| The
role of open lung biopsy in the management and outcome of patients
with diffuse lung disease.
Ann Thorac Surg. 1998 Jan;65(1):198-202
BACKGROUND: Open
lung biopsy (OLB) has long been considered the gold standard for the
diagnosis of parenchymal lung disease. With recent advances in
computed tomographic imaging and diagnostic techniques (eg,
bronchoscopy), we thought it necessary to reevaluate the role of OLB
in the management of patients with interstitial lung disease. METHODS:
We carried out a retrospective analysis of 103 OLBs performed at
Hadassah University Hospital, Jerusalem, and Carmel Medical Center,
Haifa, between 1980 and 1994. Data gathered included demographic
information, underlying condition, indications for biopsy, diagnosis
before biopsy, final diagnosis, change in therapy, and mortality.
"Benefit" was defined as a change in therapy resulting in survival.
RESULTS: There were 45 immunocompetent patients (group 1), 39
immunocompromised patients (group 2), and 26 children (group 3), 7 of
whom were included in group 2 for analysis. Overall, a diagnosis was
reached after OLB in 85% of patients. An unexpected diagnosis was
reached in 52%, and a change in therapy was instituted in 46%. The
overall mortality rate was 20%. In group 1, the mortality rate was
13%, and "benefit" from OLB was reached in only 18%. In group 2, the
mortality rate was 39%, and "benefit" was achieved in 46%, and in
group 3, the mortality rate was 12% and "benefit", 50%. CONCLUSIONS:
Open lung biopsy is an excellent diagnostic technique. In
immunocompetent patients, the "benefit" is relatively low, as therapy
(corticosteroids) is frequently used after biopsy. In
immunocompromised patients, therapy changes substantially after OLB,
but mortality is high. Therefore, OLB should be reserved for patients
in whom the diagnosis is likely to lead to a change in therapy and in
patients in whom the underlying condition has a reasonable prognosis
according to the clinical impression by the attending physician.
The utility of open lung biopsy in patients requiring mechanical
ventilation. Chest.
1999 Mar;115(3):811-7.
STUDY OBJECTIVE:
To determine the diagnostic yield, morbidity, mortality, and
therapeutic impact of the open lung biopsy in patients requiring
mechanical ventilation. DESIGN: Retrospective review of patient
records. SETTING: Tertiary ICU. PATIENTS: Patients with respiratory
failure and diffuse pulmonary infiltrates requiring mechanical
ventilation, leading up to or following an open lung biopsy.
MEASUREMENTS: Information included patient demographics, organ
failure, microbiological results before open-lung biopsy, Pao,/fraction
of inspired oxygen values before and after biopsy, immunosuppression,
timing of open lung biopsy, biopsy-related morbidity and mortality,
duration of after-biopsy ventilation, open lung biopsy results,
biopsy-initiated treatment alterations, and hospital outcome. RESULTS:
Twenty-four patients were identified. The mean age was 48.9 years
(confidence interval, 42.1 to 55.7). Twenty-one percent had
respiratory infections diagnosed before open lung biopsy but not
confirmed by open lung biopsy. Intraoperative complications occurred
in 21% of patients, and postoperative complications occurred in 17% of
patients. Operative mortality was 8.4%. The specific and the
nonspecific diagnostic rates were both 46%. Lung histology was normal
in two patients; one of those patients had a false-negative finding.
No patient with respiratory failure plus 2 2 other organ failures
survived. Alteration of therapy did not differentiate between
survivors. Open lung biopsy-guided alteration of therapy directly
benefited 39%, and withdrawal was possible in 8.4% of the patients.
CONCLUSIONS: The multiple organ dysfunction score should be considered
when deciding the relative risk of performing an open lung biopsy,
which in this group of patients provided a specific diagnosis in 46%
and carried a mortality rate of 8.4%.
Clinical utility of open lung biopsy for undiagnosed pulmonary
infiltrates.
Am J Surg. 1992
Aug;164(2):104-7; discussion 108
Open lung biopsy
(OLB) is often performed as the definitive diagnostic procedure in
patients with undiagnosed pulmonary infiltrates, but controversy
exists as to the clinical utility of this practice. A retrospective
review of 50 consecutive patients who underwent OLB for undiagnosed
pulmonary infiltrates was done to assess the diagnostic value as well
as the frequency with which these results affected therapy and
mortality. Histologic tissue diagnoses were obtained in all patients.
