12 AJTCCM VOL. 31 NO. 1 2025
ORIGINAL ARTICLES: RESEARCH
Background. Transbronchial lung cryobiopsy (TBLC) is a relatively new technique recommended for sampling of lung parenchyma in
patients with suspected interstitial lung disease (ILD) and as an alternative to surgical lung biopsy. A more recently introduced technique
is endobronchial ultrasound-guided transbronchial mediastinal lymph node lymph node cryobiopsy (EBUS-TMC) to enable tissue biopsy
of mediastinal lymph nodes. However, there are no data on the feasibility of implementing these techniques in a resource-limited African
setting, where there is a chronic bed shortage and same-day discharges are preferable.
Objectives. To determine the feasibility and diagnostic yield of TBLC and EBUS-TMC in a resource-limited African setting.
Methods. We performed an audit of lung and lymph node cryobiopsy procedures performed at the E16 Respiratory Clinic at Groote Schuur
Hospital, Cape Town, South Africa. Indications, diagnostic performance outcomes and lessons learned were documented and analysed.
Results. Sixteen patients underwent 19 cryobiopsy procedures that were performed under general anaesthesia (n=11 TBLC, n=8 EBUS-
TMC, including 3 patients in whom both TBLC and EBUS-TMC were concurrently performed). e main indications were evaluation
of ILD and suspected lymph node malignancy. e diagnostic yield was 63.6% for TBLC (n=7/11; 2 nonspecic interstitial pneumonia,
2sarcoidosis, 1 espiratory bronchiolitis-ILD, 1 organising pneumonia, 1 nonspecic chronic inammation) and 50.0% for EBUS-TMC (n=4/8;
1 plasmacytoma, 1 lymphoma, 1 cryptococcus infection, 1 patient with both cryptococcus infection and tuberculosis). Of the patients, 2 had
moderate bleeding and 3 had mild bleeding, and 14 were discharged on the day of the procedure.
Conclusion. TBLC and EBUS-TMC, with avoidance of surgical lung biopsy in most patients and same-day discharge in most patients, are
feasible in an African setting. ese data inform clinical practice and programme implementation in resource-limited settings.
Keywords. Transbronchial lung cryobiopsy (TBLC), endobronchial ultrasound-guided transbronchial mediastinal lymph node cryobiopsy
(EBUS-TMC), interstitial lung disease (ILD), interventional pulmonology.
Afr J Thoracic Crit Care Med 2025;31(1):e2448. https://doi.org/10.7196/AJTCCM.2025.v31i1.2448
Feasibility and safety of transbronchial lung cryobiopsy and
mediastinal lymph node cryobiopsy: Experience from a resource-
limited African setting
A Esmail,*1 MD, FCP, Cert Pulmonology (SA), PhD ; K Tsoka,*1 MB ChB, FCP;
R Hofmeyr,2 MB ChB, MMed (Anaes), FCA, FAMW, FEAMS ; J Chokoe Maluleke,*3,4 BSc, MB ChB, MMed (Path) ;
H Donson,1 ND Clin (Resp & Crit Care), BTech Clin Tech, NHD PSE; R Roberts,*3,4 MB ChB; T Pennell,5 MB ChB;
N Vorajee,1 MB ChB, FCP, Cert Pulmonology (SA); M Emhemed,1 MB ChB, FCP, Cert Pulmonology (SA);
S Eknewir,1 MB ChB, FCP, Cert Pulmonology (SA); B Mbena,1 MB ChB, FCP, Cert Pulmonology (SA);
K Dheda,1,6 MB ChB, FCP, Cert Pulmonology (SA), PhD
*Contributed equally; names listed in order of seniority.
1 Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of CapeTown;
University of Cape Town Lung Institute; SAMRC Centre for the Study of Antimicrobial Resistance, University of Cape Town, SouthAfrica
2 Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital,
Cape Town, South Africa
3 Division of Anatomical Pathology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, South Africa
4 National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
5 Division of Cardiothoracic Surgery, Department of Surgery, Groote Schuur Hospital, Cape Town, South Africa
6 Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, UK
Corresponding author: K Dheda (keertan.dh[email protected])
Study synopsis
What the study adds. Although transbronchial lung cryobiopsy (TBLC) is widely accessible in resource-rich settings such as Europe and the USA,
there are no data from resource-limited African settings. Endobronchial ultrasound-guided transbronchial mediastinal lymph node cryobiopsy
(EBUS-TMC) is a newer technique for which there are limited data. We provide feasibility and implementation data from an African setting.
