Elsevier

Surgery

Volume 143, Issue 3, March 2008, Pages 426-433
Surgery

Brief clinical report
Yield and safety of bedside open lung biopsy in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome

https://doi.org/10.1016/j.surg.2007.06.003Get rights and content

Background

The utility of open lung biopsy (OLB) in mechanically ventilated patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) of unknown origin has been questioned because of its potentially low diagnostic yield and possibly related morbidity. To quantify possible benefits and risks, and especially so for bedside lung biopsy, we reviewed retrospectively our 8-year, single unit experience with this procedure.

Methods

Mechanically ventilated, critically ill patients with acute respiratory failure of unknown origin who underwent OLB were analyzed in a retrospective, single-center, cohort study in a medical intensive care unit in a university medical center.

Measurements and Main Results

Twenty-seven patients were analyzed (15 female, 12 male, of mean 48 years [standard deviation, 14]), 67% of whom were immunocompromised. All patients underwent bronchoscopy and bronchoalveolar lavage before OLB. Pao2/Fraction of inspired oxygen at the time of biopsy was 188 ± 109 mm Hg. Biopsies were performed in the operating room on 9 patients and at bedside on 18. A specific diagnosis was obtained in 70% of biopsies. Biopsy results led to alteration in treatment in 81% of patients. Minor complications occurred in 52% of patients and major complications in 7%. The rate of complications did not appear to differ with the location of the procedure (bedside vs operating room). No deaths were attributed to the procedure.

Conclusions

Bedside OLB can be performed safely in selected, mechanically ventilated, critically ill patients with ALI or ARDS. Our results support the concept that lung biopsy often leads to management alterations in patients where a standardized diagnostic workup failed to yield a definitive diagnosis.

Section snippets

Materials and methods

A retrospective analysis was conducted on adult patients admitted to the 12-bed medical ICU at the University Medical Center Hamburg-Eppendorf. From 1997 to 2005, a mean of 1,300 patients per year were treated, including a small portion of surgical patients. Using the terms thoracotomy and lung biopsy, the database containing all medical reports was screened for eligible patients. Patients with ventilator-dependent ALI or ARDS who underwent OLB were considered eligible if they were ventilator

Patient Characteristics

Between 1997 and 2005, 31 ICU patients underwent 31 OLB. Among these, 4 patients were excluded because OLB was obtained during a therapeutic thoracotomy (n = 1), intermittent noninvasive ventilation was applied before OLB (n = 1), and there was incomplete medical documentation (n = 2). Demographics are shown in Table I. According to the inclusion criteria, all 27 remaining patients were mechanically ventilated owing to ALI/ARDS for a median of 8 days (range, 2-76) before lung biopsy. Median

Discussion

The current study shows that bedside OLB is an appropriate and safe diagnostic procedure in a selected population of mechanically ventilated patients with ALI or ARDS of unknown origin. We were able to show that OLB was a decisive diagnostic step in a substantial proportion of patients, in whom (>70%) a standardized diagnostic workup including laboratory diagnostics, thoracic CT, and bronchoscopy with BAL failed to obtain a definitive diagnosis. Except for CMV, nearly no infectious agents were

References (31)

  • D.O. Warner et al.

    Open lung biopsy in patients with diffuse pulmonary infiltrates and acute respiratory failure

    Am Rev Respir Dis

    (1988)
  • M.L. Chuang et al.

    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)
  • L. Papazian et al.

    Indications of BAL, lung biopsy, or both in mechanically ventilated patients with unexplained infiltrations

    Eur Respir J

    (2003)
  • Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia

    Am J Respir Crit Care Med

    (2005)
  • J.F. Murray et al.

    An expanded definition of the adult respiratory distress syndrome

    Am Rev Respir Dis

    (1988)
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    1

    The first two authors contributed equally to this work.

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