Certainly. As long as you can maintain adequate oxygenation during the procedure and the biopsy will likely produce meaningful info for the disease management, why not.

De novo acute respiratory failure in a previously healthy immunocompetent individual is frustrating. BAL should eliminate 95% of all bacterial and fungal infections. Serum titers for potential pathogens suggested by a careful history may catch viruses. Negative results might lead one to consider biopsy, but during an acute phase, the pathologist may have difficulty finding a definitive diagnosis in the background of the changes of acute lung injury.

In spite of the above, one may still desire a piece of lung. When asked to do so, I review the case and images with the treating physician, the pulmonologist, and the radiologist. We agree on the location for biopsy, usually the lower lobe. In cases of dense consolidation, I have done trans bronchoscopic biopsies, even on ventilated patients without complications. If I do an open biopsy, I do it in the OR with the patient in the same ICU bed. I use an anterolateral non-rib spreading incision using endoscopic stapling. I divide off a piece that I will send to the clinical laboratory and I bring the pathology specimen to the pathologist, since many have their own protocols for preparing the lung for histologic evaluation. For the clinical laboratory, I establish a protocol with the chief. I bring the portion directly to the lab and allow them to divide it into appropriate pieces for the following: aerobic and anaerobic culture, fungal culture, acid fast bacilli culture, PCP evaluation and viral isolation for respiratory pathogens.

Despite this rigorous approach, we arrive at a new diagnosis only about 25% of the time.

It very much depends on the clinical circumstances. Trans-bronchial biopsy is associated with the risk of pneumothorax - undesirable in a mechanically-ventilated patient - so we are really talking about open lung biopsy or trans-thoracic thoracoscopic lung biopsy (both of which require GA).

In situations where there is a diagnostic imperative, particularly if a reasonably firm diagnosis is not established on other grounds, and the therapeutic options may be detrimental rather than beneficial, then it is absolutely the correct way forward. For example if the underlying diagnosis could be infection OR eg pulmonary vasculitis, 'blind' treatment with high-dose steroids might harm one but help the other.

In my opinion the respiratory physician should be involved early, rather than when the patient is already on a cocktail of different types of drugs, and certainly before high dose steroids (eg Solumedrone) are given blindly. These drugs in particular will also alter the biopsy histological picture in a relatively short period.

So in short, yes, in the right patients, and a decision re biopsy made EARLY before the patient's condition deteriorates too far or they are blindly given every 'heavy' drug under the sun!

Usually we, thoracic surgeons, are asked to perform the biopsy in the acute patient, with abnormal findings in chest CT. I always discuss the case with the treating physician and pulmonologist. If BAL and laboratory findings are not diagnostic of any disease, the patient is not improving and the chest CT shows an abnormality in lung parenchyma that we think is the cause of respiratory failure, we indicate the lung biopsy. Usually in the Operating Room, at the same ICU bed, using videothoracoscopy; but, if the patient is extremely ill, and the transport from ICU to the OR represents a great risk, we do perform the biopsy in the ICU (notice that this is not the common approach). In this case, the surgeon must have experience and everything should be prepared befor skin incision; when doing this way, the procedure rarely takes more than 12 minutes, including skin closure. I always send a specimen to histopathology, and cultures for bacteria (aerobic and anaerobic), fungal infection and tuberculosis.

By all means. when everything else fails, one does not have a clue about what is going on, and the condition is not improving or even deteriorating, occasionally there is no other option but surgical lung biopsy. It can be obtained via VATS or even at the bedside in high risk patients. As a precise diagnosis is expected in 95-99% this is clearly and advantage , although the procedure is, needless to say risky and may increase morbidity and mortality . Therefore the suitable candidate selection has to be very careful, but nevertheless, in several cases unexpected diagnoses are established and the therapeutic choices may be different from those already in use

Hans Jorg's original question related to the value of lung biopsy, however viruses and atypicals are obviously important in 'unexplained' ALI/ARDS. In general these should be fairly rapidly diagnosed by washings/BAL serology/culture.

Here histological appearances on VATS Bx are not often diagnostically-incisive (advice from a lung pathologist here??) in these circumstances. For example in the recent Edinburgh Legionella outbreak, the diagnosis was mostly rapidly achieved by early serology based on suspicion, and specific treatment was promptly instituted. The overall mortality in the outbreak was lower than normally expected as a result of this together with excellent ICU management.

Having said that, there are circumstances in which OLB/VATS Bx is valuable in a patient deteriorating with unexplained ARDS before resorting to 'blunderbuss' empirical drug therapies.

Although I hate to rely on personal anecdote, I well remember such an example from when I was working at Hammersmith Hospital in the 19980s. The patient was in her 20s and had been on a regular 5mg dose of prednisolone for an unrelated condition. The CXR appearances were suggestive of PCP, but two BALs and a bronchoscopic bronchial (not transbronchial) Bx had not proved the diagnosis. She had an OLB (in those days), the histology of which showed the typical features of PCP. Aggressive specific anti-PCP therapy was instituted, and the patient eventually recovered.