Implications of the study. We provide useful programmatic implementational data for resource-limited African settings and show that
implementation of these techniques with same-day discharge is feasible in a setting where there is limited access to overnight beds and
anaesthetic support. Important implementational lessons learned that will facilitate initiation of a new TLBC/EBUS-TMC service are outlined.
AJTCCM VOL. 31 NO. 1 2025 13
ORIGINAL ARTICLES: RESEARCH
Interstitial lung disease (ILD) is a common clinical problem faced
by pulmonologists. Depending on the clinical context, the initial
approach involves transbronchial lung biopsy, especially in resource-
limited settings. However, diagnostic performance is suboptimal,
with a diagnosis achieved in only ~30% of patients owing to the
anatomically small volume of biopsy tissue obtained and the associated
crush artifact.[1-3] An alternative is image-guided percutaneous biopsy,
where the diagnostic yield is ~40-50%, but access to such expertise
in resource-limited settings is limited, and pneumothorax rates are
high (20-45%).[4,5] Another alternative is surgical lung biopsy, but
patients need to be admitted for several days, it is costly, and there
is associated mortality and a 5-15% complication rate (bleeding,
signicant air leak, substantial thoracic pain, cardiac arrythmias and
infectious complications).[6,7]
A more recently available alternative is transbronchial lung
cryobiopsy (TBLC), which involves insertion of a cryoprobe via the
airways into the lung periphery under screening, generally in an
intubated patient. As a precaution to tamponade any bleeding, an
endobronchial blocker is also inserted into the segment of interest,
and inflated once the cryoprobe and associated lung tissue are
removed[8] (Fig.1). e moist lung tissue adheres to the tip of the
cryoprobe, which is cooled to ~–80oC using pressurised carbon
dioxide.[9] Asignicant body of evidence, summarised in a systematic
review, showed that the procedure is useful, with a diagnostic yield
of ~80% compared with surgical lung biopsy, which has a diagnostic
yield of ~95%.[10] e ~15% lower diagnostic yield compared with
surgical lung biopsy is a trade-o for same-day discharge, lower
morbidity rates and lower mortality. is systematic review and
meta-analysis incorporated 43studies and showed that TBLC has a
diagnostic yield of 81% v. 94% for video-assisted thorascopic surgical
(VATS) lung biopsy.[10] Signicant bleeding was encountered in 6.9%
of cases and pneumothorax in 5.6%, while acute exacerbation of the
underlying ILD occurred in 1.4%. Mortality was 0.6% v. 1.7% for
VATS lung biopsy.[10]
e European Respiratory Society has now produced guidance
recommending the use of TBLC for the diagnosis of ILD.[11] While
this procedure has been adopted on several continents, there are no
data on its feasibility in a resource-limited African setting, which
has unique challenges that include severe bed shortages, budget cuts
limiting access to surgical lung biopsy, limited access to anaesthetic
support, and severely limited access to cardiothoracic procedures,
which are generally available only in large cities. Whether this
technique is feasible and implementable in a resource-limited African
setting therefore remains unclear. To address this knowledge gap, we
reviewed our experience of this technology, which was introduced
at a tertiary care hospital in Cape Town, South Africa, in July 2024.
Additionally, endobronchial ultrasound-guided transbronchial
mediastinal lymph node cryobiopsy (EBUS-TMC) has been
undertaken across several centres to obtain better samples from
mediastinal lymph nodes and masses.[12,13] In this procedure, aer
undertaking EBUS transbronchial needle aspiration (EBUS-TBNA),
a cryoprobe is inserted into the lymph node and a tissue sample
is extracted. Current experience suggests that this technique is
suitable when rapid on-site cytological analysis (ROSE) fails to
provide a diagnosis, but additionally where histological analysis
of tissue architecture may be useful, e.g. in malignancies such as
lymphoproliferative disorders and in benign conditions such as
sarcoidosis where obtaining tissue is oen useful. Given the unique
clinical context and challenges outlined above, we also reviewed our
experience with this newer technique.
