Transbronchial lung cryobiopsy may be of value for nonresolving acute respiratory distress syndrome: case series and systematic literature review

Guowu Zhou,Dan Wang,Zheng Tian,Xiaojing Wu,Shiyao Wang,Ye Tian,Qingyuan Zhan,Yi Zhang,Yingying Feng,Ling Zhao,Ying Li

doi:10.1186/s12890-020-01203-w

Abstract

BackgroundIdentification of pathologic features is helpful for the management of nonresolving acute respiratory distress syndrome (ARDS). Transbronchial lung cryobiopsy (TBLC) is a novel biopsy technique that may have comparable utility to surgical biopsy. The aim of this study was to assess the value of TBLC in patients with nonresolving ARDS.MethodsAll patients with nonresolving ARDS who underwent TBLC from January 2019 to August 2019 in a tertiary medical ICU were included. In addition, a literature search of TBLC for ARDS was performed by searching PubMed, EMBASE, ATS/ERS/APSR meeting abstracts, ClinicalTrials.gov, and Google Scholar. Data on complications, histologic diagnosis, management changes, and outcomes were analysed.ResultsFive patients (three women and two men) underwent TBLC. None of the patients developed pneumothorax, although two patients developed massive bleeding, which was controlled by continuous occlusion using bronchial blockers. There were no procedure-related deaths. Diffuse alveolar damage (DAD) and alternative histologic patterns were found in two and three patients, respectively, resulting in management changes in all cases. The literature search yielded four studies, which together with the present study comprised data from 25 cases in which TBLC was used in nonresolving ARDS. The summary diagnostic yield was 92% (23/25). Only 44% (11/25) of cases were proven to be DAD. TBLC contributed to management changes in 80% of patients (20/25). Procedure-related complications consisted of pneumothorax (16%, 4/25), significant bleeding (12%, 3/25), and persistent air leaks (8%, 2/25). There were no procedure-related deaths. The follow-up survival rate was 61.9% (13/21).ConclusionsThe complications of TBLC in selected patients with nonresolving ARDS may be acceptable. The procedure may have a high diagnostic yield and can lead to a re-evaluation of the diagnosis as well as changes in patient management. Further investigations with larger sample sizes are required.

Highlights

Identification of pathologic features is helpful for the management of nonresolving acute respiratory distress syndrome (ARDS)
Four of the patients were diagnosed with severe ARDS and one with moderate ARDS according to the Berlin definition
unfractionated heparin (UFH) was used in patients with extracorporeal membrane oxygenation (ECMO) but was stopped 4 h before Transbronchial lung cryobiopsy (TBLC) in one patient

Summary

Introduction

Identification of pathologic features is helpful for the management of nonresolving acute respiratory distress syndrome (ARDS). The aim of this study was to assess the value of TBLC in patients with nonresolving ARDS. Acute respiratory distress syndrome (ARDS) is common in critically ill patients. The Berlin definition of ARDS takes into account clinical and radiological criteria in the diagnosis and classification without considering pathologic findings [3]. Diffuse alveolar damage (DAD) is a typical pathological finding in ARDS [4], but it is not seen in all ARDS patients nor is it specific to the disease. Studies have shown that only 43–45% of ARDS patients have DAD [5,6,7,8]. Identifying the pathologic pattern in nonresolving ARDS can facilitate treatment decision-making and improve outcomes [6, 8]

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