Original article
General thoracic
Surgical Lung Biopsy in Adult Respiratory Distress Syndrome: A Meta-Analysis

https://doi.org/10.1016/j.athoracsur.2014.05.029Get rights and content

Background

Adult respiratory distress syndrome (ARDS) has a high mortality rate and consumes considerable health care resources. It is not clear whether specimens obtained from open lung biopsy (OLB) in ARDS provide a specific diagnosis, alter therapy, or affect outcome. This meta-analysis attempts to determine whether OLB is safe, provides a specific diagnosis, changes therapy, or affects survival.

Methods

A computerized search was performed of Medline and PubMed from January 1988 to December 2012 of English language studies of acute respiratory failure and diffuse pulmonary infiltrates that evaluated OLB in primarily adult mechanically ventilated patients. Of 194 abstracts retrieved, 64 articles were reviewed; 130 articles were excluded because they did not evaluate OLB. After applying the selection criteria, 24 articles were included.

Results

OLB in ARDS provided a specific diagnosis in 84% of patients and altered management in 73%. Hospital mortality was 43%. The complication rate for OLB in ARDS was 22%, but death from OLB was rare.

Conclusions

OLB in ARDS is a potentially productive procedure that provides a specific diagnosis and leads to a change in management in high proportions of patients. ARDS has a high mortality rate, which OLB does not appear to increase. Owing to a lack of randomized controlled trials, a survival advantage of OLB in ARDS could not be demonstrated.

Section snippets

Material and Methods

English language studies of acute respiratory failure and diffuse pulmonary infiltrates were eligible for the meta-analysis if they fulfilled the following criteria: original publication evaluating the use of OLB as a diagnostic tool and the inclusion of predominantly ventilated adult patients. Exclusion criteria were studies conducted solely on pediatric patients and studies that contained no ventilated patients. Five outcomes of interest were hospital mortality rate, surgical complication

Results

The frequency of making a specific diagnosis by OLB specimen was examined. The Cochrane Q statistical heterogeneity test had a p value of less than 0.0001. The random-effects (DerSimonian-Laird) pooled proportion for the specific diagnosis rate was 0.84 (95% confidence interval, 0.75 to 0.92; Appendix Table 2 and Fig 2A). One study was excluded due to lack of available data on specific diagnosis.

The frequency of each pathologic diagnosis is shown in Figure 3 (also see Appendix Table 3). The

Comment

Although diagnostic techniques such as BAL are commonly performed in patients with ARDS, they uncommonly lead to a specific diagnosis: 70% of patients had at least 1 bronchoscopy with BAL before OLB, but in only 10% was BAL was consistent with the pathologic diagnosis from OLB. The high mortality rate of ARDS without a specific diagnosis raises the question of whether OLB should be performed. Several studies (Appendix Table 1) have examined OLB in patients who are critically ill, mechanically

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