Methods
TBLC
Patients were referred for TBLC following a multidisciplinary
meeting of radiologists, pulmonologists and cardiothoracic surgeons.
All patients had ILD for which a cause needed to be ascertained,
and histological examination was therefore required. Permission
for use of the anonymised data for this study was provided by the
University of Cape Town Research Ethics Committee (ref. no. UCT
HREC REF028/2023). Key demographic and clinical variables were
captured on a database. All procedures were done under general
anaesthesia in the bronchoscopy suite of the E16 Respiratory
Clinic at Groote Schuur Hospital. Total intravenous anaesthesia
was initiated and maintained with target-controlled infusions of
propofol and remifentanil, with pressure-controlled mechanical
ventilation. Depending on patient characteristics, a supraglottic
airway (SGA) or endotracheal tube (ETT) was inserted. Using
the included multiport adaptor, an Arndt endobronchial blocker
(Cook Medical, USA) was guided through the SGA or ETT with
the bronchoscope. In some cases, patients were intubated with a
Univent ETT (Teleex Medical, USA), which contains an accessory
channel accommodating the bronchial blocker, obviating the need
for insertion of the bronchial blocker and the bronchoscope within
the same endotracheal lumen.
e bronchial blocker was placed at the entrance of the subsegment
of interest. The lung cryobiopsy probe attached to the controller
(ERBECRYO 2; Erbe Elektromedizin GmbH, Germany, paired with a
single-use 1.1 mm probe) was advanced distal to the bronchial blocker
and to the lung periphery using uoroscopic screening (see Fig.1 for
an overview). A freeze time of ~5-8 seconds was used, depending on
the quality of samples retrieved (starting at 5 seconds with incremental
increases in freeze time, with a maximum freeze time of 10 seconds).
The samples obtained were sent for histopathological analysis in
formalin, and for microbiological examination, polymerase chain
reaction and culture for Mycobacteriumtuberculosis where indicated
(GeneXpert MTB/RIF Ultra; Cepheid, USA).
EBUS-TBNA
In 3 patients who underwent TBLC, EBUS-TMC was also performed
after EBUS-TBNA. However, in 5 patients only EBUS-TMC was
performed aer EBUS-TBNA (i.e. TBLC was not performed; see Fig.2
for a study plan).
EBUS-TBNA was performed using an Olympus EBUS
bronchoscopy system (EVIS EXERA III platform BF-190, EU-ME2
ultrasound processor and BF-UC190F endobronchial ultrasound
bronchoscope; Olympus Medical Systems, USA), and a pathologist
and a medical technologist were present for ROSE. A 19-gauge EBUS
needle (ViziShot 2 EBUS-TBNA; Olympus Medical Systems, USA)
was used, and the node was sampled using ~4-6 passes prior to
insertion of the 1.1 mm single-use cryoprobe into the lymph node
though the tract created by the 19G needle. An associated EBUS
balloon was inated for better imaging when required to facilitate
14 AJTCCM VOL. 31 NO. 1 2025
ORIGINAL ARTICLES: RESEARCH
better apposition to the airway. Aer completion of the EBUS-TBNA,
and if a diagnosis was not evident on cytological examination, the
cryoprobe was inserted through the same needle tract to access the
lymph node under ultrasound guidance. When access through the
tract was dicult, a biopsy forceps (M00546270; Boston Scientic,
USA) was used to widen the tract to enable easier introduction of the
cryoprobe. Approximately 3-5 lymph node cryobiopsy samples were
obtained using a freeze time of ~7 seconds.
