Understanding lung biopsy risks in the elderly

Lung biopsy risks for ageing adults

A lung biopsy may be required for a number of reasons, and for older adults this procedure comes with some additional risks that should be considered. Here, we are exploring why a lung biopsy might be needed for older people, the risks associated with this procedure, what might increase the level of risk, how to prepare for a lung biopsy, and what happens after.

At Home Instead, our aim is to help people age positively and in place by bringing expert care to their home. For nearly 20 years, we have been providing the highest standard of care, and creating industry-leading training programmes for our Care Professionals that are accredited by nursing and medical professionals. Today, we are the world’s largest global domiciliary care network, supporting over 100,000 older adults with personalised, tailored care at home. So whatever questions you have about lung biopsies, we can help.

What is a lung biopsy?

A lung biopsy is a procedure that aims to draw a small sample of tissue from the lungs to be examined under a microscope. The sample will be used to determine if an individual has a health condition related to the lungs, such as a serious infection, inflammation, or lung cancer. This is usually recommended if the patient experiences symptoms such as chest pain or a persistent cough, or if an X-ray or scan indicates there may be something present in the lung.

During the procedure, a doctor will usually inject local anaesthetic to numb the area where they will enter through either the chest or the back, and make a small incision. They will then insert a very thin needle to remove a small piece of lung tissue. This may be slightly painful and uncomfortable, but typically does not last long.

Why are lung biopsies performed in older people?

Lung biopsies may be performed on patients of any age, but they tend to happen more often in older adults who are more prone to health issues in general, as well as lung conditions. Some of the most common reasons for lung biopsies in the elderly are:

To diagnose lung infections – Older people are more susceptible to infections than younger age groups due to a weakened immune system, and sometimes these may occur in the lungs. Often these will be treated with antibiotics first, but if this does not work, or if a doctor suspects there may be signs like fluid in the lungs which could indicate there is a serious infection like tuberculosis or pneumonia present, they may recommend a lung biopsy to better identify the cause of their symptoms.
To diagnose lung cancer – In the UK, over 4 in 10 people who are diagnosed with lung cancer are aged 75 or older, and this type of cancer tends to impact older people more than younger people. A lung biopsy will usually be needed to determine whether or not cancer is present if a scan reveals a suspicious mass in the lung. Early diagnosis can help to confirm the kind of treatment they might need and get started on this as early as possible to improve their chances of recovery. In some cases, a lung biopsy may be used to confirm metastasis from another cancer elsewhere in the body, as this is one of the most common sites of metastasis.
To diagnose a condition like Interstitial Lung Disease (ILD) – These conditions tend to cause symptoms such as shortness of breath or a persistent cough, so if a doctor suspects a patient has a condition such as this, they may recommend a lung biopsy to confirm the diagnosis. Doing so can also inform treatment protocols, as different treatments may be needed for different types of inflammation. One common type of ILD, called Idiopathic Pulmonary Fibrosis (IPF), tends to impact those over the age of 60 and cause fatigue or breathlessness, so this diagnosis could be most important for older age groups.
To determine the severity of an autoimmune condition – Certain autoimmune conditions, such as rheumatoid arthritis, can also affect the lungs and cause inflammation. In fact, according to the Arthritis Foundation, an estimated 10-30% of people with rheumatoid arthritis develop lung disease. A lung biopsy is sometimes the best way to identify any potential damage, the causes, and the most appropriate treatments.

Are there different types of lung biopsies?

There are a few ways a lung biopsy can be done, depending on what doctors are checking for. The three main methods are:

Via a needle – With this method, a local anaesthetic will be given, and a doctor will guide the needle through the chest and into the suspicious area (identified via a CT scan or similar) to obtain a tissue sample. You might hear this type of biopsy called a closed, transthoracic or percutaneous biopsy.
Via a bronchoscopy (A.K.A transbronchial biopsy) – With this method, a thin tube with a telescope on the end–called a fiberoptic bronchoscope–is inserted into the airways to take a tissue sample.
Via surgery – There are two types of surgery, both requiring a general anaesthetic; a thoracoscopic biopsy means an endoscope (a long tube with a camera on the end) is inserted through the chest cavity to obtain lung tissue, and depending on the findings, remove nodules or other tissue lesions there and then. Alternatively, an open biopsy means a doctor will make an incision in the skin of the chest and remove a piece of lung tissue manually. Again, depending on the findings, other procedures may happen at the same time. For surgical procedures, an older person may need to spend some time in hospital to recover.

The type of biopsy an older person receives will often depend on their age, health, and suspected condition, as some procedures may be considered overly invasive for older, frail people with existing health conditions.

Are there risks associated with lung biopsies in older adults?

