Risk of Acute Exacerbation After Video-assisted Thoracoscopic Lung Biopsy for Interstitial Lung Disease

Abstract

Biopsy by video-assisted thoracoscopic surgery (VATS) for interstitial pneumonia allows collection of samples sufficient for accurate histologic diagnosis. Although VATS is relatively safe, several reports have suggested that surgical lung biopsy may be a risk factor for acute exacerbation of idiopathic pulmonary fibrosis (IPF). We retrospectively reviewed data on the 113 cases that underwent biopsy by VATS to diagnose diffuse parenchymal lung disease in our department between 1994 and 2006, and analyzed its complications, in particular, risk of acute exacerbation of IPF. As the final diagnosis, idiopathic interstitial pneumonia was most frequent, involving 52 cases, of which IPF was most frequently found followed by nonspecific interstitial pneumonia and cryptogenic organizing pneumonia, in that order. Among our cases, there were 2 deaths after VATS (mortality rate, 1.8%), and both were IPF cases with acute exacerbation. When examining clinical markers in the 2 fatal IPF cases with acute exacerbation, we found that the percentage of predicted forced vital capacity was 55 or lower, percentage of predicted carbon monoxide diffusing capacity was 40 or lower, serum interstitial pneumonia markers KL-6 and SP-D were elevated, intraoperative inhalation of 100% O2 was 80 minutes or longer, and postoperative thoracic drainage was required for 10 days or longer. Although acute exacerbations of IPF seem to occur at any time during the course of disease, it is important to be aware of the possibility of acute exacerbation of IPF after VATS.

Acute Exacerbation of Idiopathic Interstitial Pneumonia Following Lung Surgery in 3 of 68 Consecutive Patients: A Retrospective Study

“…In this context, in the actual clinical setting, it is difficult to maintain the PaO2 at an adequate level with an FiO2 below the threshold that is harmful to the lung tissue. Bando et al described that AE of IPF after VATS developed in the cases in which inhalation 100% O2 was 80 min or longer (27).…”

Diagnostic yield and postoperative mortality associated with surgical lung biopsy for evaluation of interstitial lung diseases: A systematic review and meta-analysis

“…There were 2 studies predisposed to right lobes, 8,15 with a diagnostic yield of 84% and 94%, respectively. One study avoided the lingual or middle lobe, 16 and 1 study focused on the lingular lobe, 21 reporting a diagnostic yield of 97% and 100%, respectively. Two studies demonstrated that biopsy samples from the lingual or middle lobe have the same diagnostic yield as those from others.…”

“…7,11,12,15,23,24,26,27 Only 1 study stated that multiple biopsies may increase the diagnostic yield. 8 A total of 21 studies specified SLB methods performed; 10 studies used both VATS and OLB, [5][6][7]9,10,14,15,17,20,22 10 studies used VATS, [11][12][13]16,18,19,23,24,26,27 and 2 studies used OLB. 21 Significant heterogeneity was still observed in subgroup analysis based on different surgical methods (data not shown).…”

Acute exacerbation of idiopathic pulmonary fibrosis: shifting the paradigm

“…For example, idiopathic AE-IPF is more common in the winter months [24,30], and in patients that are immunosuppressed [9], indicating that some cases of idiopathic AE-IPF may be triggered by a preceding infection [40][41][42]. Additional potential triggers that can lead to a similar presentation in patients with IPF include aspiration [43,44], pollution [45], thoracic surgical procedures [20,25,26,37,[46][47][48][49][50], cryobiopsy [51] and, possibly, bronchoalveolar lavage [20,52]. AE-IPF has also been reported following non-pulmonary surgery [47], potentially related to mechanical trauma secondary to mechanical ventilation.…”