Results
ere were 16 patients selected, and 19 cryobiopsies were performed
(3 patients underwent both TBLC and EBUS-TMC), with an equal
distribution of males and females. e median age was 58 (95% CI
36.2-66.1) years. Eleven patients (57.9%) were smokers (median of
22.5 pack-years). Baseline comorbidities included hypertension (n=9;
47.4%), followed by diabetes mellitus (n=6; 31.6%). e most common
indication reported for TBLC was ILD (n=9; 81.8%), with suspected
Figure 1. A) Suspected interstitial lung disease confirmed on imaging. B) Cooled cryoprobe
control module. C) Multidisciplinary team of pulmonologists, anaesthesiologists,
radiographers, and pulmonary technicians carrying out the procedure. D) Cryoprobe passed
through the end of the bronchoscope under screening distal to the bronchial blocker. E)
Cartoon outlining the relationship of the uninflated bronchial blocker and cryoprobe. F)
Extracted tissue sample at the end of the cryoprobe to be sent for histology.
A)
B)
D)
E)
F)
A B C
D E F
Fig.1. (A) Suspected interstitial lung disease conrmed on imaging. (B) Cooled cryoprobe control module. (C) Multidisciplinary team of
pulmonologists, radiographers and pulmonary technicians carrying out the procedure. (D) Cryoprobe passed through the end of the bronchoscope
under screening distal to the bronchial blocker. (E) Sketch outlining the relationship of the uninated bronchial blocker and the cryoprobe.
(F)Extracted tissue sample at the end of the cryoprobe to be sent for histological examination.
AJTCCM VOL. 31 NO. 1 2025 15
ORIGINAL ARTICLES: RESEARCH
TBLC diagnostic yield
n
=5/8 (62.5%)
• RB-ILD n=1/8,
NSIP n=2/8, OP n=1/8,
sarcoidosis n=1/8
• *Non-diagnostic
n=3/8 (37.5%)
TBLC diagnostic yield
n
=2/3 (66.7%)
• Sarcoidosis n=1/3,
chronic inammation n=1/3
• *Non-diagnostic
n=1/3 (33.3%)
Total TBLC
•
Diagnostic yield
n
=7/11 (63.6%)
•
*Non-diagnostic n=4/11 (36.4%)
EBUS-TMC diagnostic yield
n
=1/3 (33.3%)
• Plasmacytosis n=1/3
• *Non-diagnostic
n=2/3 (66.7%)
EBUS-TMC diagnostic yield
n
=3/5 (60.0%)
• B-cell lymphoma n=1/5,
cryptococcus infection n=1/5,
cryptococcus + TB n=1/5
• *Non-diagnostic
n=2/5 (40.0%)
Total EBUS-TMC
• Diagnostic yield
n
=4/8 (50.0%)
• *Non-diagnostic n=4/8 (50.0%)
Cryobiopsies performed,
N
=19
TBLC only,
n
=8
TBLC + EBUS-TMC in the same patients,
n
=6 (
n
=3 TBLC,
n
=3 EBUS-TMC)
EBUS-TMC only,
n
=5
TBLC +
EBUS-TMC
n
=3 patients
(
n
=6 biopsies)
TBLC
only,
n
=8
EBUS-
TMC
n
=5
Fig.2. Study overview demonstrating patient selection and distribution of types of cryobiopsy (TBLC, TBLC + EBUS-TMC, and EBUS-TMC alone). (TBLC = transbronchial lung cryobiopsy;
EBUS-TMC = endobronchial ultrasound-guided transbronchial mediastinal lymph node cryobiopsy; RB-ILD = respiratory bronchiolitis-interstitial lung disease; NSIP = nonspecic interstitial
pneumonia; OP = organising pneumonia; *Non-diagnostic = suboptimal or insucient amount of tissue and benign tissue.)
16 AJTCCM VOL. 31 NO. 1 2025
ORIGINAL ARTICLES: RESEARCH
malignancy and suspected tuberculosis (TB) accounting for 7 (36.8%)
and 5 (26.3%) of the referred patients, respectively (Table1).
In total, 11 TBLC procedures were performed: 2 patients were
diagnosed with sarcoidosis, 4 with ILD (2 had nonspecic interstitial
pneumonia, 1 organising pneumonia, and 1 respiratory bronchiolitis-
ILD), and 1 with chronic nonspecic inammation. Four procedures
(4/11; 36.4%) were non-diagnostic (Fig.2).
