With respect to open or video-assisted thorascopic surgical lung biopsy in the management of respiratory failure in the critically ill, discuss the indications, advantages, limitations and complications.
Usually performed in setting of progressive and non resolving respiratory failure/ARDS where no
aetiologic diagnosis has been reached by conventional testing such as:
Microbiological/serological/histological examination of sputum and secretions
o Bronchoscopic samples required
Radiologically guided (CT or ultrasound) biopsies
Decision to perform lung biopsy based on:
The need to make a specific diagnosis and thereby direct specific treatment
With-hold potentially harmful or ineffective empiric treatment when other investigations including biopsy obtained by less invasive techniques have been inconclusive
Provide important prognostic information
May be useful in identifying a range of potentially treatable pathologies
May diagnose other less treatable pathologies that may alter directions of treatment (limitation of care
Fibrotic disease e.g. IPF
Other : e.g. veno-occlusive disease
Potentially avoid administration of high dose steroids or other potent immunosuppressants if concern
exists about a possible infectious aetiology.
Also may allow cessation of unnecessary/toxic anti-infective medications.
However, if all such treatments are initiated empirically then it is often argued that the
procedure is unnecessary (see “limitations” below)
Obtain larger and/or multiple samples
Ability to treat co-existing pathology e.g. perform pleurodesis, drain empyema simultaneously
May be difficult to know where best to biopsy (especially if radiology unhelpful) or the most likely
useful area may be inaccessible to the surgeon.
May not give useful diagnostic information especially if not performed early enough,
If all treatment modalities are administered empirically, the value of the test is debatable.
Bleeding, infection, poor wound healing etc.
Increased analgesia requirements post open procedure
Pneumothoraces (persistent/tension etc.)
Persistent air leak (may be prolonged >7 days)(difficult to treat): most common Cx
Haemothorax, massive haemorrhage, pseudotamponade, circulatory collapse
Serous effusions, empyema
Need for single lung ventilation during surgery (VATS)
Respiratory decompensation intra/post procedure
May not obtain adequate sample
Summary statement (for example)
There is no high-grade evidence for its utility in this context. However, there are multiple case series in the literature that describe high rates of specific diagnostic yield (65-95%), with results leading to treatment alterations in the majority of cases (42 – 89%). All series had a low serious complication rate, and air leaks were the commonest complication.
Additional Examiners’ Comments: Some candidates misread the question as ‘compare and contrast’
Overall well answered.
The LITFL lung biopsy page is a definitive resource for the time-poor exam candidate.
Rationale for an open lung biopsy
Potential findings from a lung biopsy:
Complications of lung biopsy
Evidence in support of lung biopsy
In their answer, the college mention some numbers from "multiple case series in the literature". It would be lovely if they gave a reference.
Even in 1976 (Hill et al) the mortality rate from this procedure was zero, and the morbidity rate was around 4%. In that ancient case series, 33% of the patients enjoyed some sort of positive change in their management because of the biopsy result.
Flabouris and Myburgh (1999) reported something similar. Their complication rate was higher (21%) but these were "proper" mechanically ventilated ICU patients. "Open lung biopsy-guided alteration of therapy directly benefited 39%, and withdrawal was possible in 8.4% of the patients". However, the change to management did not discriminate survivors from non-survivors (i.e. it didn't matter that you changed to an appropriate therapy, the patient died anyway).
A retrospective series by Lim et al (2007) also reported that a specific diagnosis was achieved in 86% of the biopsied patients, and that in 64% changes to management occurred. Those who were biopsied earlier (within 1 week of intubation) did better in terms of mortality (63% survival vs 11%), which contrasts with the earlier studies.
UpToDate has a nice article about lung biopsy.
Bensard, Denis D., et al. "Comparison of video thoracoscopic lung biopsy to open lung biopsy in the diagnosis of interstitial lung disease." CHEST Journal103.3 (1993): 765-770.
Hill, J. D., et al. "Pulmonary pathology in acute respiratory insufficiency: lung biopsy as a diagnostic tool." The Journal of thoracic and cardiovascular surgery 71.1 (1976): 64-71.
Nguyen, W., and K. C. Meyer. "Surgical lung biopsy for the diagnosis of interstitial lung disease: a review of the literature and recommendations for optimizing safety and efficacy." Sarcoidosis vasculitis and diffuse lung disease 30.1 (2013): 3-16.
Flabouris, Arthas, and John Myburgh. "The utility of open lung biopsy in patients requiring mechanical ventilation." CHEST Journal 115.3 (1999): 811-817.
Lim, Seong Y., et al. "Usefulness of open lung biopsy in mechanically ventilated patients with undiagnosed diffuse pulmonary infiltrates: influence of comorbidities and organ dysfunction." Critical care 11.4 (2007): R93.