So, in my opinion, there are circumstances in these conditions where judicious VATS/OLB is justified, and a plan as to when it should be done is discussed early, rather than waiting until the patient is almost moribund and is already being treated with blunderbuss empirical therapy (anti-bacterials, anti-atypicals, anti-virals and even ant-TB drugs) and high dose steroids which distort the histological picture.

As a neonatologist I never had a chance to request a open lung biopsy since such a sick kid will not be able to tolerate the procedure (most of us think that way). Most moribund or extremely difficult neonates under ventilator require DNA study for surfactant, or its associated proteins, production disturbance.

I don't think that the patient suffer with acute lung injury will benifit more from surgical lung biospy. first, when a patients is under going invasive mechanical ventilation, he is critical ill, and the status of health is very unstable. he probably may not suffer the surgery, although the operation is limited mostly. second, the biospy probably may produce no useflu info. then, the treatment can not be guided by the biospy.

Several years ago we reviewed 20 consecutive cases of persistent bilateral infiltrates in mechanically ventilated patients who underwent open lung biopsy. All 20 had negative BALs prior to OLB. One case of focal CMV was discovered on lung biopsy, three non specific vasculitis and the remainder had DAD or COP. There were three significant post op air leaks that persisted. Based on our review we felt that open lung biopsy did not significantly add to the care of our patients. Therefore we reserve consideration of OLB to patients who have a negative BAL, negative vasculitis serology and have failed a course of corticosteroids.

It is a very real and challenging dilemma if and when to opt for surgical lung biopsy in a ventilated patient. In terms of my expeirence, it is useful in selected cases where the management is going to be significantly altered by histology. I have found it useful in circumstances where patient has had first presentation of ILD with rapid ventilatory failure and the question is to differentiate it from acute vasculitis/ infection and immunosuppression is felt hazardous if infection is the cause of respiratory failure. Agree it is a very contentious topic and thanks for highlighting it on this forum...

It's always a great loss of time and will nearly never give a clue to help the patient and , last but not least, it can worsen even kill the patient: we NEVER do such a biopsy in the institution where I work.

we perform bedside surgical biopsy.

when? in the second week of ARDS if we suspect a fibrotic evolution (decreased compliance and worsened blood gases)

Why to justify cortico steroides and sometime we can find virus (CMV)

papazian and all published a great paper about this.

we don't use fiberoptic our scan biopsy because the risk of pneumothorax is high

OLB in patiens undergoing MV with PEEP and possibly on extracorporeal respiratory support (veno-venous blood perfusion) carries a high risk of bronchopleural fistula, tension pneumothorax and in the latter bleeding which can be life threatening ! In our experience (see Lewandowski et al) we used a minithoracotomy (done in the ICU) with good vision for the surgeon and best possible control of bleeding vessels. In the nineties we did OLBs quite frequently and we often found significant fibrosis also in the patients who survived. I do not think that possibility of lung fibrosis per se justifies an open lung biopsy. More recently OLB has become rare in our hands.

OLB is stil a subject of controverse although it was studied in many published articles. Actually, we have worked recently on this subject and our manuscript has been submitted. OLB should be considered when all other less invasive procedures have failed to reach a diagnosis. But I can say that Although OLB provides a specific diagnosis in the majority of mechanically ventilated patients, it is unclear if this procedure improves overall survival. A specific diagnosis of irreversible disease could be particularly helpful for the medical team and patient’s family, since it avoids prolonging unnecessary treatment. Furthermore, OLB can lead to alteration of the trearment at a considerable number of patient. However, the survival or final outcome can not be predicted.

One of the known causes of acute exacerbation of IPF/ILD is an open lung biopsy. That adds to the already high surgical rsik of the procedure in someone on a ventilator. We do not do it at our hospital, but on the negative side, are often instead forced to start empirical treatments like co-trimoxazole for suspected PCP.

Why do you want to add a pneumothorax?

No not at least in our set up

Well, as stated above , one has to consider the risk- benefit ratio and make a decision in the best interest of the patient.

although anecdotal , I recall a colleague of mine who has returned from a trip in India , with a high grade fever, progressive shortness of breath and progressing pulmonary infiltrates. despite wide antibiotic coverage .He developed an episode of severe SOB necessitating mechanical ventilation. After many ardent discussions we opted for an Open Lung Biopsy (minithoracotomy ) It turned out that he has had a combination of Pulmonary embolism ( seen only when looked for speciifcally on CT) and Organizing Pneumonia. Mycoplasma serology also was positive .

He has had a very favorable outcome , treated with ttherapeutic anticoaguation and cortocosteroids .