A total of 8 EBUS-TMC biopsies were performed (aer a non-
diagnostic EBUS-TBNA): in 4, a diagnosis was obtained (cryptococcus
infection, plasmacytosis, B-cell lymphoma, and a patient with both
cryptococcus and TB), and 4 were non-diagnostic. All mediastinal
lymph nodes targeted by EBUS-TMC measured between 15-30 mm
in the largest plane on endobronchial ultrasound.
ere was moderate bleeding in 2 patients, who required instillation
of 3 aliquots of 1:20 000 (diluting a 1 mg (1:1 000) adrenaline ampoule
to 20 mL with sterile water) adrenaline ushes and recurrent ination
of the balloon blocker, while 3 patients had mild bleeding that
was controlled with use of the balloon blocker. One patient had a
pneumothorax following TBLC which was managed conservatively,
with discharge the next day, and another had pneumomediastinum
after EBUS-TMC. He was also managed conservatively and
hospitalised for 72 hours to monitor the pneumomediastinum to its
resolution. e latter patient was recruited in the initial phase, during
which we had little control of the depth of the cryoprobe, but in the
patients recruited later we marked the cryoprobe to prevent over-
insertion of the probe beyond the lymph node (Box 1).
Discussion
To the best of our knowledge, this is the rst report outlining initial
experience with TBLC and EBUS-TMC in a resource-limited African
centre. e key ndings were: (i) both TBLC and EBUS-TMC were
feasible in our setting; (ii) the majority of patients with severe and
extensive ILD achieved same-day discharge without any major
complications; and (iii) the diagnostic yield of TBLC was ~64% and
that of EBUS-TMC 50%, although the sample size was small.
Initiation and implementation of the lung and lymph node
cryobiopsy programme was feasible in our setting and obviated
admission for 14/16 patients (87.5%) (i.e. these patients were
discharged on the same day), with 1 patient with a non-diagnostic
TBLC requiring surgical lung biopsy aer MDT discussion, while 3
other patients were managed as per the recommendation of the MDT.
is was critical in our clinical context because of a severe shortage
Table1. Demographic and clinical characteristics of the study participants who underwent cryobiopsy procedures*
Characteristic EBUS-TMC (n=8), n (%)†TBLC (n=11), n (%)†Total (N=19), n (%)†
Age (years), median 53 58 58
Sex
Male 4 (50.0) 5 (45.5) 9 (47.3)
Female 4 (50.0) 6 (54.5) 10 (52.6)
Comorbidities
HIV 2 (25.0) 0 2 (10.5)
Cancer 1 (12.5) 1 (9.1) 2 (10.5)
Connective tissue disease 0 2 (18.2) 2 (10.5)
Hypertension 3 (37.5) 6 (54.5) 9 (47.4)
Diabetes mellitus 3 (37.5) 3 (27.3) 6 (31.6)
Dyslipidaemia 1 (12.5) 2 (18.2) 3 (15.8)
Chronic lung disease 2 (25.0) 2 (18.2) 4 (21.1)
Smokers 5 (62.5) 6 (54.5) 11 (57.9)
Pack-years, median 20 27.5 22.5
Indication
Suspected malignancy 4 (50.0) 3 (27.3) 7 (36.8)
Interstitial lung disease 2 (25.0) 9 (81.8) 11 (57.9)
Tuberculosis 2 (25.0) 3 (27.3) 5 (26.3)
Other (fungal) 1 (12.5) 1 (9.1) 2 (10.5)
Complication
Ye s 2 (25.0) 7 (63.6) 9 (47.4)
No 6 (75.0) 4 (36.4) 10 (52.6)
Intraoperative complications
Moderate bleeding 0 2 (18.2) 2 (10.5)
Minimal bleeding 0 3 (27.3) 3 (15.8)
Pneumothorax 0 1 (9.1) 1 (5.3)
Pneumomediastinum 1 (12.5) 0 0
Hypercapnia 1 (12.5) 1 (9.1) 2 (10.5)
EBUS-TMC = endobronchial ultrasound-guided transbronchial mediastinal lymph node cryobiopsy; TBLC = transbronchial lung cryobiopsy.
