Open Lung Biopsy

Reviewed and revised 12 September 2014

OVERVIEW

• Biopsy should be taken from a representative area, not one with a high likelihood of non-specific fibrosis (eg. dependent segments of RML)
• Biopsy should not be performed too late in disease process
• Risks versus utility of information gathered must be weighed carefully

INDICATIONS

Useful in the investigation of diffuse pulmonary infiltrates in the following situations:

• cause is not known
• patient not responding to management
• another specific disease that would require different management is suspected
  (e.g. disseminated malignancy, alveolar haemorrhage, Bronchiolitis Obliterans Organising Pneumonia/Cryptogenic Organising Pneumonia)
• diagnosis not able to be made by less invasive tests (e.g. BAL, VATS)
• determination of prognosis
• potentially able to stop harmful/expensive medication and/or introduce others (ie. high dose corticosteroids)

ADVANTAGES

• sensitivity and specificity of 95%
• early OLB seems to be useful in critically ill patients with isolated respiratory failure
• useful in patients with rapidly progressive disease or conditions that make the risk of bronchoscopy unacceptably high, such as severe hypoxemia, bleeding diathesis or cardiac compromise
• Interstitial pneumonia appears to be the most common cause of diffuse lung infiltrates in critically ill based on OLB results
• leads to a change in management in about 2/3 cases

DISADVANTAGES

• rarely performed
• invasive

Complications

• intraoperative hypoxia
• Persistent air-leak from the biopsy site appears to be the most important complication of OLB in critically ill
• Transient atelectasis
• Pneumonitis
• Serous effusions, empyema, and hemorrhage
• sampling error (limited tissue removed)
• operative mortality rate for OLB ~ 1.5%

EVIDENCE

• Limited evidence
• Most studies are retrospective with small patient numbers
•  Information obtained from OLB has little effect on subsequent hospital (30%) or 1-year (10%) survival

References and Links

Journal articles

• Flabouris A, Myburgh J. The utility of open lung biopsy in patients requiring mechanical ventilation. Chest. 1999 Mar;115(3):811-7. PMID: 10084496. [Free Full Text]
• Lim SY, Suh GY, Choi JC, Koh WJ, Lim SY, Han J, Lee KS, Shim YM, Chung MP, Kim H, Kwon OJ. Usefulness of open lung biopsy in mechanically ventilated patients with undiagnosed diffuse pulmonary infiltrates: influence of comorbidities and organ dysfunction. Crit Care. 2007;11(4):R93. PMC2206485.