<h3>Purpose</h3> With the advent of transbronchial biopsy (TBB), open lung biopsy (OLB) has played a smaller role in surveillance of pediatric lung transplant recipients. We review our experience with diagnostic OLB at a high-volume institution. <h3>Methods</h3> Pediatric lung transplant recipients undergoing OLB from 2008-2020 were reviewed to identify preoperative characteristics, indications, and outcomes. Patients requiring intubation or increased oxygen were deemed "respiratory failure". We performed Cox univariate analysis to identify risk factors for one-year retransplant-free survival. Data are expressed as percent or median (interquartile range). <h3>Results</h3> Of 128 patients transplanted from 2008-2020, 32(25%) had subsequent OLB. The most common indications were respiratory failure (15/32, 46.9%) and bronchiolitis obliterans (9/32, 28.1%) (Table). 28 patients (87.5%) had a median of 5 (2-9) TBB prior to OLB. 28/32 (87.5%) patients' treatments were adjusted following OLB, with most requiring immunosuppression changes. 5/32 (15.6%) of patients died in-hospital; one died 3 days after discharge. Mechanical ventilation at OLB was associated with decreased one-year transplant-free survival. 24 patients were followed up for 2.3 (0.6-4.9) years. One-year transplant-free survival was 44% (30-65%) (Figure). Only 7 (29.2%) remained alive at latest follow-up, including one retransplanted patient. <h3>Conclusion</h3> Although OLB is useful for making new diagnoses and treatment adjustments, it is currently used in sicker children in whom less invasive diagnostic approaches have failed. 66% of patients undergoing OLB were retransplanted or died within 1 year.