Specific pathologic diagnoses were obtained in 56% of patients,
nonspecific in 44%. Lobar or lateralized infiltrates were more likely
to yield a specific diagnosis (87%) than diffuse, bilateral
infiltrates (42%). Thirty-four patients (68%) had previously had a
nondiagnostic transbronchial biopsy; 58% of these patients had a
specific diagnosis established by OLB. Twelve patients (24%) were in
acute respiratory failure at the time of OLB; this group had a 50%
mortality rate as compared with only 2.6% for patients not in acute
respiratory failure (p less than 0.01). Therapy was altered (new
specific or nonspecific treatment initiated or therapy withdrawn) in
78% of patients undergoing OLB. Thirty-day in-hospital survival was
significantly higher in patients for whom either specific or
nonspecific therapy was indicated and initiated versus those in whom
no therapy was initiated or all therapy was withdrawn (mortality: 5.5%
versus 35.7%; p = 0.01). Mortality was not related to the presence of
immunosuppression or to the finding of a specific diagnosis. The
overall mortality rate of 14% in this series compares favorably with
mortality rates found in similar series, reflecting differences in
patient populations and possibly the timing of intervention. OLB
remains a clinically valuable diagnostic tool in selected patients.
Role of open
lung biopsy in lung transplant recipients in a single children's
hospital: a 13-year experience.J
Thorac Cardiovasc Surg. 2006 Jan;131(1):204-8.
BACKGROUND: There
are few data in the literature regarding the utility of open lung
biopsy for the assessment of graft dysfunction after pediatric lung
transplantation. The aim of this study is to review our experience
with diagnostic open lung biopsy in lung transplant recipients in a
children's hospital. METHODS: Records of lung transplant recipients
from January 1990 through December 2002 were reviewed to identify the
indications, outcomes, and complications of open lung biopsy. RESULTS:
Two hundred twenty-four patients (mean age, 9.9 +/- 6.2 years; median
age, 11 years; age range, 0.01-19.6 years) underwent 249 lung
transplantations: 231 bilateral, 8 single, and 10 heart-lung
transplantations. Mean follow-up was 3.4 years. One hundred three open
lung biopsies were performed in 89 (40% of all recipients) patients.
Thirteen recipients underwent open lung biopsy twice, and 1 recipient
had 3 open lung biopsies. The indications for open lung biopsy were
suspicion of bronchiolitis obliterans (n = 70), posttransplantation
lymphoproliferative disorder (n = 15), infection (n = 8), and
unexplained respiratory failure (n = 10). A new diagnosis was made in
49 biopsies (48%), 50 biopsies (49%) confirmed the preoperative
clinical diagnosis, and 4 biopsies (3%) were nondiagnostic.
Bronchiolitis obliterans was confirmed in 40 (57%) of 70 open lung
biopsies, posttransplantation lymphoproliferative disorder was
confirmed in 4 (27%) of 15 open lung biopsies, and infection was
confirmed in 6 (75%) of 8 open lung biopsies. A change in therapy
occurred in 69% of the cases as a result of the diagnosis made from
open lung biopsy. There was no mortality as a direct result of open
lung biopsy. Eleven major complications and 22 minor complications
occurred in 103 procedures. CONCLUSION: Open lung biopsy can be
performed safely, and established or confirmed a diagnosis in 97% of
the cases. A change in therapy occurred in 69% of the cases as a
result of the diagnosis made from open lung biopsy. In our experience
open lung biopsy appears to be a useful tool.
Morbidity and mortality of open lung biopsy in children.Pediatrics.