*A total of 19 cryobiopsies were undertaken in 16 patients; 3 patients had both TBLC and EBUS-TMC. Demographic characteristics are reported for each procedure.
†Except where otherwise indicated.
AJTCCM VOL. 31 NO. 1 2025 17
ORIGINAL ARTICLES: RESEARCH
of admission beds, budget cuts limiting the volume of surgical
procedures, and limited access to anaesthesia support. e situation
has recently worsened further because of budget-related austerity
measures introduced in the hospital. A surgical lung biopsy approach
would have required admission of all 16 patients, with hospital stays
of between 5 and 7 days in each case, and potential complications
in some of these patients may have included infection, bleeding,
signicant air leak, etc.[7] Routine post-bronchoscopic observation in
the bronchoscopic recovery area was adequate in all the patients who
underwent biopsy. Although we did not directly evaluate costs per
patient, circumventing theatre use and several days of admission makes
TBLC and EBUS-TMC much more cost-eective procedures. Indeed,
despite the ~15-20% lower diagnostic yield of TBLC compared with
VATS lung biopsy,[10] studies have shown that TBLC has better setting-
specic cost-eectivness.[14] Like TBLC, surgical lung biopsy is also
prone to sampling error, but much less so owing to the larger size of
the biopsy specimen and the lack of crush artifact.[2,15] Interestingly,
the optimal area to biopsy (ground-glass shadowing v. honeycombing)
remains unclear and is currently a subject of further study.
In our study, of the 11 TBLCs performed, 4 were non-diagnostic
(1specimen showed normal alveoli and was therefore from an area with
no pathology, 2 showed bronchial tissue only, and 1 showed fragments
of bronchus and was therefore non-representative). Our sample size
was too small to make any inferences about the reasons for the non-
diagnostic results. We did not encounter signicant complications in
the patients who underwent TBLC. However, we used a 1.1 mm probe,
and recent data indicate that complication rates with this smaller probe
are signicantly lower because of the smaller pieces of tissue that are
extracted. Recent data also showed that the low complication rate
using the 1.1 mm probe means that use of a supraglottic airway may be
acceptable.[16] A recent randomised controlled trial from India showed
that when a 1.9 mm probe was used it was possible to undertake the
procedure using conscious sedation.[17]
We found that undertaking EBUS-TMC was also feasible. However,
we learned important lessons on how to conduct the procedure
eciently (Box 1). Accessing the lymph node with the cryoprobe
can be challenging when the tracheal or bronchial wall is thick and
resistant, and we therefore occasionally used biopsy forceps to widen or
enlarge the biopsy tract. Nevertheless, 4 of the 8 lymph nodes sampled
were non-diagnostic (3 were unsatisfactory samples, and 1 showed
benign tissue). Patient selection in this context is important; published
data have shown that EBUS-TMC has ~10% better yield than EBUS-
TBNA, and the specic advantage is in cases where a tissue diagnosis/
architecture is required, e.g. in patients with lymphoproliferative
malignancies, haematological malignancies, and benign disorders such
as sarcoidosis. In our context, we only subjected patients with enlarged
mediastinal nodes of at least 15mm to the EBUS-TMC procedure
when their conventional EBUS was non-diagnostic or if lymphoma
was suspected. Furthermore, EBUS-TMC may also be useful in cases
when EBUS-TBNA does not provide sucient material for genomic
analysis to enable the selection of specic immunotherapy/targeted
therapy for lung cancer.[12]
Our study was limited by the small sample size, and conclusions
about diagnostic yield in our setting would therefore be unreliable.
However, our key objective was not to ascertain diagnostic yield or
complication rates, but to determine the feasibility of implementing
complex interventional procedures in a resource-limited setting where
anaesthesia services and bed capacity are extremely limited, and to
outline the lessons learned for the benet of other centres that may
wish to initiate TBLC and/or EBUS-TMC.
