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Communications to the Editor |

Open-Lung Biopsy for ARDS Patients FREE TO VIEW

Mauro Oddo, MD; Lucas Liaudet, MD
Author and Funding Information

Affiliations: University Hospital, Lausanne, Switzerland,  Harvard Medical School, Boston, MA

Correspondence to: Lucas Liaudet, MD, Assistant Professor, Division of Critical Care, Department of Internal Medicine, University Hospital, 1011 Lausanne, Switzerland; e-mail: lucas.liaudet@chuv.hospvd.ch



Chest. 2004;126(3):1003-1004. doi:10.1378/chest.126.3.1003
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To the Editor:

We read with interest the article by Patel and colleagues (January 2004),1 who presented the results of a retrospective study evaluating open-lung biopsy (OLB) in a cohort of 57 patients with clinically diagnosed ARDS. The main observation of this study was that a pathologic diagnosis other than diffuse alveolar damage (the histologic hallmark of ARDS) was found in 60% of cases, resulting in a change in therapy in a majority of patients (ie, discontinuation of unneeded therapy, 37% of patients; addition of specific therapy, 60% of patients). Surprisingly, however, the therapeutic alterations guided by these precise histopathologic findings did not confer any survival benefit.,1 Such an observation is disappointing, as it contradicts the clinical principle that knowing the underlying pathology and instituting a specific therapy should positively affect outcome.

A plausible explanation for these negative results is that complications related to the surgical procedure may have cancelled out any potential benefit of obtaining a definitive diagnosis. Indeed, complications were noted in as much as 39% of patients, were defined as major (eg, death, myocardial infarction, stroke, institution of dialysis, or hemothorax within 48 h of surgery) in 7% of patients, and were defined as minor (eg, acute renal failure, 11% of patients; persistent air leak for > 1 week, 21% of patients) in 32% of patients.1We do not agree with the authors’ statement that, due to its low rate of major complications, OLB is a safe procedure in ARDS patients. In contrast, we think that the impact of the so-called minor complications has been underestimated by the authors, especially when it comes to the problem of persistent air leak. Persistent air leak (in effect, a bronchopleural fistula) requires prolonged chest tube drainage, may pose important problems in achieving adequate ventilation, and is associated with a poor prognosis in mechanically ventilated patients with severe respiratory failure.24 As such, the occurrence of a bronchopleural fistula has to be regarded as an ominous complication of OLD, rather than a minor complication, in the series reported by Patel et al. It would be meaningful to know about the outcomes of patients who developed such a complication in this study.

In summary, although this study provides important information on a pathologic viewpoint, we think that it does not support the use of OLB in mechanically ventilated patients with ARDS. Rather, it suggests that complications related to the procedure may be severe enough to negate any potential benefit provided by a precise histopathologic diagnosis.

Patel, SR, Karmpaliotis, D, Ayas, NT, et al (2004) The role of open-lung biopsy in ARDS.Chest125,197-202. [CrossRef] [PubMed]
 
Baumann, MH, Sahn, SA Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient.Chest1990;97,721-728. [CrossRef] [PubMed]
 
Pierson, DJ, Horton, CA, Bates, PW Persistent bronchopleural air leak during mechanical ventilation: a review of 39 cases.Chest1986;90,321-323. [CrossRef] [PubMed]
 
Pierson, DJ Management of bronchopleural fistula in the adult respiratory distress syndrome.New Horiz1993;1,512-521. [PubMed]
 
To the Editor:

We thank Drs. Oddo and Liaudet for their interesting and insightful comments. We also were disappointed that therapeutic changes made in response to the etiologic diagnosis were not associated with an improved outcome.1 We do not, however, believe that this lack of improvement is due to an offset from morbidities related to the lung biopsy procedure, as the risk of surgical complications (including prolonged air leakage) was independent of the etiologic diagnosis or the institution of specific therapy. Rather, we think that the lack of improvement was a reflection of the lack of efficacious therapies that are currently available for many of the causes of ARDS that were discovered. These findings highlight the need for further research into better therapies for diffuse alveolar damage and other pathologies causing ARDS.

