European Respiratory Society guidelines on transbronchial lung cryobiopsy in the diagnosis of interstitial lung diseases

Abstract

BackgroundIn patients with interstitial lung diseases (ILD), histopathological input is often required to obtain a diagnosis. Surgical lung biopsy (SLB) is considered the reference standard, but many patients are clinically unfit to undergo this invasive procedure, and adverse events, length of hospitalization and costs are considerable. This guideline provides evidence-based clinical practice recommendations for the role of transbronchial lung cryobiopsy (TBLC) in obtaining tissue-based diagnosis in patients with undiagnosed ILD.Materials and methodsThe European Respiratory Society task force consisted of clinical experts in the field of ILD and/or TBLC, and methodological experts. Four PICO questions and two narrative questions were formulated. Systematic literature searches were performed in Medline and Embase (up to June 2021). GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology was applied.ResultsIn patients with undiagnosed ILD and an indication to obtain histopathological data: 1) TBLC is suggested as replacement test in patients considered eligible to undergo SLB, 2) TBLC is suggested in patients not considered eligible to undergo SLB, 3) SLB is suggested as add-on test in patients with a non-informative TBLC, 4) no recommendation is made for or against second TBLC in patients with a non-informative TBLC, and 5) TBLC-operators should undergo training, but no recommendation is made for the type of training required.ConclusionTBLC provides important diagnostic information in patients with undiagnosed ILD. Diagnostic yield is lower compared to SLB, at reduced serious adverse events and length of hospitalization. Certainty of the evidence is mostly “very low”.

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“…A transbronchial lung cryobiopsy (TBLC) is a bronchoscopic technique that allows larger pieces of tissue to be obtained in comparison with a conventional forceps biopsy by using a cryoprobe. Recent European Respiratory Society guidelines [ 33 ] consider a TBLC to be an acceptable alternative to a surgical lung biopsy (SLB) for a histopathological diagnosis in patients with ILD of an undetermined type in experienced centers as they have a similar sensitivity and specificity [ 34 , 35 ]. Compared with a surgical lung biopsy, a TBLC is less invasive and less expensive; the main complications are a pneumothorax (9%) and bleeding (30%) and the technology is not widely available.…”

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“…Rapid, accurate and minimally invasive diagnosis is paramount for both therapeutic intervention and prognostication in ILD patients. Whilst transbronchial cryobiopsy (TBCB) has been documented to be a promising alternative to surgical procedures in the diagnosis of ILD [ 48 ], there has been concern regarding the nondiagnostic rate and TBCB-related complications ( e.g. bleeding, pneumothorax and acute exacerbation of ILD) [ 49 ], which has hampered its further development.…”

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“…The recently updated ATS/ERS/JRS/ALAT clinical practice guideline for IPF and PPF ( 8 ) includes a conditional recommendation to regard TBLC as an acceptable alternative to surgical lung biopsy in centers with appropriate expertise. The 2022 ERS Guidelines on TBLC in the diagnosis of interstitial lung diseases recommend TBLC as either a replacement first test in patients considered eligible for surgical lung biopsy (SLB); or as an option for patients considered unsuitable for SLB ( 53 ). As such, consideration of TBLC is likely to become more widely adopted into the ILD MDM diagnostic paradigm.…”