olb (open lung biopsy) in ards - home - critical care ... · open lung biopsy at the bedside in the...
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OLB (Open Lung Biopsy) in
ARDS
Claude GUERIN MD PhD
Réanimation Médicale
Hôpital de la Croix-Rousse
Université de Lyon
Lyon, France
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CCF Toronto
October 28th 2012
Disclosure
No conflict of interest for this talk
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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
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Time course of major pathological changes
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Barghava
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ACUTESUBACUTE
CHRONIC
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
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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
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How can OLB be done in ARDS?
Trans-bronchial
Trans-thoracic
Open Lung Biopsy
◦ At the bedside
◦ In the operating room
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Lung fibrosis associated with higher
mortality in ARDS
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1995
Mortality 0/8 8/14
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
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Small wound
Direct lung visionLarge sample
staples
lung
Risks of OLB
Air leaks
Hemorrhage
Infection
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Post procedure care in our ICU
Chest tube: continuous suctioning -20 cmH2O
Wound care: twice/day
Chest X Ray: daily
Staples removed by D10 (D21 if steroids)
Chest Tube removed by D5
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WHAT ARE THE DATA IN THE LITERATURE ?
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In early ARDS stage
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Patel Chest 2004
60%Period 1989-2000
N0 OLB 57
Thoracotomy/Thoracoscopy 51/6
Bedside/other NA
Timing from ICU
admission/intubation (days)
7/4
Treatment alteration 97%
Complications 39%
Mortality 47%
In early ARDS stage
CCF 2012 15Kao CC 2006
Period 1999-2005
N0 OLB 41
Thoracotomy/Thoracoscopy 41
Bedside/other 15/26
Timing from ICU
admission/intubation (days)
NA/3
Treatment alteration 73%
Complications 20%
Mortality 50%
29%
In early ARDS stage
CCF 2012 16Baumann Surgery 2008
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%
ARDS in immunodeficient patients
CCF 2012 17Charbonney J Crit Care 2009
Period 1993-2005
N0 OLB 19
Thoracotomy/Thoracoscopy 19/
Bedside/other 19/
Timing from ICU
admission/intubation (days)
NA/5
Treatment alteration 89%
Complications 26%
Mortality 90%
BMT or autologous
stem cells
7
Steroids 7
Chemotherapy 2
Long term
immunosuppressive
agents
1
No
immunodeficiency
2
Contributed to end-of-life decision in 12 out of 17 patients who died
100 consecutive OLB in ARDS
patients with negative BAL
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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
100 consecutive OLB in ARDS patients with negative
BAL
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Papazian CCM 2007Fibrosis 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
1
Acute eosinophilic pneumonia 1
Carcinomatous lymphangitis 2
Micro-angiitis 1
CCF 2012 20Papazian et al. CCM 2007
Contributive
Non contributive
Odds ratio and day 28 survival
OLB = 18.66
Female gender = 16.37
OSF = 0.23
Let’s share our experience in this
field
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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
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Histo-pathological findings
◦ Organizing Pneumonia (OP) only in
16 patients
◦ DAD in 43
◦ OP + Fibrosis 4
◦ IPF 22
◦ Miscellaneous 15
◦ Pneumonia 5
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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]
OLB features
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Organ. pneu
(n=16)
DAD
(n=43)
Days to OLB from ICU
admission10 [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]
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Survival analysis
HR Lower
95% CI
Higher
95% CI
P value
Organ.Pneu 0.35 0.12 1.01 0.053
SAPS II 1.03 1.01 1.06 0.012
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Case study
Thirty-two-year old male
Severe denutrition BMI 16 kg/m2 - 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 underVCV 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?
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