As I've seen also grim outcomes , I reserve surgical biopsy for those cases in whom there is a fair chance that management could be altered by the result and no other option is available. Bronchoscopy is easier to do but bears considerable risk in these very sick patients and I think that some of these patient tolerate the surgery remarkably well. So one has to think this through very thoroughly, advisably conduct a multi-specialist team discussion on pro and cons , but do not hesitate if there is hope that you'll make a difference given the results

There are very limited treatment options in ventilated patients with interstitional or alveolar affections and clinlcal and less invasive investigatory tools narrow the diagnostic spectrum so that to our experience Open biopsie is never needed. Given the huge impact of invasive ventilation treatment should be focused rather on less invasive Ventilation than on improving the lung.

In our institutional experience, when the biopsy is done for a patient who is in an outpatient setting it usually provides useful information and a therapeutic change for over 50% of the patients. For critically ill and mechanically ventilated patients that require high PEEP and FiO2, perhaps it is too late and surgical intervention not only adds insult to injury but also doesnt change much in terms of therapy. Our mortality rate for outpatients is 0% and for ICU patients jumps to 45%.

I agree with Dr Parekh that a biopsy in a mechanically ventilated patient is seldom helpful to aid management and may be associated with increased mortality. Our experience with ILD patients is a change in the diagnosis in 30% or so with VATS biopsy when HRCT is not very definitive....

I think that is not has been mentioned the endobronchial ultrasound biopsy (EBUS)

I have indicated surgical biopsy in very limited occasions. In this context the frequent diagnosis is opportunists infection, but neoplasia or drug reactions must be considered. A detailed clinical history is mandatory, but when the serologic information and BALF are negative, the empirical treatment with a wide antibiotic coverage plus corticosteroids must be considered. In this context, I have reserved surgical biopsy only for very selective cases. I.e., a patient with strongly suspicion of proteinosis alveolar in a TC with negative BALF (!!) and severe respiratory faillure, diagnosis was obtain by VATS.

Our center experience is so bad that we consider mechanical ventilation as an absolute contraindication (except extraordinary situations such as patients on ECMO).

In selective cases where the clinical diagnosis is not clear e.g. in immunosuppressed/post transplant cases this can be helpful.

The risks (and benefits)can be overstated, so we are highly selective.

De acuerdo con muchas de las opiniones.

Realicé biopsias en UCI.

Estamos hablando de "pacientes críticos con ventilación mecánica invasiva".

1.-Vi pacientes a los que no pude retirar el drenaje pleural por fuga aérea contínua hasta su muerte.

2.-Vi pacientes a los que se colocó un drenaje pleural de urgencia por neumotórax hipertensivo y gran enfisema subcutáneo. Habia que explicarlo a los familiares.

3.-Ví pacientes con infección pleural por largo tiempo con el drenaje.

4.-Vi demasiados pacientes que los patólogos solo podian diagnosticar de Fibrosis pulmonar y nada mas.

5.-La irreversibilidad del proceso solo servía para considerar ¿suprimir la respiración asistida ?. ¿El transplante pulmonar ?.

Desde hace años trato de que no me convenzan en realizarla.

Regarding the current topic (usefulness and safety of open lung biopsy in ARDS of unknown origin) very recently a meta-analysis was published:

Ann Thorac Surg. 2014 Oct;98(4):1254-60. doi: 10.1016/j.athoracsur.2014.05.029. Epub 2014 Jul 25.

Surgical lung biopsy in adult respiratory distress syndrome: a meta-analysis.

Libby LJ1, Gelbman BD2, Altorki NK3, Christos PJ4, Libby DM2.

The authors conclude that OLB is a potentially productive procedure in this scenario with probably no significant increase in complication rate.

I believe this work is a good summary of the currently available evidence regarding this technique. As the number of suitable cases (in our experience roughly 2-4 patients per year in a very active intensive care department) will be too low to see an adequately powered RCT to finally answer the question, the question will probably not be answered on the grounds of RCTs.

In the absence of RCTs, the presented data at least allow to consider OLB in highly selected patients. It is obvious that in highly vulnerable, critically ill patients with ARDS any invasive procedure needs to be very carefully evaluated in terms of potential risks and benefits. If the expected benefit of additional diagnostic information retrieved by performing OLB is judged to be greater than the albeit limited but always relevant risk of the procedure, than OLB appears to be adequate. 

To responses to previous posts to this question (awfully late…):

To respond to the post bei Dr. Rafael Martinez-Giron: Use of EBUS may help if malignancies are suspected or occasionally to identify an infectious agent that can be detected in lymph node samples. However, in most cases of ARDS of unknown origin non-specific lymph node enlargements can be seen. In these cases, EBUS-FNA will be of little help.

To respond to the post by Dr. Xosé Pérez: In our institution (my former place of work: University Medical Center Hamburg-Eppendorf), use of ECMO is considered a contraindication for OLB due to (at least according to our experience) the increased risk of bleeding in this patient population.

Actually, I consider OLB is a short cut and precise way to reach a diagnosis in diagnosed pulmonary patient with radiological problem. However, benefits should be weighted against risks.

Actually, I consider OLB is a short cut and precise way to reach a diagnosis in diagnosed pulmonary patient with radiological problem. However, benefits should be weighted against risks.