1997 May;99(5):660-4.
OBJECTIVE: In
patients with diffuse pulmonary infiltrates, when empiric therapy or
less-invasive diagnostic procedures fail, physicians frequently resort
to open lung biopsy (OLB) to provide a definite diagnosis and to help
redirect therapeutic treatment. OLB is still widely regarded as a safe
diagnostic procedure, even in the critically ill child. The objective
of this study is to evaluate the accuracy of this view with regard to
children with acute respiratory failure (ARF) and, for this purpose,
compares the mortality and morbidity of such patients with those
without ARF. DESIGN: Retrospective chart review. SETTING: University
hospital. PATIENTS: Forty-two patients (mean age, 6.6 years) underwent
47 OLBs for undiagnosed diffuse pulmonary infiltrates between July
1984 and December 1994. Twenty-six patients (55%) were in ARF. Fifteen
of these patients were intubated and receiving mechanical ventilatory
support before the OLB procedure. RESULTS: The overall incidence of
serious complications associated with the OLB procedure was 51%. Of
the patients with ARF, 17 (65%) had at least one major complication
compared with 3 (14%) of the patients without ARF. Pleural air
complications (62% of the total) occurred only in patients with ARF:
pneumothoraces and/or prolonged air leaks developed in 10 (38%) after
their OLBs; 9 of these patients died, and 7 had pneumothorax
complicating their chest tube removal, which required replacement
chest tubes. All patients with ARF preoperatively required prolonged
ventilatory support after the OLB procedure, whereas 90% of the
patients without ARF could be extubated within 24 hours. Overall, 10
patients (24%) died after the OLB procedure. All deaths occurred in
patients with ARF. Both ARF preoperatively and the presence of
postoperative complications were significantly associated with
decreased survival. CONCLUSIONS: The morbidity and mortality rates of
children with ARF undergoing OLB for diffuse pulmonary infiltrates
differ considerably from those of children without ARF. For children
with ARF, OLB is associated with the risk of prolonged ventilatory
support, recurrent pneumothoraces, and air leaks. These complications
may be attributable to such patients' having diseased lungs with poor
healing. Moreover, these complications may, in turn, contribute to the
patients' poor outcomes.
Diffuse pulmonary infiltrates after bone marrow transplantation: the
role of open lung biopsy.Ann
Thorac Surg. 2004 Jul;78(1):267-72
BACKGROUND:
Diffuse pulmonary infiltrates is the major complication and cause of
mortality after bone marrow transplantation. We analyzed the
etiologies and prognostic factors in bone marrow recipients with
diffuse pulmonary infiltrates and assessed the role of open lung
biopsy in managing this complication. METHODS: Medical records of
patients with diffuse pulmonary infiltrates after bone marrow
transplantation were reviewed. Possible prognostic factors were
analyzed by multivariate logistic regression. RESULTS: Sixty-eight
(20%) of 341 bone marrow recipients had diffuse pulmonary infiltrates
and 34 died. Thirty-five underwent open lung biopsy, resulting in
therapeutic changes in 22 (63%) and clinical improvement in 16 (46%).
The leading diagnoses were idiopathic interstitial pneumonitis (40%)
and cytomegalovirus pneumonitis (20%). Cytomegalovirus pneumonitis
caused radiographically observable interstitial infiltrates
exclusively and was frequently associated with hepatitis. Idiopathic
interstitial pneumonitis resulted in either diffuse ground-glass
opacity or interstitial infiltrates. Three (9%) patients had miliary
tuberculosis. Respiratory failure (p < 0.001) and acute
graft-versus-host disease (p = 0.016) were the poor prognostic
factors. CONCLUSIONS: Among bone marrow recipients, we found diffuse
pulmonary infiltrates in 20% and a mortality rate of 50%. Idiopathic
interstitial pneumonitis and cytomegalovirus pneumonitis were the most
common causes and should be suspected in patients with diffuse
interstitial infiltrates. In endemic areas, miliary tuberculosis
should be suspected in bone marrow recipients with diffuse
reticulonodular lesions. Respiratory failure and acute
graft-versus-host disease were poor prognostic factors. By
establishing a correct diagnosis, open lung biopsy led to treatment
changes in about two-thirds of these patients.
Role of open lung biopsy in patients with diffuse lung infiltrates
and acute respiratory failure.J
Formos Med Assoc. 2005 Jan;104(1):17-21
BACKGROUND AND
PURPOSE: Open lung biopsy (OLB) is the standard procedure for the
diagnosis of specific parenchymal lung diseases. The purpose of this
study was to investigate the influence of OLB on subsequent treatment
strategy and outcome in patients with diffuse lung infiltrates and
acute respiratory failure. METHODS: This retrospective review included
32 patients (aged 50.6 +/- 21.7 years) with acute respiratory failure
and diffuse pulmonary infiltrates who underwent OLB from 1990-2002.