While we agree that the occurrence of bronchopleural fistula (BPF) in mechanically ventilated patients with emphysema has poor prognostic implications, we think that this is a reflection of the severity of the patient’s underlying parenchymal lung disease rather than of the air leak itself.2Thus, we do not think that BPF secondary to lung biopsy in ARDS patients carries major deleterious consequences. In our study, the presence of BPF was not associated with the in-hospital mortality rate (mortality in patients with BPF, 46%; mortality in patients without BPF, 50%). In our experience, BPF rarely has important effects on gas exchange, and, in fact, a substantial quantity of ventilation has been reported34 to occur via the chest tube in patients with BPF. While BPF has limited ventilator liberation in the past, the current guidelines recommend continuing spontaneous breathing trials to liberate patients from mechanical ventilation regardless of chest tube status.5Finally, our experience has been that with the use of lower transpulmonary pressures in the ventilation of ARDS patients, the risk of BPF from lung biopsy has fallen considerably.67 Thus, we continue to believe that surgical lung biopsy can be safely performed in selected ARDS patients.

References
Patel, SR, Karmpaliotis, D, Ayas, NT, et al The role of open-lung biopsy in ARDS.Chest2004;125,197-202. [CrossRef] [PubMed]
 
Sekine, Y, Behnia, M, Fujisawa, T Impact of COPD on pulmonary complications and on long-term survival of patients undergoing surgery for NSCLC.Lung Cancer2002;37,95-101. [CrossRef] [PubMed]
 
Bishop, MJ, Benson, MS, Pierson, DJ Carbon dioxide excretion via bronchopleural fistulas in adult respiratory distress syndrome.Chest1987;91,400-402. [CrossRef] [PubMed]
 
Powner, DJ, Cline, CD, Rodman, GH, Jr Effect of chest-tube suction on gas flow through a bronchopleural fistula.Crit Care Med1985;13,99-101. [CrossRef] [PubMed]
 
Ely, EW, Baker, AM, Dunagan, DP, et al Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously.N Engl J Med1996;335,1864-1869. [CrossRef] [PubMed]
 
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.N Engl J Med2000;342,1301-1308. [CrossRef] [PubMed]
 
Pierson, DJ Management of bronchopleural fistula in the adult respiratory distress syndrome.New Horiz1993;1,512-521. [PubMed]
 

Figures

Tables

References

Patel, SR, Karmpaliotis, D, Ayas, NT, et al (2004) The role of open-lung biopsy in ARDS.Chest125,197-202. [CrossRef] [PubMed]
 
Baumann, MH, Sahn, SA Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient.Chest1990;97,721-728. [CrossRef] [PubMed]
 
Pierson, DJ, Horton, CA, Bates, PW Persistent bronchopleural air leak during mechanical ventilation: a review of 39 cases.Chest1986;90,321-323. [CrossRef] [PubMed]
 
Pierson, DJ Management of bronchopleural fistula in the adult respiratory distress syndrome.New Horiz1993;1,512-521. [PubMed]
 
Patel, SR, Karmpaliotis, D, Ayas, NT, et al The role of open-lung biopsy in ARDS.Chest2004;125,197-202. [CrossRef] [PubMed]
 
Sekine, Y, Behnia, M, Fujisawa, T Impact of COPD on pulmonary complications and on long-term survival of patients undergoing surgery for NSCLC.Lung Cancer2002;37,95-101. [CrossRef] [PubMed]
 
Bishop, MJ, Benson, MS, Pierson, DJ Carbon dioxide excretion via bronchopleural fistulas in adult respiratory distress syndrome.Chest1987;91,400-402. [CrossRef] [PubMed]
 
Powner, DJ, Cline, CD, Rodman, GH, Jr Effect of chest-tube suction on gas flow through a bronchopleural fistula.Crit Care Med1985;13,99-101. [CrossRef] [PubMed]
 
Ely, EW, Baker, AM, Dunagan, DP, et al Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously.N Engl J Med1996;335,1864-1869. [CrossRef] [PubMed]
 
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.N Engl J Med2000;342,1301-1308. [CrossRef] [PubMed]
 
Pierson, DJ Management of bronchopleural fistula in the adult respiratory distress syndrome.New Horiz1993;1,512-521. [PubMed]
 
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