For the most part, lung biopsies are considered safe, but they do carry some risks, and this can be especially true for older adults with less resilience to simple procedures, and who already suffer from health conditions. Some of the most common risks to know of include:

Bleeding – All types of lung biopsies require some sort of incision in the skin and lung tissue, so regardless of the method used, this could mean bleeding at the site of the incision which can be either mild or severe. It is more common in those who take blood-thinning medications, and if this happens, medical attention will be needed. According to a 2022 study involving 786 patients who received a bronchoscopic lung biopsy, 3.8% experienced bleeding complications, with 16% of those being severe complications. Also, higher rates of bleeding were found in patients aged 65+. In another 2023 study, the incidence of pulmonary hemorrhage (bleeding in the lungs) after a biopsy was higher in the elderly group compared to younger age groups.
Infections – As with many procedures, infections like pneumonia may be a concern if bacteria is introduced to the lungs. Although this is uncommon thanks to sterile instruments used to carry out the procedure, it is not impossible, and so this risk should always be considered in older adults with weaker immune systems.
Pneumothorax – This is also known as a collapsed lung, and can occur when air leaks into the space between the lung and chest wall. It is the most common risk following a percutaneous (needle) biopsy, occurring in roughly 15% to 25% of cases. While most small air leaks resolve on their own with rest and oxygen, around 5% to 10% may require a temporary chest tube to drain the air. Bronchoscopic biopsies carry a much lower pneumothorax risk (around 1% to 3%). Symptoms include sudden shortness of breath or sharp chest pain when breathing in.
Anaesthesia-related complications – Any procedure that requires anaesthesia can pose additional risks for older people who are more sensitive to this, and they may experience issues such as low blood pressure, breathing difficulties or heart issues. This is why older adults may be offered a needle biopsy with a local anaesthesia instead of general anaesthesia to minimise complications.

Why are lung biopsies sometimes more risky for older patients?

There are several reasons why a lung biopsy can be a more complicated procedure for older adults as opposed to younger age groups. For example, many older adults live with pre-existing health conditions and chronic illnesses like heart disease or diabetes, which can impact their ability to heal quickly after a procedure. These can also increase the risk of certain complications, such as bleeding. In addition, they may have lung conditions such as chronic obstructive pulmonary disease (COPD) that reduce overall lung function, and therefore make a lung biopsy more risky. In those with a lung condition, a biopsy in this area could cause serious breathing issues, or lead to further complications such as those mentioned above.

Due to these additional medical conditions, many older adults also tend to take more medications than younger age groups, which can cause their own complications. For example, blood thinners can increase the chances of experiencing bleeding after a procedure.

More generally, older adults tend to become more frail with age, and their level of frailty will be taken into consideration by doctors to inform what kind of lung biopsy they will carry out, and how to progress with treatment depending on the results. Frailty means reduced muscle strength, less energy, and overall, less resilience when recovering from medical procedures such as sedation or surgeries.

When considering a lung biopsy for an older person, their doctor must balance the risks versus benefits to determine whether the information that can be gathered from a biopsy (such as confirmation of cancer or another condition) is vital enough to risk complications like bleeding, infections or a lung collapse. They will need to take into account the patient’s potential quality of life following the procedure – if it is likely to lead to diagnosis and effective treatment, it may be worthwhile, however if it is unlikely to change the direction of care or could cause the person harm, alternative options may be considered.

Are there any alternatives to a lung biopsy?

In some cases, a lung biopsy might be considered too invasive for older adults who are not in good health, and an alternative option may be explored instead. In these cases, imaging tests like CT scans or PET scans may be able to provide an adequate picture of what is going on inside the lungs, and identify any issues. Blood tests and analysis of phlegm produced while coughing can also offer diagnostic insight if an infection is suspected.

One other helpful option is a bronchoalveolar lavage, which is a simple procedure done via a bronchoscopy that washes fluid out of the lungs with sterile saline in order to be analysed for diagnosis.

How to prepare for a lung biopsy

Before a lung biopsy procedure, your doctor will prepare you with all of the advice you need, but if you are curious to know how things will go, here are some typical pre-procedure considerations for older patients and their families:

