The Role of Open-Lung Biopsy in ARDS

doi:10.1378/chest.125.1.197

Chest

Volume 125, Issue 1, January 2004, Pages 197-202

https://doi.org/10.1378/chest.125.1.197 Get rights and content

Study objectives

The role of open-lung biopsy in ARDS has been questioned due to potentially high morbidity and low diagnostic yield. The goals of this study were to better define the frequency of unexpected diagnoses made by open-lung biopsy, the frequency biopsy results lead to a change in clinical management, and the frequency of procedural complications.

Design

Case series.

Setting

A large tertiary referral center.

Patients

All individuals with available records undergoing open-lung biopsy between 1989 and 2000 for evaluation of ARDS based on the American-European Consensus Conference definition.

Interventions

None.

Measurements and results

The mean age in this cohort of 57 patients was 53 years (SD, 18 years) with Pao₂/fraction of inspired oxygen ratio of 145 mm Hg (SD, 61 mm Hg) at the time of biopsy. A pathologic diagnosis other than diffuse alveolar damage or fibroproliferation was found in 60% of patients. The most common alternative diagnoses were infection (n = 8), alveolar hemorrhage (n = 5), and bronchiolitis obliterans organizing pneumonia (n = 5). Alternative diagnoses were as frequent in immunocompetent as immunosuppressed hosts (60% vs 59%, respectively). Biopsy results led to a change in management in the majority of patients, with addition of specific therapy in 60% and withdrawal of unneeded therapy in 37%. Although the overall complication rate was 39%, major complications occurred in only 7% of cases. No deaths were attributable to the procedure.

Conclusions

In selected patients with clinical ARDS, open-lung biopsy can be performed safely, often reveals an unsuspected diagnosis, and frequently leads to alterations in therapy.

Section snippets

Materials and Methods

A retrospective review was performed using inpatient medical records at Massachusetts General Hospital, a tertiary care referral center, over a 12-year period from 1989 through 2000. Prior approval for this study was obtained from the appropriate institutional review board. Charts with a discharge diagnosis code 518.82 of the International Classification of Diseases, Ninth Revision, Clinical Modification⁵ suggesting ARDS not related to surgery or trauma, and a procedure code of 3328 (open-lung

Results

A total of 68 patients underwent open-lung biopsy for evaluation of ARDS during the time period of this review. One chart could not be obtained, one patient had no arterial blood gas studies performed, and nine patients were breathing without ventilatory assistance prior to surgery. Therefore, a total of 57 patients are included in this review. Of these patients, 51 patients (89%) underwent thoracotomy, and the remainder had a thorascopic procedure. Baseline features of these patients are

Discussion

In reviewing our experience with critically ill patients meeting the AECC definition of the ARDS, we have found open-lung biopsy to be useful and safe, often providing a diagnosis not previously suspected. This knowledge frequently led to the institution of specific therapies as well as the discontinuation of unnecessary (and potentially harmful) therapies. Given the retrospective nature of this study, it is impossible to determine whether these changes in therapy resulted in changes in

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The severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) pandemic has had devastating effects on global health and worldwide economy. Despite an initial reluctance to perform autopsies due to concerns for aerosolization of viral particles, a large number of autopsy studies published since May 2020 have shed light on the pathophysiology of Coronavirus disease 2019 (COVID-19). This review summarizes the histopathologic findings and clinicopathologic correlations from autopsies and biopsies performed in patients with COVID-19. PubMed and Medline (EBSCO and Ovid) were queried from June 4, 2020 to September 30, 2020 and histopathologic data from autopsy and biopsy studies were collected based on 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 58 studies reporting 662 patients were included. Demographic data, comorbidities at presentation, histopathologic findings, and virus detection strategies by organ system were collected. Diffuse alveolar damage, thromboembolism, and nonspecific shock injury in multiple organs were the main findings in this review. The pathologic findings emerging from autopsy and biopsy studies reviewed herein suggest that in addition to a direct viral effect in some organs, a unifying pathogenic mechanism for COVID-19 is ARDS with its known and characteristic inflammatory response, cytokine release, fever, inflammation, and generalized endothelial disturbance. This study supports the notion that autopsy studies are of utmost importance to our understanding of disease features and treatment effect to increase our knowledge of COVID-19 pathophysiology and contribute to more effective treatment strategies.
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Improved tools have led to a burgeoning understanding of lung regeneration in mice, but it is not yet known how these insights may be relevant to acute lung injury in humans. We report in detail two cases of fulminant idiopathic acute lung injury requiring extracorporeal membrane oxygenation in previously healthy young adults with acute respiratory distress syndrome, one of whom required lung transplantation. Biopsy specimens showed diffuse alveolar injury with a striking paucity of alveolar epithelial regeneration, rare hyaline membranes, and diffuse contiguous airspace lining by macrophages. This novel constellation was termed diffuse alveolar injury with delayed epithelization. In addition, mirroring data from murine models of lung injury/regeneration, peribronchiolar basaloid pods (previously described as squamous metaplasia) and ciliated bronchiolarization were identified in these patients and in 39% of 57 historical cases with diffuse alveolar damage. These findings demonstrate a common and clinically relevant human disease correlate for murine models of severe acute lung injury. Evidence suggests that peribronchiolar basaloid pods and bronchiolarization are related spatially and temporally and likely represent overlapping sequential stages of the response to severe distal airway injury.

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This work was performed at the Pulmonary and Critical Care Unit, Massachusetts General Hospital.

Support was provided by departmental funds.

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Chest

Clinical Investigations in Critical CareThe Role of Open-Lung Biopsy in ARDS

Study objectives

Design

Setting

Patients

Interventions

Measurements and results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Chest

The American-European Consensus Conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination

Am J Respir Crit Care Med

Prognostic significance of histopathologic subsets in idiopathic pulmonary fibrosis

Am J Respir Crit Care Med

The American-European Consensus Conference on ARDS, part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling

Am J Respir Crit Care Med

Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial

JAMA

The International Classification of Diseases, 9th Revision, Clinical Modification: ICD-9-CM Vols. 1 and 3

Clinical Investigations in Critical Care
The Role of Open-Lung Biopsy in ARDS