Data analyzed included diagnoses, treatment alterations, 30-day
survival, oxygenation status, and histologic results. RESULTS:
Specific diagnoses were made in 53.1% of patients (17/32), 23 (71.9%)
of whom had acute respiratory distress syndrome (ARDS). Diagnostic
yields did not differ with immunity status or ARDS. OLB led to
specific decisions of treatment in 46.9% of patients (15/32), and only
7 of these 32 patients (21.8%) survived. Overall mortality was 56.2%
(18/32) and was not influenced by pre-OLB oxygenation or histologic
results. Although perioperative complications affected 40.6% of
patients (13/32), none of the deaths were surgery-related.
Complication rates were significantly higher in patients with ARDS (p
= 0.04). CONCLUSIONS: OLB is associated with a low perioperative
mortality rate and acceptable morbidity rate in patients with diffuse
lung infiltrates and acute respiratory failure, including those
patients with ARDS. In this study, a specific diagnosis was obtained
by OLB in more than half of patients with diffuse pulmonary
infiltrates and ARDS. In addition, OLB resulted in either use of a new
therapeutic strategy or elimination of unnecessary treatment in nearly
one-half of patients (46.9%).
Surgical lung biopsy for diffuse pulmonary disease: experience of 196
patients.J
Thorac Cardiovasc Surg. 2005 May;129(5):984-90.
OBJECTIVE:
Surgical lung biopsy is considered the final method of diagnostic
modality in patients with undiagnosed diffuse pulmonary disease.
Nevertheless, the effect of surgical lung biopsy on the diagnosis,
treatment, and outcome of the patient still remains controversial.
This study reviewed the experiences of surgical lung biopsies in 196
consecutive patients during the past 7 years. METHODS: Surgical lung
biopsy was performed after achievement of general anesthesia through
video-assisted thoracoscopic surgery or a 7-cm minithoracotomy. Biopsy
specimens were swabbed for aerobic and anaerobic bacterial, fungal,
and mycobacterial cultures. The sections of specimens were routinely
stained with hematoxylin and eosin, and acid-fast, Gomori methenamine
silver, Gram stain, or other special stains were added if necessary.
RESULTS: The pathologic diagnosis after surgical lung biopsy included
infection (30.6%), interstitial pneumonia or fibrosis (21.9%), diffuse
alveolar damage (17.3%), neoplasm (13.3%), autoimmune diseases (8.2%),
and others (8.2%). After surgical lung biopsy, 165 (84.2%) patients
had changes in their therapy, 124 (63.3%) patients had clinical
improvement of their conditions, and 119 (60.7%) patients survived to
hospital discharge. Comparison between immunocompromised and
immunocompetent patients showed that diagnosis of infection was
significantly higher ( P < .01) in the former group (41.2% vs 20.2%).
In addition, there was no significant difference in the distribution
of diagnosis and rate of change in therapy between the respiratory
failure and nonrespiratory failure groups. However, the rates of
response to therapy and patient survival were significantly lower in
the respiratory failure group (51.2% and 41.5%) than in the
nonrespiratory failure group (71.9% and 78.1%, P < .05). There was no
surgical mortality directly related to the procedure. The surgical
morbidity rate was 6.6%. CONCLUSION: Surgical lung biopsy is a safe
and accurate diagnostic tool for diffuse pulmonary disease. For a
large proportion of the patients, change of therapy and then clinical
improvement can be achieved after surgical lung biopsy. Surgical lung
biopsy should be considered earlier in patients with undiagnosed
diffuse pulmonary disease, especially when the respiratory condition
is deteriorating.
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 Jan-Feb;18(1):21-8.
Patients with
diffuse pulmonary infiltrates (DPI), especially those who present with
respiratory distress (RD), may benefit from early open lung biopsy (OLB)
to guide management. Benefits of urgent OLB would be expected by
saving the time to reach accurate specific diagnoses. The objectives
of this study were (1) to evaluate the impact of OLB between patients
presenting with and without RD, (2) to focus on the impact of an
urgent OLB as compared to an elective OLB, and (3) to compare the
different yields of specific diagnoses in the middle lobe or lingula
as compared to the other lobes. Thirty-four patients (17 patients
presented with RD and 17 patients did not) with an average age of 43
years who presented with DPI were selected to undergo an OLB. An
urgent OLB was performed in 11 unselected patients. Twelve specimens
from the middle lobe or lingula were compared to 25 specimens from the
other lobes. The impact of the OLB results on decision making did not
differ significantly between patients with and without RD. Patients
with RD suffered a higher in-hospital mortality rate, OLB-related
complications, and longer mechanical ventilation requirements than the
patients without RD. The impact on decision making and complications
between urgent OLB and elective OLB was comparable. The diagnostic
yield from biopsy sites in the middle lobe or lingula resembled those
specimens from the other lobes. The authors conclude that OLB may play
a role in decision making for patients with DPI. However, OLB makes no
difference in decision making between patients with and without RD.
