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5. Video-assisted thorascopic surgery (VATS) biopsy
Studies have shown that video assisted thorascopic surgery has the highest yields in diagnosing undefined interstitial lung diseases (1,2). However in a cirrhotic with a MELD score of 13, Yeh et al. (3) demonstrated that the 30 day post-operative mortality is 25% and Park et al. (4) showed a 28.6% mortality rate if surgical biopsy was performed during the acute exacerbation. Therefore the risk of this elective procedure may far outweigh the value of the biopsy.
Transbronchial lung biopsy (TBLB) is frequently diagnostic in certain forms of ILD for example granulomatous lung disease, but in most cases, the tissue retrieved is often inadequate or nondiagnostic (6), and the risk of complications are higher with TBLB than with BAL (7,8).
The American Thoracic Society practice guidelines (9) state that there is insufficient data to confirm that BAL cell analysis is beneficial in the diagnosis of certain types of ILD and, therefore it is impossible to fully weigh the potential benefits against the risks, costs, and burdens of the procedure. The decision to perform BAL should be made on a case by case basis.
Hospital Course Continued
VATS was cancelled in favor of conservative management due to his high peri-operative risk. He was pulsed with high dose steroids with no improvement and broad spectrum antibiotics were also empirically initiated.
For the next 10 days, the patient was often transferred back and forth between ICU and step down unit due to hypoxia. Finally, as he was not improving and was too ill for surgical biopsy, bronchoscopy with BAL and transbronchial biopsy was obtained demonstrating normal airways and only non-specific fibrosis.
Azathioprine 50mg/day was initiated as a last resort. He received Azathioprine for two weeks with no improvement in hypoxia. He was transitioned to 100% on non-rebreather mask in the ICU still worsening dyspnea and positional desaturation.
He was not a candidate for lung transplantation due to his severe cirrhosis and was ruled out for liver transplantation due to his untreated active Hepatitis C.
Would a surgical lung biopsy have changed his treatment course? (click on correct answer to move to next panel)