In this guidance, 'peripheral lung lesions' describes lung lesions that cannot be visualised using conventional bronchoscopy because they do not protrude into the bronchial tree. This guidance is concerned only with the diagnosis of such lesions, and not with their treatment.
Patients with peripheral lung lesions are often asymptomatic and the abnormality is detected incidentally on chest X-ray or computed tomography (CT) scanning. Symptoms of cough, haemoptysis and breathlessness may be present, but are more often associated with endobronchial tumours that are accessible to standard bronchoscopic biopsy.
Current biopsy techniques include blind transbronchial lung biopsy, image-guided percutaneous lung biopsy, or (thoracoscopic or open) surgical biopsy.
The procedure can be undertaken with the patient under general anaesthesia or under local anaesthesia with or without sedation. The lesion is identified by prior CT, positron emission tomography (PET) or conventional chest X-ray imaging. A flexible fibreoptic bronchoscope with a radial mini-probe or catheter is inserted through the nose or mouth, and advanced towards the peripheral lung lesion using endobronchial ultrasound (EBUS) guidance. Once the bronchoscope is in the appropriate location, the ultrasound mini-probe or catheter is withdrawn and biopsy forceps or needles are introduced into the working channel to obtain a histological sample of the target lesion, with or without fluoroscopic guidance. Use of a guide sheath can help to keep the bronchoscope in place during the removal of the probe and insertion of biopsy instruments.