Impact of bedside open lung biopsies on the management of mechanically ventilated immunocompromised patients with acute respiratory distress syndrome of unknown etiology

Abstract

Background: Open lung biopsy (OLB) is helpful in the management of patients with acute respiratory distress syndrome (ARDS) of unknown etiology. We determine the impact of surgical lung biopsies performed at the bedside on the management of patients with ARDS. Methods: We reviewed all consecutive cases of patients with ARDS who underwent a surgical OLB at the bedside in a medical intensive care unit between 1993 and 2005. Results: Biopsies were performed in 19 patients mechanically ventilated for ARDS of unknown etiology despite extensive diagnostic process and empirical therapeutic trials. Among them, 17 (89%) were immunocompromised and 10 patients experienced hematological malignancies. Surgical biopsies were obtained after a median (25%-75%) mechanical ventilation of 5 (2-11) days; mean (±SD) PaO 2 / FiO 2 ratio was 119.3 (±34.2) mm Hg. Histologic diagnoses were obtained in all cases and were specific in 13 patients (68%), including 9 (47%) not previously suspected. Immediate complications (26%) were local (pneumothorax, minimal bleeding) without general or respiratory consequences. The biopsy resulted in major changes in management in 17 patients (89%). It contributed to a decision to limit care in 12 of 17 patients who died. Conclusion: Our data confirm that surgical OLB may have an important impact on the management of patients with ARDS of unknown etiology after extensive diagnostic process. The procedure can be performed at the bedside, is safe, and has a high diagnostic yield leading to major changes in management, including withdrawal of vital support, in the majority of patients.

Open lung biopsy in nonresolving ARDS frequently identifies diffuse alveolar damage regardless of the severity stage and may have implications for patient management

“…The operating ARDS definitions have been used in confrontations with lung histology in two autopsy studies. In previous studies on OLB in ARDS, the rates of DAD ranged between 7 [20] and 60 % [19], but most of these studies were performed in the early stage of ARDS [6,[19][20][21][22], making the comparison with the present study difficult. When 284 patients with ARDS risk factors were analyzed, sensitivity was found to be 76 % and specificity 75 %.…”

Diffuse Alveolar Damage of the Lungs in Forensic Autopsies: Assessment of Histopathological Stages and Causes of Death

“…An open biopsy may trigger acute attacks in patients with idiopathic pulmonary fibrosis [10]. Given the restrictions when performing an open-lung biopsy in patients with acute and severe respiratory distress, a limited number of studies have examined biopsy data from this patient group [11–13]. Thus, forensic autopsies and the examination of DAD prevalence may be an alternative area of research [14, 15].…”

The diagnostic yield and complications of open lung biopsies in kidney transplant patients with pulmonary disease

“…The diagnostic yield of OLB, which does not specifically address solid organ transplant patients, ranges between 34% and 100% (16,17,19,(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41). In solid organ transplant patients, Defranchi et al reported that 29% had a change in clinical management as a result of the OLB findings (16).…”