OLB (Open Lung Biopsy) in

ARDS

Claude GUERIN MD PhD

Réanimation Médicale

Hôpital de la Croix-Rousse

Université de Lyon

Lyon, France

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CCF Toronto

October 28th 2012

Disclosure

No conflict of interest for this talk

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Causes of ARDS

DIRECT (primary)

◦ Lung infections

Bacterial

Viral (H1N1)

Fungal

◦ Lung aspiration

◦ Near-drowning

◦ Trauma

◦ Smoke inhalation

INDIRECT (secondary)

◦ Sepsis

◦ Blood transfusions

(TRALI)

◦ Drugs

◦ Vascularitides, systemic

diseases

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Time course of major pathological changes

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Barghava

Trans Res 2012

ACUTESUBACUTE

CHRONIC

What is expected from OLB in ARDS?

To assess diagnosis of ARDS

◦ Identification of pathological hallmark of ARDS:

Diffuse Alveolar Damage (DAD)

◦ To rule out other diseases (ARDS mimickers)

To assess ARDS stage

To assess VAP (gold standard)

To contribute to management

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How can OLB contribute to management?

Starting specific new drugs

◦ Steroids

◦ Immunosuppressive drugs

◦ Anti-infectious drugs

Stopping not useful medications

Contributing to end-of-life decision

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How can OLB be done in ARDS?

Trans-bronchial

Trans-thoracic

Open Lung Biopsy

◦ At the bedside

◦ In the operating room

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Lung fibrosis associated with higher

mortality in ARDS

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1995

Mortality 0/8 8/14

Advantages of OLB

Safe

◦ CT scan-oriented

◦ Direct lung visualization under thoracotomy

◦ Easier Control of aerostasis

◦ Selective intubation not required

Large tissue samples

Feasible at the bedside

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Small wound

Direct lung visionLarge sample

staples

lung

Risks of OLB

Air leaks

Hemorrhage

Infection

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Post procedure care in our ICU

Chest tube: continuous suctioning -20 cmH2O

Wound care: twice/day

Chest X Ray: daily

Staples removed by D10 (D21 if steroids)

Chest Tube removed by D5

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WHAT ARE THE DATA IN THE LITERATURE ?

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In early ARDS stage

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Patel Chest 2004

60%Period 1989-2000

N0 OLB 57

Thoracotomy/Thoracoscopy 51/6

Bedside/other NA

Timing from ICU

admission/intubation (days)

7/4

Treatment alteration 97%

Complications 39%

Mortality 47%

In early ARDS stage

CCF 2012 15Kao CC 2006

Period 1999-2005

N0 OLB 41

Thoracotomy/Thoracoscopy 41

Bedside/other 15/26

Timing from ICU

admission/intubation (days)

NA/3

Treatment alteration 73%

Complications 20%

Mortality 50%

29%

In early ARDS stage

CCF 2012 16Baumann Surgery 2008

Period 1997-2005

N0 OLB 27

Thoracotomy/Thoracoscopy 27

Bedside/other 18/9

Timing from ICU

admission/intubation (days)

NA/8

Treatment alteration 81%

Complications 59%

Mortality 48%

ARDS in immunodeficient patients

CCF 2012 17Charbonney J Crit Care 2009

Period 1993-2005

N0 OLB 19

Thoracotomy/Thoracoscopy 19/

Bedside/other 19/

Timing from ICU

admission/intubation (days)

NA/5

Treatment alteration 89%

Complications 26%

Mortality 90%

BMT or autologous

stem cells

7

Steroids 7

Chemotherapy 2

Long term

immunosuppressive

agents

1

No

immunodeficiency

2

Contributed to end-of-life decision in 12 out of 17 patients who died

100 consecutive OLB in ARDS

patients with negative BAL

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Period 1996-2003

N0 OLB 100

Thoracotomy/Thoracoscopy 100/

Bedside/other 64/36

Timing from ICU

admission/intubation (days)

7/11

Treatment alteration 78%

Complications 11%

Mortality 45%

Papazian CCM 2007

100 consecutive OLB in ARDS patients with negative

BAL

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Papazian CCM 2007Fibrosis 16

Fibrosis +infection 29

Infection 28

DAD 13

Miscellaneous

SLE 2

Bronchioalveolar carcinoma 1

Amiodarone toxicity 2

Intra-alveolar hemorrhage 1

Allograft rejection 1

Drug toxicity 2

Rheumatoid lung +mycobacterial

infection

1

Acute eosinophilic pneumonia 1

Carcinomatous lymphangitis 2

Micro-angiitis 1

CCF 2012 20Papazian et al. CCM 2007

Contributive

Non contributive

Odds ratio and day 28 survival

OLB = 18.66

Female gender = 16.37

OSF = 0.23

Let’s share our experience in this

field

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Patients

Between January 1st 1998 and July 2012, 105

OLBs were performed in our ICU

OLB performed due to need for persistent

mechanical ventilation or no identified cause

for ALI/ARDS/ARF

Focus on histo-pathological findings

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Histo-pathological findings

◦ Organizing Pneumonia (OP) only in

16 patients

◦ DAD in 43

◦ OP + Fibrosis 4

◦ IPF 22

◦ Miscellaneous 15

◦ Pneumonia 5

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Data entry

OP

(n=16)

DAD

(n=43)

Age (years) 67 [61-79] 65 [53-75]

Male gender 81.3% 70%

SAPS 2 37 [29-46] 42 [35-50]

Immunodeficiency 31.3% 14%

MEDIAN [IQR]

OLB features

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Organ. pneu

(n=16)

DAD

(n=43)

Days to OLB from ICU

admission10 [9-13] 10 [7-14]

Days to OLB from dyspnea 19 [12-20] 21 [14-30]

SOFA 5 [3-7] 9 [5-11]*

PaO2/FiO2 (mmHg) 194 [137-268] 131 [104-153]*

PEEP (cm H2O) 5 [0-8] 8 [5-10]

VT (ml/kg ibw) 6 [4-6] 6 [6-7]

OLB Complication 25% 28%

OLB at bedside 63% 72%

Contributive OLB 94% 58%*

*P < 0.05 MEDIAN [IQR]

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Survival analysis

HR Lower

95% CI

Higher

95% CI

P value

Organ.Pneu 0.35 0.12 1.01 0.053

SAPS II 1.03 1.01 1.06 0.012

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Case study

Thirty-two-year old male

Severe denutrition BMI 16 kg/m2 - 45 kgs

Chronic alcoholism

Active smoker

Admitted for hypoxemia

Intubated for acute severe hypoxemia

a few hours after left thoracic drainage

At day 8 after intubation PaO2/FIO2

234 mmHg underVCV but tachypneic

and not weanable

OLB on day 9

Organizing pneumonia

Steroids 1 mg/kg/day

Rapid improvement in ABG

and chest-X ray

Extubation 9 days later

Conclusions

OLB frequently contributed to altering treatment

Frequent but « mild » complications

Low level of evidence for recommendation (4 =

case series)

What should be the next step?

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