Conclusion
TBLC and EBUS-TMC can provide useful diagnostic information,
and both are feasible in a resource-limited setting, allowing for same-
day discharge without the need for surgical lung biopsy in selected
patients. EBUS-TMC allows for improved tissue sampling in selected
cases where histological tissue architecture is important, such as in
lymphoma and sarcoidosis. Our data will be useful for centres in
resource-limited settings in Africa and elsewhere that are attempting
to implement a programme incorporating TBLC and/or EBUS-TMC.
Valuable lessons were learned in setting up this service, and there is a
clear need to expand it.
Data availability. e datasets generated and analysed during the present
study are available from the corresponding author (KD) on reasonable
request. Any restrictions or additional information regarding data access
can be discussed with the corresponding author.
Box 1. Lessons learned from initiating a TBLC and EBUS-TMC
programme
• Pre-discussion and negotiation with the anaesthesia team
are essential in an environment where there is a shortage of
anaesthesiologists and operating theatre time.
• Cardiothoracic support is important in case of complications
such as severe bleeding.
• Choice of a bronchoscope of appropriate diameter and
use of a large enough endotracheal tube are essential in
order to accommodate both the bronchoscope and the
bronchial blocker within the ETT or SGA lumen. We used
bronchoscopes with 2.2 mm and 2.8 mm working channels,
but the critical factor for t through the airway device is
the external diameter of the bronchoscope. e sum of the
external diameters of the bronchoscope and blocker should
not exceed 80-90% of the internal diameter of the ETT or
SGA, of which the latter usually has a larger internal diameter.
Owing to the shared airway, we used a bronchoscope with a
2.2 mm working channel with a smaller ETT because of the
extremely tight t, and a bronchoscope with a larger 2.8 mm
channel was used with the SGA. e Arndt endobronchial
blocker is available in three diameters (5, 7 and 9Fr). While
the 5Fr oers the smallest external diameter (~1.6mm), it
may not have sucient length to block distal subsegments in
all patients; the 7Fr (external diameter ~2.3 mm) is a good
compromise.
• Use of ETTs with a dedicated bronchial blocker mounted in a
side channel (e.g. Univent tube) is advantageous, as it allows
easier passage of the scope in the absence of competition for
space with the blocker.
• Experimentation is required to obtain the optimal cryoprobe
freeze time depending on the type of tissue being biopsied.
18 AJTCCM VOL. 31 NO. 1 2025
ORIGINAL ARTICLES: RESEARCH
Declaration. e research for this study was done in partial fullment of
the requirements for KT’s MPhil degree at the University of Cape Town.
Acknowledgements. We thank Erbe Elecktromedizin GmbH for
providing training on the use of equipment, our patients who formed part
of this research, and the administration of Groote Schuur Hospital for
facilitating this research.
Author contributions. AE, KT and KD conceived the trial design; AE,
KT, KD, RH, JCM, HD, RR, TP, NV, ME, SE and BM were involved in
data collection; JCM and RR interpreted the cytological and histological
data; AE and KT did the data analysis; and AE, KT, KD and RH were
involved in data interpretation and the draing of the manuscript. All
authors approved the nal version of the manuscript.
Funding.is research was conducted as part of operational research in
the Division of Pulmonology and no dedicated funding was used.
Conicts of interest. None.
1. Sheth JS, Belperio JA, Fishbein MC, etal. Utility of transbronchial vs surgical
lung biopsy in the diagnosis of suspected brotic interstitial lung disease. Chest
2017;151(2):389-399. https://doi.org/10.1016/j.chest.2016.09.028
2. Berbescu EA, Katzenstein A-LA, Snow JL, Zisman DA. Transbronchial biopsy in
usual interstitial pneumonia. Chest 2006;129(5):1126-1131. https://doi.org/10.1378/
chest.129.5.1126
3. Shim HS, Park MS, Park IK. Histopathologic ndings of transbronchial biopsy in
usual interstitial pneumonia. Pathol Int 2010;60(5):373-377. https://doi.org/10.1111/
j.1440-1827.2010.02528.x
4. Huo YR, Chan MV, Habib AR, Lui I, Ridley L. Pneumothorax rates in CT-guided lung
biopsies: A comprehensive systematic review and meta-analysis of risk factors. Br J
Radiol 2020;93(1108):20190866. https://doi.org/10.1259/bjr.20190866
5. Peng M, Xu W-b, Shi J-h, etal. [e diagnostic value of CT-guided percutaneous
needle lung biopsy in diuse parenchymal lung diseases]. Zhonghua Jie He He Hu Xi
Za Zhi 2012;35(3):171-175.
