The absolute contraindication for a pleural biopsy is the presence of an
uncorrectable coagulation defect. The relative contraindications are as follows:
- A Dry Tap:
In the absence of sufficient pleural fluid, it is difficult to perform a pleural biopsy.
The plane of cleavage of visceral and parietal pleura cannot be recognized without fluid.
The risk of puncturing the lung is high, resulting in pneumothorax. I carry the nickname,
"Chicken Chand", because of my stalling to perform a pleural biopsy in a patient
with no effusion.
I did perform a dry pleural biopsy eventually on that
patient without any complications. Incidentally, the patient had a caseating granuloma in
the pleura. In general, you should not attempt a pleural biopsy if there is no fluid. If
there is a strong indication, it is best left to an physician with extensive past
experience. You mainly have to judge by the feel of the needle as to its locale withot the
benefit of fluid.
Empyema is a relative contraindication. Granulation tissue is very vascular and the blood
tends to ooze from the biopsy site. Unless you are considering tuberculous empyema, there
is no indication to do a pleural biopsy in a patient with empyema.
- An Uncooperative Patient:
A certain amount of cooperation is required from the patient to accomplish the procedure
I am afraid of doing any kind of biopsy in patients with uremia, even if their coagulation
indices are normal. I had three major bleeding problems in my life time performing
pulmonary procedures. Two occurred in renal patients. Be sure to evaluate platelet
functions. If they are abnormal, transfuse platelets prior to proceeding with a pleural
- Coagulation Defect:
You never want to perform a pleural biopsy on a patient with a coagulation defect. This
- Patients with hemophilia or other factor deficiencies
- Patients with low platelets or platelet function abnormalities
- Patients with an abnormal PT and PTT
If there is a strong indication for a pleural biopsy without a reasonable
alternative, you may want to consider the biopsy following correction of the coagulation
The most common situation is a patient on coumadin. I discontinue the coumadin
and switch to heparin. On the day of the biopsy, heparin should be stopped four hours
prior to the procedure. You can resume anticoagulation four hours after the biopsy,
assuming all is well.