Trans-bronchial lung cryobiopsy in patients at high-risk of complications

Abstract

Background The surgical lung biopsy (SLB) is the recommended sampling technique when the pathological analysis of the lung is required in the work-up of an interstitial lung disease (ILD) but trans-bronchial lung cryobiopsy (TBLC) is increasingly recognized as an alternative approach. As TBLCs have lower mortality and morbidity risks than SLB, this study aimed to investigate the safety of TBLCs in patients at higher risk of complications and for whom SLB was not considered as an alternative. Method This prospective study was conducted in two hospitals in which TBLCs were performed in patients with body mass index (BMI) > 35, and/or older than 75 years, and/or with severely impaired lung function (FVC < 50% or DLCO < 30%), and/or systolic pulmonary artery pressure > 45 mmHg, and/or a clinically significant cardiac disease. Patients with any of these risk factors constituted the high-risk group. Clinical outcomes were compared with those obtained in patients without these risk factors (low-risk group). Results Ninety-six patients were included between April 2015 and April 2020, respectively 38 and 58 in the high-risk or the low-risk group. No statistically significant difference was observed between both groups in terms of severity and rate of bleeding, pneumothorax, or duration of hospital stay (p value ranging from 0.419 to 0.914). Conclusion This preliminary study on a limited number of patients suggests that TBLC appears safe in those in whom lung biopsy is at high-risk of complications according to their age, BMI, lung impairment, and cardiac comorbidities.

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

“…Regarding adverse events, the Task Force acknowledges that the variety of potential patients (and corresponding risk of performing TBLC) in this context is wide, and weighing the advantages and disadvantages of performing TBLC will vary accordingly. Limited evidence suggests safety in high-risk patients described in the study by BONDUE et al [36]. However, the risk of accelerating disease in patients who are critically ill or have rapidly progressive ILD, such as in the study by MATTA et al [35], may be unacceptably high.…”

“…In the same study by MATTA et al [35], pneumothorax occurred in 35.3% (n=6) and moderate bleeding in 5.9% (n=1), with 30-day ICU mortality of 47.1% (n=8; although, according to the authors, none directly attributable to TBLC). BONDUE et al [36] compared adverse events of TBLC in 38 patients with undiagnosed ILD at high risk of SLB (defined as age ⩾75 years, body mass index (BMI) ⩾35 kg•m −2 , systolic pulmonary arterial pressure (sPAP) by echocardiography ⩾45 mmHg, forced vital capacity (FVC) <50%, diffusing capacity of the lung for carbon monoxide (D LCO ) <30% and/or significant cardiac comorbidities with reduced heart ejection fraction) with 58 patients at low risk. Numbers of bleeding, pneumothorax, mortality and hospital stay were equal between both groups (see Narrative Question 2).…”

“…These vary, based on two non-comparative studies (table S1 in supplementary appendix S8) [35,36]. This was probably due to considerable differences in disease severity across included patients.…”

“…Pooling of data was not performed due to heterogeneity in study populations and reported outcomes. Three studies reported on adverse events in patients with lung function impairment, and one study compared adverse events in patients with more and less lung function impairment[35][36][37]49]. MATTA et al[35] included 17 critically ill patients with acute hypoxaemic respiratory failure, in whom pneumothorax occurred in 35.3% (n=6), moderate haemorrhage in 5.9% (n=1) and 8-day mortality (although not directly related to TBLC) in 47.1% (n=8).…”

A realist (re)view on surgical lung biopsy in interstitial lung disease: who, how, when and at what risk?

“…Relative contraindications of the procedure are severe lung function derangement, moderate or severe pulmonary hypertension, high bleeding risk, and/or significant hypoxemia (17,19). However, emerging data suggests that TBLC may be an option in some high-risk patients, particularly when performed in higher volume centres (21,22). It is important to note that application of the histopathological criteria for UIP is more challenging with TBLC specimen because subpleural changes might not be represented and the potential for sampling error (3).…”