6. Blackhall V, Asif M, Renieri A, etal. e role of surgical lung biopsy in the management
of interstitial lung disease: Experience from a single institution in the UK. Interact
Cardiovasc orac Surg 2013;17(2):253-257. https://doi.org/10.1093/icvts/ivt217
7. Nguyen W, Meyer KC. Surgical lung biopsy for the diagnosis of interstitial lung
disease: A review of the literature and recommendations for optimizing safety and
ecacy. Sarcoidosis Vasc Diuse Lung Dis 2013;30(1):3-16.
8. Madan K, Mittal S, Hadda V, Mohan A. Cryoprobe transbronchial lung biopsy with
exible bronchoscope using Arndt endobronchial blocker. Lung India 2019;36(3):241-
243. https://doi.org/10.4103/lungindia.lungindia_35_18
9. Lentz RJ, Argento AC, Colby TV, Rickman OB, Maldonado F. Transbronchial
cryobiopsy for diffuse parenchymal lung disease: A state-of-the-art review of
procedural techniques, current evidence, and future challenges. J Thorac Dis
2017;9(7):2186-2203. https://doi.org/10.21037/jtd.2017.06.96
10. Rodrigues I, Estêvão Gomes R, Coutinho LM, etal. Diagnostic yield and safety of
transbronchial lung cryobiopsy and surgical lung biopsy in interstitial lung diseases:
A systematic review and meta-analysis. Eur Respir Rev 2022;31(166):210280. https://
doi.org/10.1183/16000617.0280-2021
11. Korevaar DA, Colella S, Fally M, etal. European Respiratory Society guidelines on
transbronchial lung cryobiopsy in the diagnosis of interstitial lung diseases. Eur Respir
J 2022;60(5):2200425. https://doi.org/10.1183/13993003.00425-2022
12. Ariza-Prota M, Pérez-Pallarés J, Fernández-Fernández A, etal. Endobronchial
ultrasound-guided transbronchial mediastinal cryobiopsy in the diagnosis of
mediastinal lesions: Safety, feasibility and diagnostic yield – experience in 50 cases.
ERJ Open Res 2023;9(2):00448-2022. https://doi.org/10.1183/23120541.00448-2022
13. Troy LK, Williamson JP. Mediastinal cryobiopsy: Safe and eective but in whom
and when? Lancet Respir Med 2023;11(3):217-219. https://doi.org/10.1016/S2213-
2600(22)00410-6
14. Katgi N, Çimen P, Çirak AK, etal. Complication and cost analysis of transbronchial
lung cryobiopsy and awake video-assisted thoracic surgery in diagnosis of interstitial
lung disease. Sarcoidosis Vasc Diuse Lung Dis 2022;39(1):e2022005. https://doi.
org/10.36141/svdld.v39i1.12293
15. Leslie KO, Gruden JF, Parish JM, Scholand MB. Transbronchial biopsy interpretation
in the patient with diffuse parenchymal lung disease. Arch Pathol Lab Med
2007;131(3):407-423. https://doi.org/10.5858/2007-131-407-TBIITP
16. iboutot J, Illei PB, Maldonado F, etal. Safety and feasibility of a sheath cryoprobe
for bronchoscopic transbronchial biopsy: The FROSTBITE trial. Respiration
2022;101(12):1131-1138. https://doi.org/10.1159/000526876
17. Khot MS, Chakraborti A, Saini JK, etal. Comparison of the diagnostic yield of
transbronchial lung biopsies by forceps and cryoprobe in diffuse parenchymal
lung disease. Afr J orac Crit Care Med 2023;29(3):e799. https://doi.org/10.7196/
AJTCCM.2023.v29i3.799
Received 22 July 2024. Accepted 29 January 2025. Published 28 March 2025.
