Transbronchial Lung Biopsy in Diffuse Pulmonary Disease

Abstract

The paper by Claude W. Smith and associates, “The role of transbronchial lung biopsy in diffuse pulmonary disease” (p 54, this issue) is unusual because it is presented by a group of thoracic surgeons who traditionally have favored open-lung biopsy. Their success in obtaining an apparently correct diagnosis in 34 of 40 patients (85%) compares very favorably with the results of open-lung biopsy, especially when the additional ”morbidity related to general anesthesia, chest tubes, and postoperative pain” (in addition to hospitalization and expense) is considered. Their success also compares very favorably with that of others who have used the transbronchoscopic technique. Our own success in obtaining diagnostic tissue using this technique in diffuse pulmonary diseases is 83% in 814 patients. We perform our procedures just a bit differently. We do not use roentgenological guidance for placement of forceps in diffuse bilateral pulmonary diseases. If lower lobes are involved equally as much as the upper lobes, we still prefer to use the rigid bronchoscope because the size of the forceps allows a larger biopsy. Our pathologists prefer to receive as much tissue as possible, short of the entire lung, which is hardly possible with this procedure. When the disease is limited to or maximal in the upper lobes, however, we do not hesitate to use the flexible fiberoptic bronchoscope even though the cup of the forceps is smaller. Our greatest number of failures among the 17% in whom diagnostic tissue was not obtained has been in the group with interstitial pneumonitis and fibrosis, particularly in the advanced phase of this disease when the lung is very fibrotic. In reviewing this group we have discovered characteristics that allow a diagnosis without biopsy. Early classic interstitial pneumonitis with fibrosis begins in the lower portions of the lungs. Roentgenographically, it starts in the supradiaphragmatic portions with the costophrenic angles involved. Late in the disease there is involve-