OLB (Open Lung Biopsy) in ARDS

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1 OLB (Open Lung Biopsy) in ARDS Claude GUERIN MD PhD Réanimation Médicale Hôpital de la Croix-Rousse Université de Lyon Lyon, France CCF Toronto October 28 th 2012 CCF

2 Disclosure No conflict of interest for this talk CCF

3 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 CCCF

4 Time course of major pathological changes ACUTE SUBACUTE CHRONIC Barghava Trans Res 2012 CCCF

5 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 CCF

6 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 CCF

7 How can OLB be done in ARDS? Trans-bronchial Trans-thoracic Open Lung Biopsy At the bedside In the operating room CCF

8 Lung fibrosis associated with higher mortality in ARDS 1995 Mortality 0/8 8/14 CCF

9 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 CCF

10 Large sample Small wound Direct lung vision lung staples CCF

11 Risks of OLB Air leaks Hemorrhage Infection CCF

12 Post procedure care in our ICU Chest tube: continuous suctioning -20 cmh 2 O Wound care: twice/day Chest X Ray: daily Staples removed by D10 (D21 if steroids) Chest Tube removed by D5 CCF

13 WHAT ARE THE DATA IN THE LITERATURE? CCF

14 In early ARDS stage 60% Period N0 OLB 57 Thoracotomy/Thoracoscopy 51/6 Bedside/other Timing from ICU admission/intubation (days) NA 7/4 Treatment alteration 97% Complications 39% Mortality 47% Patel Chest 2004 CCF

15 In early ARDS stage Period N0 OLB 41 Thoracotomy/Thoracoscopy 41 Bedside/other 15/26 Timing from ICU admission/intubation (days) NA/3 Treatment alteration 73% 29% Complications 20% Mortality 50% Kao CC 2006 CCF

16 In early ARDS stage Period 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% Baumann Surgery 2008 CCF

17 ARDS in immunodeficient patients Period N0 OLB 19 BMT or autologous stem cells 7 Thoracotomy/Thoracoscopy 19/ Steroids 7 Bedside/other 19/ Timing from ICU admission/intubation (days) NA/5 Treatment alteration 89% Complications 26% Mortality 90% Chemotherapy 2 Long term immunosuppressive agents No immunodeficiency 1 2 Contributed to end-of-life decision in 12 out of 17 patients who died Charbonney J Crit Care 2009 CCF

18 100 consecutive OLB in ARDS patients with negative BAL Period 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 CCF

19 100 consecutive OLB in ARDS patients with negative BAL Fibrosis 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 Acute eosinophilic pneumonia 1 Carcinomatous lymphangitis 2 1 Micro-angiitis 1 Papazian CCM 2007 CCF

20 Contributive Odds ratio and day 28 survival Non contributive OLB = Female gender = OSF = 0.23 Papazian et al. CCM 2007 CCF

21 Let s share our experience in this field CCF

22 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 CCF

23 Histo-pathological findings Organizing Pneumonia (OP) only in 16 patients DAD in 43 OP + Fibrosis 4 IPF 22 Miscellaneous 15 Pneumonia 5 CCF

24 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] CCF

25 OLB features Organ. pneu (n=16) DAD (n=43) Days to OLB from ICU admission 10 [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 [ ] 131 [ ]* 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] CCF

26 CCF

27 Survival analysis HR Lower Higher P value 95% CI 95% CI Organ.Pneu SAPS II CCF

28 Case study Thirty-two-year old male Severe denutrition BMI 16 kg/m 2-45 kgs Chronic alcoholism Active smoker Admitted for hypoxemia

29 Intubated for acute severe hypoxemia a few hours after left thoracic drainage

30 At day 8 after intubation PaO2/FIO2 234 mmhg under VCV but tachypneic and not weanable

31 OLB on day 9 Organizing pneumonia Steroids 1 mg/kg/day Rapid improvement in ABG and chest-x ray Extubation 9 days later

32 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? CCF