Diagnostic yield and therapeutic impact of open lung biopsy in the critically ill patient

Carole Philipponnet, Lucie Cassagnes, Bruno Pereira, Jean-Louis Kemeny, Mojgan Devouassoux-Shisheboran, Alexandre Lautrette, Claude Guerin, Bertrand Souweine, Carole Philipponnet, Lucie Cassagnes, Bruno Pereira, Jean-Louis Kemeny, Mojgan Devouassoux-Shisheboran, Alexandre Lautrette, Claude Guerin, Bertrand Souweine

Abstract

Background: Open lung biopsy (OLB) is a rare procedure in intensive care units (ICUs) for therapeutic management of acute respiratory failure (ARF). The purpose of this study was to analyze the diagnostic yield, therapeutic contribution and complications of OLB in ICU patients with ARF of unclear etiology, including acute respiratory distress syndrome (ARDS) and ARDS mimics.

Methods: Retrospective study conducted in a 10-bed ICU over a 13-year period. Patients undergoing OLB for ARF with undiagnosed infiltrates on CT scan were included. ARDS was defined according to Berlin criteria, and ARDS mimics as a condition looking like ARDS except for the presence of a known cause. OLB was contributive when the OLB findings yielded a specific diagnosis resulting in a change in the patients' treatment or management.

Results: Forty six patients were included (sex ratio = 2.5, median and [interquartile range] age = 69 [59-77] years, and admission SAPS II = 42 [33-50]. ARF corresponded to ARDS in 22 patients and to ARDS mimics in 16. OLB yielded 61 diagnoses in 45 patients including diffuse alveolar damage (N = 21), lung fibrosis (N = 18), and organizing pneumonia (N = 11). OLB was contributive in 37 patients (80%), including 13/16 ARDS mimickers. The main contributions of OLB were the introduction or maintenance of steroids (N = 32) and discontinuation of antibiotics (N = 9). In 4 patients OLB resulted directly in the decision to forgo life-sustaining treatment. OLB complications occurred in 16 patients (35%), in one case associated with fatal outcome.

Conclusion: OLB can play a useful role in the management of ICU patients with ARF of undetermined origin, including ARDS mimickers. Further studies should be done to identify the groups of ICU patients likely to benefit from the procedure with minimum risk.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Panel of histologic patterns: DAD,…
Fig 1. Panel of histologic patterns: DAD, UIP, and infectious pneumonia.
1A –Diffuse alveolar damage (HES X 20). 1B –Diffuse alveolar diffuse and EBV pneumonia (Hybridization in situ with EBER probe X 40). 1C - CMV pneumonia with typical large cell with basophilic nuclear inclusion (HES X 60). 1D –UIP, microscopic honeycomb cysts with subpleural areas of fibrosis (HES X 40).
Fig 2. OLB contribution, treatment decisions induced…
Fig 2. OLB contribution, treatment decisions induced by OLB results.

