Affiliations: Salt Lake City, UT
Dr. Suchyta is a Clinical Pulmonary Research Physician at the LDS Hospital and University of Utah in Salt Lake City.
Correspondence to: Mary R. Suchyta, DO, FCCP, Pulmonary Division, LDS Hospital, Eighth Ave and C St, Salt Lake City, UT 84143; e-mail: firstname.lastname@example.org
The relatively high sensitivity and specificity of open-lung biopsy (OLB) in chronic pulmonary diseases has made it a valuable diagnostic tool for those diseases.1
OLB is a surgical procedure requiring anesthesia and is associated with risks. Consequently, OLB is usually not considered a first-choice procedure in the diagnosis of most lung processes.
OLB has been previously used in ARDS to identify the acute pathologic process (diffuse alveolar damage),2–
and the ensuing fibroproliferative damage reported as ARDS progresses.3
In addition, OLB has been used when less invasive technology (eg, transbronchial biopsy) fails to provide a diagnosis for a rapidly deteriorating patient with ARDS. Most patients with ARDS are receiving mechanical ventilation and are critically ill at the time of OLB. This increases the risk of morbidity and mortality associated with the procedure and explains, in part, the infrequent reports of OLB during ARDS.
The earliest studies2,4
of OLB in patients with ARDS reported during the late 1970s and early 1980s were observations of small numbers of patients, and describe the acute pathologic and the late fibroproliferative changes. In spite of the institution of alternative therapies based on OLB findings (including high-dose corticosteroids), reported mortality remained high (57 to 78%).
Warner et al5
studied 80 patients who had OLB early in the course of acute respiratory failure. OLB was usually performed when the patient had progressive hypoxemia. Only 20 patients (25%) were receiving mechanical ventilation at the time of OLB. The complication rate was low (15%), and consisted of pneumothoraces that resolved with tube thoracostomy. There were no deaths. OLB led to therapy changes in 70% of the patients but mortality was still high (70%), and no obvious benefit was associated with OLB.
Meduri et al3
used OLB later in the course of ARDS for patients presenting with fever and leukocytosis. OLB revealed diffuse alveolar damage in addition to an intra-alveolar fibrotic process in 12 patients. Meduri et al3
treated these patients with high-dose IV corticosteroids and reported a low mortality (25%). There were no deaths in these 12 patients, and only 1 patient had a pneumothorax. Unfortunately, 44% of the patients acquired nosocomial pneumonia while receiving steroids.
Papazian et al6
performed OLB on 36 of 197 patients with ARDS over a 4-year period. His study was specifically conducted to assess the development of fibrosis in patients, and infected patients were not included. OLB was performed 10 days after the onset of ARDS, and 34 of 36 patients had a diagnosis that led to a therapy change. Only six patients had OLB evidence of fibrosis. There was one pneumothorax, but no deaths. Despite therapeutic changes, mortality was high (50%).
Flabouris and Myburgh7
used a retrospective approach to identify OLB during mechanical ventilation. In a 10-year period, the incidence of OLB was < 1% of all ICU admissions. Twenty-four patients had OLB, but only 14 patients were receiving mechanical ventilation at the time. OLB provided a specific diagnosis in 46% of the patients and a nonspecific diagnosis in 46%. Therapy was changed in 18 patients, but mortality was still 66%.
The most recent report of OLB in patients with ARDS is presented in this issue of CHEST by Patel et al (see page 197), and provides the largest review to date of OLB in ARDS. Patel et al retrospectively identified 57 patients over 12 years who underwent OLB during ARDS. OLB was performed approximately 7 days after hospital admission. Thirty percent of these patients were immunocompromised. A specific diagnosis was found in 60% of the patients, and therapy was changed in these patients. There was one death and a 12% pneumothorax rate. Unfortunately, mortality was high (47%) and not significantly different from ARDS mortality at their institution.
There are no published criteria or guidelines to aid the clinician in determining why or when to perform OLB in a patient with ARDS. Mechanical ventilation increases the risk of complications in OLB, and significant discussion usually occurs prior to OLB. Unfortunately, none of the articles, including this most recent publication, elucidate new logic for answering the “why and when” questions. These questions are in fact the most crucial with which clinicians struggle.
More importantly, no report has demonstrated a survival advantage for patients subjected to OLB, even when appropriate therapeutic changes are instituted. This may be explained by the small number of patients involved in aggregate in all the reports. A further explanation might be that OLB is not performed expeditiously enough in deteriorating patients, and consequently, there is a fatal delay in instituting a new therapy. Or perhaps, those patients who deteriorate and need OLB are in the final cascade of multiple organ failure that frequently leads to death in ARDS, and no therapy changes would alter the outcome. Unfortunately, these questions may only be answered with a prospective randomized trial with well-elucidated logic for OLB, and consistent application of OLB.
The bright notes in reviewing the study by Patel et al are that OLB is a relatively safe procedure even when performed in critically ill patients with ARDS receiving mechanical ventilation and frequently provides an unexpected diagnosis. This may encourage clinicians to use OLB biopsy more freely in patients with ARDS who fail to improve or continue to deteriorate. This might lead to a change of therapy as quickly as possible. However, the definition of the best role for OLB in patients with ARDS will depend on future studies that include prospective, randomized trials to present guidelines and protocols that are useful to clinicians and widely applicable.
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