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 2012 1
Disclosure No conflict of interest for this talk CCF 2012 2
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 2012 3
Time course of major pathological changes ACUTE SUBACUTE CHRONIC Barghava Trans Res 2012 CCCF 2012 4
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 2012 5
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 2012 6
How can OLB be done in ARDS? Trans-bronchial Trans-thoracic Open Lung Biopsy At the bedside In the operating room CCF 2012 7
Lung fibrosis associated with higher mortality in ARDS 1995 Mortality 0/8 8/14 CCF 2012 8
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 2012 9
Large sample Small wound Direct lung vision lung staples CCF 2012 10
Risks of OLB Air leaks Hemorrhage Infection CCF 2012 11
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 2012 12
WHAT ARE THE DATA IN THE LITERATURE? CCF 2012 13
In early ARDS stage 60% Period 1989-2000 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 2012 14
In early ARDS stage Period 1999-2005 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 2012 15
In early ARDS stage Period 1997-2005 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 2012 16
ARDS in immunodeficient patients Period 1993-2005 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 2012 17
100 consecutive OLB in ARDS patients with negative BAL Period 1996-2003 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 2012 18
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 2012 19
Contributive Odds ratio and day 28 survival Non contributive OLB = 18.66 Female gender = 16.37 OSF = 0.23 Papazian et al. CCM 2007 CCF 2012 20
Let s share our experience in this field CCF 2012 21
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 2012 22
Histo-pathological findings Organizing Pneumonia (OP) only in 16 patients DAD in 43 OP + Fibrosis 4 IPF 22 Miscellaneous 15 Pneumonia 5 CCF 2012 23
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 2012 24
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 [137-268] 131 [104-153]* 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 2012 25
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Survival analysis HR Lower Higher P value 95% CI 95% CI Organ.Pneu 0.35 0.12 1.01 0.053 SAPS II 1.03 1.01 1.06 0.012 CCF 2012 27
Case study Thirty-two-year old male Severe denutrition BMI 16 kg/m 2-45 kgs Chronic alcoholism Active smoker Admitted for hypoxemia
Intubated for acute severe hypoxemia a few hours after left thoracic drainage
At day 8 after intubation PaO2/FIO2 234 mmhg under VCV but tachypneic and not weanable
OLB on day 9 Organizing pneumonia Steroids 1 mg/kg/day Rapid improvement in ABG and chest-x ray Extubation 9 days later
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 2012 32