References

    1. Guerin C, Bayle F, Leray V, Debord S, Stoian A, Yonis H, et al. Open lung biopsy in nonresolving ARDS frequently identifies diffuse alveolar damage regardless of the severity stage and may have implications for patient management. Intensive Care Med. 2015. February;41(2):222–30. doi:
    1. Cardinal-Fernández P, Bajwa EK, Dominguez-Calvo A, Menéndez JM, Papazian L, Thompson BT. The Presence of Diffuse Alveolar Damage on Open Lung Biopsy Is Associated With Mortality in Patients With Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Chest. 2016. May;149(5):1155–64. doi:
    1. Papazian L, Thomas P, Bregeon F, Garbe L, Zandotti C, Saux P, et al. Open-lung biopsy in patients with acute respiratory distress syndrome. Anesthesiology. 1998. April;88(4):935–44.
    1. Papazian L, Doddoli C, Chetaille B, Gernez Y, Thirion X, Roch A, et al. A contributive result of open-lung biopsy improves survival in acute respiratory distress syndrome patients. Crit Care Med. 2007. March;35(3):755–62. doi:
    1. Kao K-C, Hu H-C, Chang C-H, Hung C-Y, Chiu L-C, Li S-H, et al. Diffuse alveolar damage associated mortality in selected acute respiratory distress syndrome patients with open lung biopsy. Crit Care Lond Engl. 2015. May 15;19:228.
    1. Patel SR, Karmpaliotis D, Ayas NT, Mark EJ, Wain J, Thompson BT, et al. The role of open-lung biopsy in ARDS. Chest. 2004. January;125(1):197–202.
    1. Charbonney E, Robert J, Pache J-C, Chevrolet J-C, Eggimann P. Impact of bedside open lung biopsies on the management of mechanically ventilated immunocompromised patients with acute respiratory distress syndrome of unknown etiology. J Crit Care. 2009. March;24(1):122–8. doi:
    1. Wong AK, Walkey AJ. Open Lung Biopsy Among Critically Ill, Mechanically Ventilated Patients. A Metaanalysis. Ann Am Thorac Soc. 2015. August;12(8):1226–30. doi:
    1. Aublanc M, Perinel S, Guérin C. Acute respiratory distress syndrome mimics: the role of lung biopsy. Curr Opin Crit Care. 2017;23(1):24–29. doi:
    1. Gibelin A, Parrot A, Maitre B, Brun-Buisson C, Mekontso Dessap A, Fartoukh M, de Prost N. Acute respiratory distress syndrome mimickers lacking common risk factors of the Berlin definition. Intensive Care Med. 2016;42(2):164–72. doi:
    1. de Prost N, Pham T, Carteaux G, Mekontso Dessap A, Brun-Buisson C, Fan E, Bellani G, Laffey J, Mercat A, Brochard L, Maître B; LUNG SAFE investigators; ESICM trials group; REVA network. Etiologies, diagnostic work-up and outcomes of acute respiratory distress syndrome with no common risk factor: a prospective multicenter study. Ann Intensive Care. 2017;7(1):69 doi:
    1. Libby LJ, Gelbman BD, Altorki NK, Christos PJ, Libby DM. Surgical lung biopsy in adult respiratory distress syndrome: a meta-analysis. Ann Thorac Surg. 2014. October;98(4):1254–60. doi:
    1. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012. June 20;307(23):2526–33. doi:
    1. Kao K-C, Tsai Y-H, Wu Y-K, Chen N-H, Hsieh M-J, Huang S-F, et al. Open lung biopsy in early-stage acute respiratory distress syndrome. Crit Care Lond Engl. 2006;10(4):R106.
    1. Warner DO, Warner MA, Divertie MB. Open lung biopsy in patients with diffuse pulmonary infiltrates and acute respiratory failure. Am Rev Respir Dis. 1988. January;137(1):90–4. doi:
    1. Canver CC, Mentzer RM. The role of open lung biopsy in early and late survival of ventilator-dependent patients with diffuse idiopathic lung disease. J Cardiovasc Surg (Torino). 1994. April;35(2):151–5.
    1. Flabouris A, Myburgh J. The utility of open lung biopsy in patients requiring mechanical ventilation. Chest. 1999. March;115(3):811–7.
    1. Chuang M-L, Lin I-F, Tsai Y-H, Vintch JRE, Pang L-C. The utility of open lung biopsy in patients with diffuse pulmonary infiltrates as related to respiratory distress, its impact on decision making by urgent intervention, and the diagnostic accuracy based on the biopsy location. J Intensive Care Med. 2003. February;18(1):21–8. doi:
    1. Kao K-C, Tsai Y-H, Wu Y-K, Chen N-H, Hsieh M-J, Huang S-F, et al. Open lung biopsy in early-stage acute respiratory distress syndrome. Crit Care Lond Engl. 2006;10(4):R106.
    1. Arabi Y, Ahmed R, Ahmed Q, Rahman MU, Yamani N. Risks and benefits of open-lung biopsy in the mechanically ventilated critically ill population: a cohort study and literature review. Med Sci Monit Int Med J Exp Clin Res. 2007. August;13(8):CR365–371.
    1. Lim SY, Suh GY, Choi JC, Koh WJ, Lim SY, Han J, et al. Usefulness of open lung biopsy in mechanically ventilated patients with undiagnosed diffuse pulmonary infiltrates: influence of comorbidities and organ dysfunction. Crit Care Lond Engl. 2007;11(4):R93.
    1. Baumann HJ, Kluge S, Balke L, Yekebas E, Izbicki JR, Amthor M, et al. Yield and safety of bedside open lung biopsy in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome. Surgery. 2008. March;143(3):426–33. doi:
    1. Almotairi A, Biswas S, Shahin J. The Role of Open Lung Biopsy in Critically Ill Patients with Hypoxic Respiratory Failure: A Retrospective Cohort Study. Can Respir J. 2016;2016:8715024 doi:
    1. Canver CC, Mentzer RM. The role of open lung biopsy in early and late survival of ventilator-dependent patients with diffuse idiopathic lung disease. J Cardiovasc Surg (Torino). 1994. April;35(2):151–5.
    1. Depuydt OE, Daeze C, Benoit D, Praet M, Vermassen E, Decruyenaere M. Diagnostic potential of open lung biopsy in mechanically ventilated patients with diffuse pulmonary infiltrates of unclear aetiology. Anaesth Intensive Care. 2013. September;41(5):610–7.
    1. Steinberg KP, Hudson LD, Goodman RB, Hough CL, Lanken PN, Hyzy R, Thompson BT, Ancukiewicz M; National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med. 2006. April 20;354(16):1671–84. doi:
    1. Wells AU. The revised ATS/ERS/JRS/ALAT diagnostic criteria for idiopathic pulmonary fibrosis (IPF)—practical implications. Respir Res. 2013;14 Suppl 1:S2.

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