Having the test will help your doctor to make a correct diagnosis and plan the most suitable treatment for you.

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1 Percutaneous lung biopsy is a procedure in which a special needle is used to remove a small piece of tissue from your lung for examination in the laboratory. This examination is usually done under local anaesthetic using some form of imaging guidance, such as x-ray, CT (computed tomography) scan or ultrasound. Your doctor will usually request a percutaneous lung biopsy when he/she suspects that there is something wrong with the surface of your lungs, the lung tissue or the chest wall. An abnormality seen on a chest x-ray or a CT scan is the most common reason for a lung biopsy. Having the test will help your doctor to make a correct diagnosis and plan the most suitable treatment for you. The benefit of a percutaneous lung biopsy is that it is a very safe and quick procedure, which will provide important information about your condition. There are some risks and complications that can arise: Pneumothorax (collapsed lung) This occurs in up to 30 per cent* of patients. If this happens, it usually occurs during the first hour after the biopsy. It is caused by an air leak through the needle puncture hole from the lung into a space between the lung and the inner chest wall (also known as the pleural space ). A small air leak after percutaneous lung biopsy is fairly common and usually gets better on its own. A large air leak may cause the biopsied lung to compress and collapse, causing breathlessness and/or chest pain on the side of the lung biopsy. This rarely happens ( per cent* of patients), but if it does it is treated by inserting a small drainage tube under local anaesthetic into the air pocket surrounding the lung and allowing the trapped air to escape. Your symptoms will 1

2 improve immediately after this. You will then need to remain in hospital until your lung has reinflated and the tube has been removed. More rarely this can happen a few days after the biopsy and you will need to let your doctor or local A&E know. Pulmonary haemorrhage (bleeding in your lung) This occurs in 5 20 per cent* of patients. It usually stops on its own. The blood in the lungs is slowly reabsorbed by the body and the lungs clear. Sometimes your doctors give you antibiotics if you have a fever after this. Haemothorax (bleeding into your chest cavity) This is rare and occurs in 2 per cent* of patients. This is treated by inserting a drain into the area, to drain the blood off, and taking antibiotics. Haemoptysis (coughing up blood) This occurs in per cent* of patients, but this should stop after an hour or so. *Percentages of risks supplied by the British Thoracic Society, the Royal College of Radiologists and the British Society of Interventional Radiology. The risk of bleeding or bruising around the puncture site can be minimised by having a blood test to check that your blood clots normally before the biopsy is done. If there is major bleeding, you may require a blood transfusion (one per cent or one in 100 patients). Very rarely (0.1 per cent or one in 1000 patients), surgery is needed to stop the bleeding. The use of some form of imaging guidance such as x-rays, CT scan or ultrasound can help to minimise the risk of complications. The interventional radiologist (specialist x-ray doctor) will discuss these risk factors with you again before starting the procedure and will be happy to answer any questions you may have. A lung biopsy will only have been requested if your doctor feels that this is the best way to find out more information about your condition. He/she will be happy to discuss the procedure with you before starting the test. The only alternative to this type of a biopsy is a surgical biopsy, which we may need to do if the results of your lung biopsy do not help with diagnosis. However, as surgical biopsy involves a general anaesthetic and a longer recovery time for you, we prefer to use the method described in this information sheet initially. If you are an inpatient or a day case patient, your ward doctor and/or nurses will see you before you come to the imaging (x-ray) department for your lung biopsy. 2

3 If you are an outpatient, follow the instructions on your appointment letter, which will advise you to come straight to the imaging department. We may ask you not to eat or drink anything for four hours before your appointment time. Your doctor or ward nurse will advise you It is very important that you have had a blood test recently because the results of these tests will tell us how well your blood clots. Please note that we will not do your lung biopsy without having normal results from your blood tests You can take all your medications as usual, except blood-thinning tablets. If you take bloodthinning medications, such as warfarin or aspirin or clopidogrel, you must tell your doctor, as you may be advised to stop taking them for some time before you have your lung biopsy Please let us know if you are allergic to any medications or dye before you have your lung biopsy If you are diabetic, please tell the ward staff so that they are aware of your condition. If you are diabetic and have been asked not to have anything to eat and drink before your appointment, please do not take your morning medication, or you will risk having a hypo If you are having the procedure as a day patient, you must arrange for a relative or friend to take you home It is sometimes necessary for patients to stay in hospital overnight after having a lung biopsy because of unexpected difficulties, which your doctor will discuss with you. Please allow for this possibility Please contact us as soon as possible. We can then offer this date to another patient and agree a new appointment date and time with you. You will find the appropriate telephone number on your appointment letter. You are advised to travel, if possible, by public transport when visiting our hospitals. Car parking is severely limited and you may find it very difficult to find a place to park near the hospital. The nearest tube stations for Hammersmith Hospital are East Acton and White City (both on the Central Line) and Wood Lane (Hammersmith & City Line). Buses that stop outside the hospital are numbers 7, 70, 72, 272 and 283. The nearest tube stations for Charing Cross Hospital are Hammersmith (District, Piccadilly and Hammersmith & City lines) and Barons Court (District and Piccadilly lines). Buses that stop outside the hospital are numbers 190, 211, 220 and 295. The nearest train station to St Mary s Hospital is Paddington Mainline Station, and Paddington and Edgware Road Underground stations are about 5 minutes walk away. St Mary s is served by bus routes 6, 7, 15, 16, 18, 23, 27, 36, 98 and

