Criteria for Open Lung Biopsy: Focusing on Patients With AIDS

Abstract

To the Editor: The retrospective review by LoCicero entitled, “Does Every Patient With Enigmatic Lung Disease Deserve a Lung Biopsy? The Continuing Dilemma” (CHEST 1994; 106:706-11) attempts to define candidates regardless of underlying clinical disease who could best benefit from open lung biopsy (OLB). We appreciate the reference and use of our article, which focuses on OLB in patients with AIDS.1Trachiotis GD Hafner GH Hix WR et al.Role of open lung biopsy in diagnosing pulmonary complications of AIDS.Ann Thorac Surg. 1992; 54: 898-902Abstract Full Text PDF PubMed Scopus (15) Google Scholar Unfortunately, the premise and message of our work is misquoted and underemphasized. Our article attempted to define which patients with AIDS and an ongoing pulmonary process would have clinical benefit from OLB. This still is an important issue nationwide, since AIDS continues to be a major disease and these patients are presenting with more complex diseases, particularly within the lung parenchyma. Since our article, we have performed OLBs on another 35 to 50 patients and have found our criteria very useful. Our criteria for OLB are (1) nondiagnostic bronchoscopy, with or without deteriorating clinical status; (2) diagnostic bronchoscopy with failure to respond to medical therapy, with or without deteriorating clinical status; (3) nondiagnostic bronchoscopy with deteriorating clinical status; (4) failure to yield a pathogen after repeat bronchoscopy or failure of radiologic improvement for any of the above; and (5) respiratory failure or mechanical ventilation are contraindications for OLB. Only about 10% of AIDS patients with pulmonary complications will ultimately undergo OLB. Fiberoptic bronchoscopy with lavage and brushings, and transbronchial biopsy are still the mainstay for diagnosing diffuse pulmonary infiltrates in these patients. High-resolution thoracic computed tomography scanning can also provide useful information. As our paper clearly states, and LoCicero concludes, the recommendation for OLB ultimately should be individualized and based on underlying clinical status. We do not imply that OLB is fine for all patients that are not ventilated, but state that most deaths in patients with AIDS undergoing OLB are because of the underlying disease process, yet there is a select group of patients with AIDS that can tolerate OLB with an acceptable mortality and clinical outcome. Using our criteria, our operative mortality rate is less than 8%. Our diagnostic algorithm is useful for a coordinated treatment plan among the medical, pulmonary, radiologic, infectious disease, and thoracic surgical services. Our experience and data have shown,1Trachiotis GD Hafner GH Hix WR et al.Role of open lung biopsy in diagnosing pulmonary complications of AIDS.Ann Thorac Surg. 1992; 54: 898-902Abstract Full Text PDF PubMed Scopus (15) Google Scholar like others,2Wachter RM Lace JM Lo B et al.Life-sustaining treatment for patients with AIDS.Chest. 1989; 95: 647-652Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar,3Peters SG Meadows JA Gracey OR Outcome of respiratory failure in hematologic malignancy.Chest. 1989; 94: 99-102Abstract Full Text Full Text PDF Scopus (100) Google Scholar and LoCicero that AIDS patients with respiratory deteriorations or mechanical ventilation have an overall mortality in the ICU between 86 to 100%. Although we believe the ICU can provide short-term improvement in some AIDS patients with respiratory failure, we do not believe OLB can benefit these patients. We have also not found thoracoscopic biopsy a safer approach, as most of the patients we see can barely tolerate intubation, let alone any component of single-lung ventilation. We agree that diagnostic procedures in critically ill patients is becoming a more common problem. As LoCicero states, each patient has unique circumstances, and in reference to patients with AIDS, the ability to perform OLB should be weighed with both therapeutic and clinical outcome. It is our policy that when an AIDS patient's status deteriorates, issues regarding diagnostic procedures, predicted therapeutic outcome, diagnosis and survival, and aggressive ICU care, including mechanical ventilation should be discussed with the patient.1Trachiotis GD Hafner GH Hix WR et al.Role of open lung biopsy in diagnosing pulmonary complications of AIDS.Ann Thorac Surg. 1992; 54: 898-902Abstract Full Text PDF PubMed Scopus (15) Google Scholar This is particularly true in a population whose survival is measured in weeks to months. We believe this approach helps both patients and clinicians plan future treatment and evaluate its consequences in a rational, efficacious, and humane way.