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.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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