4 You will have a chest x-ray and blood tests to check that your blood clots normally. A CT scan of the chest or a bronchoscopy (or bronchi, where a long, thin, flexible tube with a bright light on the end is used to help the doctor examine your breathing tubes) may also be necessary. If you have breathing problems, your doctor may ask you to have a breathing test before the biopsy. We will discuss the procedure with you in detail and ask you to sign a consent form. This is to make sure that you understand the risks and benefits of having the test. You will be asked to change into a hospital gown. Staff in the imaging department will then check your details and examine you before taking you into the x-ray room. Percutaneous lung biopsy can be done under the guidance of x-ray, ultrasound or CT (computed tomography) scan. The interventional radiologist will have decided which is the best method to use for you, depending on the appearance of your lung abnormality. The imaging staff will position you on the x-ray table before connecting you to a monitor, which will record your blood pressure and pulse throughout the procedure. The interventional radiologist may use both the ultrasound machine and x-rays to identify and mark the area where the biopsy is to be taken from. This area will then be cleaned with antiseptic fluid and covered with a sterile drape (towel). The interventional radiologist will use a fine needle to inject local anaesthetic to numb the area. This will sting for a moment before the skin goes numb. The interventional radiologist will then insert the biopsy needle into the lung tissue, through a small incision (cut) if necessary. This is done under x-ray guidance so that the doctor can see where the needle is going. S/he will then take the tissue sample using the needle and a special biopsy device. You may experience some discomfort or a dull pain and will be aware of some pressure and pushing. You will also hear a clicking sound when the biopsy device is used to take the sample. You will need to stay very still and will be asked to hold your breath while the biopsy is being taken. A small sample of lung tissue will be removed with the needle and smeared onto a slide or placed in a preservative solution. The radiologist may need to repeat the procedure to make sure that there is sufficient tissue for testing. The procedure will be the same as above, but the imaging staff will ask you to lie on the CT table instead of the x-ray table. The CT scanner uses a different method of taking images (pictures) from a conventional x-ray machine. The scanner is like a short tunnel, which the table moves in and out of, 4

5 depending on which area of the body is being scanned. A CT scan allows the doctor to look in detail at the soft tissues and bones in your body. This technique helps the doctor to identify or locate areas that are not easily seen using ordinary x-rays or ultrasound. You will hear a humming sound while the pictures are being taken. The doctor and imaging staff will explain what is happening throughout the procedure. Lung biopsies usually take approximately 30 to 45 minutes to complete. Any discomfort usually disappears after the biopsy has been done. If you do experience any pain, you must tell your doctor or ward staff, who may be able to give you some medication to relieve your discomfort. We will ask you to rest in bed for four hours after your lung biopsy. The nursing staff will continue to record your pulse and blood pressure during this time, as well as check your biopsy site regularly. If you feel unwell, are in pain or are having problems breathing, please let the nursing staff or doctor know immediately. Do not wait until a nurse or doctor comes to check on you. You will need to have a chest x-ray four hours after your lung biopsy to make sure there is no pneumothorax (collapsed lung) or other problems. If you are an outpatient, you will be able to go home once the doctor is satisfied with your condition. If you are an inpatient, the x-ray porter will take you back to your ward. Laboratory analysis of the tissue samples usually takes a few days and so you should make an appointment with your doctor to get the results of the biopsy. Please note that in a number of cases, the first biopsy may not be sufficient for the doctor to make a diagnosis. If this happens, your doctor may arrange for the biopsy to be repeated at a further appointment. You may have a small amount of bruising or discomfort where the biopsy needle was inserted and can take painkilers, such as paracetamol (but not drugs containing aspirin or ibuprofen) to relieve any pain if you wish. However, if you have continuous severe pain, a high temperature or fever, difficulty in breathing or are coughing up blood, you should contact your GP or go to your nearest accident & emergency (casualty) department. You should be able to resume all your usual activities the day after your appointment. The doctor will give you further advice about this. 5

6 Please do not hesitate to contact us if you have queries or concerns: Imaging department - Hammersmith Hospital Du Cane Road London W12 0HS Telephone: Imaging department - Charing Cross Hospital Fulham Palace Road Hammersmith London W6 8RF Telephone: Imaging department - St Mary s Hospital Praed Street London W2 1NY Telephone: We aim to provide the best possible service and staff will be happy to answer any questions you may have. However, if your experience of our services does not meet your expectations and you would like to speak to someone other than staff caring for you, please contact the patient advice and liaison service (PALS) on (Hammersmith Hospital) or (Charing Cross Hospitals), or (St Mary s Hospital). You can also PALS at pals@imperial.nhs.uk. The PALS team is able to listen to your concerns, suggestions or queries and is often able to help sort out problems on behalf of patients. Alternatively, you may wish to express your concerns in writing to: The chief executive Imperial College Healthcare NHS Trust Trust Headquarters The Bays, South Wharf Road London W2 1NY This leaflet can be provided on request in large print, as a sound recording, in Braille, or in alternative languages. Please contact the communications team on Imaging Published: Sep 2012 Review date: Sep 2015 Reference no: 1257T Imperial College Healthcare NHS Trust 6