline a couple key learning points or take-home messages for our trainees?

SPEAKER_04 18:51

Um, so look, I think um, you know, again, I'm going to use this as a bit of a platform to try and plug um the National Lung Cancer Screening Program because it is an important program. Um so just to remind everyone that, you know, age 50 to 70 years, asymptomatic, and they have either they're a current smoker or they've quit in the last 10 years and they have a 30-pack year history of smoking, those patients are eligible for lung cancer screening and will get a low dose CT and then fall into the national program. So I think that's one of the key messages to take away from this uh podcast. When it comes to nodules, um, I think it's very important to recognise that there's patient factors as well as nodule factors. Um, so the size of the nodule, the the type of the nodule, whether it's solid, subsolid, or part solid is important. If we if you have the ability to look for uh a historical relationship with the nodule, if there's price CTs and to compare to, that can really help in terms of trying to risk stratify that nodule. Biopsy, I think, really comes down to uh expertise. So speak to your respiratory team because uh what we want to try and do ideally is approach nodules with the endobronchial bronchoscopic technique if we can, just because that risk profile is lower. In some patients, the only approach is a CT guided approach, so that would be appropriate in those settings. Um, with etrogenic pneumothorax and persistent air leak, I think the key messages are even though in this case there was a very protracted uh course and they needed intervention, the majority of the atrogenic pneumothoraces actually will resolve spontaneously. But of those that don't, I think it's important to recognise early when there's a persistent air leak. So if the air leak is looking like it's not settling down within the first few days, you really have to position yourself to be planning for a persistent air leak, you know, determining if the patient is a surgical candidate, making sure you've got all the imaging in line, and then uh going through all the other options if they're not for surgery and they're for medical management, and uh then referring to a centre that has expertise with intermolecule valves would be appropriate in that setting as a relatively uh minimally invasive approach.

SPEAKER_01 20:58

And potentially, um, if people found this interesting, are you aware of any maybe upcome upcoming conferences later this year that you might like to plug, prof?

SPEAKER_04 21:07

Oh yes, of course. Yeah, no, uh thanks for the plug. So we we uh are actually hosting the World Congress of Broncology and Interventional Pulmonology in Australia for the first time this year. It's going to be held in Melbourne in December. Um, and so I'm lucky enough to be one of the conveners for that uh conference. So um definitely putting it out there because it's the first time uh that we're getting uh all the you know interventional pulmonology and plural leads around the world attending one place in Australia. So it'll be a big conference um and uh quite interesting for those that are interested in this field. So uh have a look out for it. The website's uh up, uh registrations uh are are open, and if you've got an abstract to submit, we're also accepting abstracts now.

SPEAKER_00 21:46

Brilliant, thank you. Well, I'll get Mix help and include the link to the conference in the show notes as well. But for full details of this case, listeners could listen or review the article titled Persistent Air League Successfully Treated with Endobronchial Valves and a Drainage System. And it was published in Rispirology Case Reports in 2018. The authors Ultry, Jerzman, and Nun. And thank you again to our expert discussant, Prof. Betty. Really appreciate it, it's been a great broadcast.

SPEAKER_04 22:16

Thanks for having me, I appreciate it.

SPEAKER_02 22:25

Before I lose you, I'm gonna flag again the National Lung Cancer Screening Programme, which started in July 2025. People between 50 and 70 years are eligible if they're considered high risk but asymptomatic for lung cancer. That is, they currently smoke or have quit smoking within the past 10 years, or have a history of at least 30 pack years of cigarette smoking. Many thanks to Associate Professor Stephen Bucky for another fascinating case report. This is just an extracurricular passion project of his, so please forgive any gaps you may find in the content. Thanks also to Dr. Aidan Tan and Med students Sarishti Sharma, Rakhritish Arma and Sindish Chi for their feedback on this before publication. You're welcome to email us on podcast at racp.edu.au if you have any thoughts of your own or suggestions for new episodes. If you're a fellow of the RACP, you can automatically lodge your time spent listening to these podcasts toward continuing professional development. Just look for the blue button at the top of the episode page that says add educational activity to my CPD. If plural medicine is your thing, episode 124 with Professor Gary Lee was a cracker. And there are more than a dozen lectures on respiratory medicine at the College Learning Series. You can find these at the new look page eLearning.recp.edu.au. I'd like to give credit to the RECP Digital Learning team for all their work on that. They Tuznim Jahan, Izumi Takashima, Alfina Khan, Shila Kuraeg, and Briney Wormsley. So as not to miss a podcast episode, make sure you subscribe to Pomegranate Health from any pod browser like Apple Podcasts, Spotify, Overcast or Castbox. You can even sign up to our mailing list at recp.edu.au slash podcast. This podcast was recorded on the lands of the Cardinal people in Adelaide and the Gadigul clans around Sydney Harbour. I pay respect to their elders past, present, and in training. I'm Mickey Covenant C and Cards.