Patients with RD undergoing OLB procedures may suffer a poorer
outcome. Urgent OLB may not benefit patients with DPI in decision
making. The biopsy site does not appear to affect the accuracy of the
diagnostic yield from an OLB procedure.
Open lung biopsy for investigation of acute respiratory episodes in
patients with HIV infection and AIDS.Genitourin
Med. 1995 Oct;71(5):280-5
BACKGROUND--Open
lung biopsy (OLB) is rarely necessary for investigation of HIV
positive patients with acute respiratory episodes because of the high
yield from fibreoptic bronchoscopy with bronchoalveolar lavage (BAL).
METHODS--A retrospective review of OLB in HIV positive patients
admitted to a specialist inpatient unit with acute respiratory
symptoms was carried out in order to define clinical indications,
diagnostic yield, impact on management, complications and outcome.
RESULTS--OLB was performed in 23 patients; 21 had undergone one or
more bronchoscopies with BAL (5 also had negative results from
transbronchial biopsy). Indications for OLB were: Group A, 15 patients
thought clinically to have pneumocystis pneumonia but not responding
to treatment; Group B, 4 patients with focal chest radiographic
abnormalities; Group C, 4 patients with diffuse radiographic
abnormalities and miscellaneous conditions. Preoperative PaO2 (on air)
ranged from 4.4 to 14.5 (mean = 9.5) kPa. The results of OLB were in
Group A 5 patients had non specific interstitial pneumonitis (NIP), 1
also had Kaposi's sarcoma, 4 had pneumocystis pneumonia (1 also had
bronchiolitis obliterans organising pneumonia [BOOP]), 3 had Kaposi's
sarcoma and 1 had BOOP and emphysema, 1 had pulmonary infarction and
no infection and 1 had normal lung tissue. In Group B diagnoses were
NIP, B cell lymphoma, occult alveolar haemorrhage and Pseudomonas
aeruginosa pneumonia with BOOP; In Group C 2 patients had NIP and 2
had pneumocystis pneumonia (1 also had cytomegalovirus pneumonitis).
All patients survived surgery and none required mechanical
ventilation. OLB results significantly affected management; in Group A
inappropriate treatment was discontinued in 11 patients found not to
have pneumocystis pneumonia, and alternative therapy was begun in the
4 with pneumocystis and in Groups B and C 6 patients began specific
therapy; unnecessary therapy was avoided in one and antimicrobial
treatment was modified in one. CONCLUSIONS--Open lung biopsy in HIV
positive patients with focal and diffuse radiographic abnormalities
has a high diagnostic yield and low morbidity. This investigation
should be considered in those with acute respiratory episodes and
negative results from bronchoscopic investigations or who have
contra-indications to this procedure.
Open lung biopsy in patients with diffuse pulmonary infiltrates and
acute respiratory failure.Am
Rev Respir Dis. 1988 Jan;137(1):90-4.
Patients with
diffuse pulmonary infiltrates and acute respiratory failure (ARF)
potentially can benefit from diagnostic information provided by open
lung biopsy (OLB). To better quantify possible benefits and risks, we
reviewed an 11-yr experience with 80 such patients. Although OLB did
provide a specific etiologic diagnosis in 53 patients (66%) and did
influence therapy in 56 patients (70%), only 24 patients (30%)
survived to hospital discharge, and 9 patients (11%) survived for 1 yr
or more. Survival rates did not depend on the availability of a
specific diagnosis, changes in diagnosis, or changes in therapy.
Survival was improved in younger patients and patients not requiring
preoperative mechanical ventilation. Fifteen patients (19%) suffered
complications possibly related to OLB; the survival rate to discharge
was decreased in these patients, although not significantly. We
conclude that OLB provides a specific etiologic diagnosis in many
patients with diffuse pulmonary infiltrates and ARF, but that its
utility in these patients is limited by current shortcomings of
therapy.
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