Do any pre-appointment preparation mentioned on the referral paperwork you are given, and inform the appropriate consultants as well as your GP. They may wish to speak to you at an initial appointment or on the phone to discuss your procedure.
Make sure the doctor performing your lung biopsy knows if you are taking any blood thinning medications (i.e. warfarin or aspirin) so they can prepare for this or adjust the type of procedure they plan to give you. Also, make sure they know if you are diabetic, as this may inform what they ask you to do before your appointment.
Make travel arrangements to and from hospital on the day of your procedure – you will not be able to drive yourself home.
If you are asked to stop taking certain medications before your procedure, do so at the appropriate times. Similarly, if you are given any additional medications to take beforehand, do so when asked.
On the day, it is usually helpful to wear loose, comfortable clothing so it is easy for the doctor to make any incisions or punctures required, depending on the type of biopsy you are receiving.
Attend any pre-procedure appointments, such as blood tests if necessary. Often the doctor will recommend having a blood test 4-5 days before the procedure to check your risk of bleeding.
Follow any instructions on eating and drinking the morning of your appointment. You may be able to have a light meal early in the day, and will usually be instructed to avoid eating or drinking 4 hours before the appointment. You will usually be allowed to have small sips of water before your appointment, but if in doubt, ask your doctor.
The doctor will explain the procedure beforehand, and a nurse will prepare you when you arrive at the hospital. It will usually involve cleaning the incision site, and/or preparing for a local or general anaesthetic. If you are awake during the procedure, you won’t need to do anything.

What happens after the procedure?

After the procedure, you will be monitored in a recovery area for a few hours. If you had a needle biopsy through the chest, you will usually have a chest X-ray 1 to 4 hours later to ensure your lung has not collapsed before you are allowed home. You may be asked to lie on the side where the biopsy was taken for the first hour or two to help the puncture site seal. You must have a family member or caregiver drive you home, as you will not be allowed to drive. Plan to rest quietly at home for at least 24 to 48 hours afterward.

Your family or caregiver may need to monitor you during the initial recovery period to watch for any complications, particularly if you received anaesthesia. This might involve vital signs monitoring, oxygen level monitoring, and checking the site of the biopsy for any bleeding or signs of infection. You can expect some mild pain and discomfort after a biopsy which can be managed with over-the-counter pain medications, and in some cases, mild coughing and fatigue can occur.

If you or your caregiver notice symptoms of the aforementioned complications, these should be reported as soon as possible. They might include:

Chest pain
Breathing difficulties or sudden shortness of breath
Excessive bleeding
Signs of infection (such as fever, or redness around the incision)

If all goes to plan, follow-up appointments are typically scheduled to discuss the results of your biopsy and any further testing or treatments needed.

Questions to ask your doctor before a lung biopsy.

Before you attend your lung biopsy appointment, here is a handy checklist of important questions you may wish to ask, to make sure you and your caregivers are fully informed:

Why do I need a lung biopsy?
What exactly are you looking for?
What type of lung biopsy will I be having, and why has this method been chosen?
What are the risks and potential complications?
Will any of my existing health conditions or medications impact this?
What do I need to do to prepare in advance?
Will I be receiving local or general anaesthesia?
Where and when will the procedure take place?
How long do you expect me to remain in the hospital afterwards?
How long should I be resting for at home afterwards?
What symptoms of complications do I need to watch out for?
Under what circumstances should I call 999 or come to A&E?
How soon will I get the results?

How can caregivers support older adults through lung biopsies?

A lung biopsy can be a stressful procedure for anyone, and particularly for older adults, for whom it may be more risky. Having family members and caregivers nearby may be essential in the days leading up to and following the procedure.

Beforehand, they can provide support by assisting the older person in better understanding the reasons for the procedure and the doctor’s preparation instructions. This might mean managing medications, arranging transport to and from hospital, and ensuring any advice about fasting beforehand is followed accurately. Older people may also require some emotional support during this stage if they are anxious about the procedure, so caregivers can offer peace of mind by attending the appointment with them for moral support.

Afterwards, family and caregivers are critical in the older person’s recovery to help with:

Monitoring for signs of complications such as breathing difficulties or infections
Assisting with daily tasks such as home help or providing transportation
Assisting with personal care if they have post-operative mobility issues
Medication management during recovery
Providing wound cleaning for the site of the incision
Offering emotional encouragement during recovery

Families can often help their loved one through this procedure and the subsequent recovery at home, but professional home care can also be enlisted to help on a temporary basis, which is particularly useful for those with a higher risk of complications. At Home Instead, we provide the tailored recovery care you need, whether that means visiting care to check on wounds and help with housekeeping, or more permanent live-in care to closely monitor for signs of complications in those with existing health conditions.

Our Care Professionals are trained to provide the bespoke care needed to keep older adults healthy and happy in their own home, and you can reach out to your local Home Instead office before a lung biopsy procedure to discuss how we can help.

We’re an award-winning home care provider and part of a worldwide organisation devoted to providing the highest-quality relationship-led care for older people in their own homes. Arranging care for yourself or your loved one shouldn’t be stressful, so whatever questions you would like answered, feel free to reach out to the Home Instead team to discuss your needs.