The Korean journal of internal medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지
DOI QR코드

DOI QR Code

Histopathologic heterogeneity of acute respiratory distress syndrome revealed by surgical lung biopsy and its clinical implications

  • Park, Jimyung (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital) ;
  • Lee, Yeon Joo (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital) ;
  • Lee, Jinwoo (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital) ;
  • Park, Sung Soo (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center) ;
  • Cho, Young-Jae (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital) ;
  • Lee, Sang-Min (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital) ;
  • Kim, Young Whan (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital) ;
  • Han, Sung Koo (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital) ;
  • Yoo, Chul-Gyu (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital)
  • Received : 2016.10.29
  • Accepted : 2017.05.16
  • Published : 2018.05.01
⟨ Previous Next ⟩

Abstract

Background/Aims: Diffuse alveolar damage (DAD) is the histopathologic hallmark of acute respiratory distress syndrome (ARDS). However, there are several non-DAD conditions mimicking ARDS. The purpose of this study was to investigate the histopathologic heterogeneity of ARDS revealed by surgical lung biopsy and its clinical relevance. Methods: We retrospectively analyzed 84 patients with ARDS who met the criteria of the Berlin definition and underwent surgical lung biopsy between January 2004 and December 2013 in three academic hospitals in Korea. We evaluated their histopathologic findings and compared the clinical outcomes. Additionally, the impact of surgical lung biopsy on therapeutic alterations was examined. Results: The histopathologic findings were highly heterogeneous. Of 84 patients undergoing surgical lung biopsy, DAD was observed in 31 patients (36.9%), while 53 patients (63.1%) did not have DAD. Among the non-DAD patients, diffuse interstitial lung diseases and infections were the most frequent histopathologic findings in 19 and 17 patients, respectively. Although the mortality rate was slightly higher in DAD (71.0%) than in non-DAD (62.3%), the difference was not significant. Overall, the biopsy results led to treatment alterations in 40 patients (47.6%). Patients with non-DAD were more likely to change the treatment than those with DAD (58.5% vs. 29.0%), but there were no significant improvements regarding the mortality rate. Conclusions: The histopathologic findings of ARDS were highly heterogeneous and classic DAD was observed in one third of the patients who underwent surgical lung biopsy. Although therapeutic alterations were more common in patients with non-DAD-ARDS, there were no significant improvements in the mortality rate.

Keywords

References

  1. Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med 2000;342:1334-1349. https://doi.org/10.1056/NEJM200005043421806
  2. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012;307:2526-2533.
  3. Tomashefski JF Jr. Pulmonary pathology of acute respiratory distress syndrome. Clin Chest Med 2000;21:435-466. https://doi.org/10.1016/S0272-5231(05)70158-1
  4. Schwarz MI, Albert RK. "Imitators" of the ARDS: implications for diagnosis and treatment. Chest 2004;125:1530-1535. https://doi.org/10.1378/chest.125.4.1530
  5. Spieth PM, Zhang H. Pharmacological therapies for acute respiratory distress syndrome. Curr Opin Crit Care 2014;20:113-121. https://doi.org/10.1097/MCC.0000000000000056
  6. Bhargava M, Wendt CH. Biomarkers in acute lung injury. Transl Res 2012;159:205-217. https://doi.org/10.1016/j.trsl.2012.01.007
  7. Baumann HJ, Kluge S, Balke L, et al. Yield and safety of bedside open lung biopsy in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome. Surgery 2008;143:426-433. https://doi.org/10.1016/j.surg.2007.06.003
  8. Charbonney E, Robert J, Pache JC, Chevrolet JC, Eggimann P. Impact of bedside open lung biopsies on the management of mechanically ventilated immunocompromised patients with acute respiratory distress syndrome of unknown etiology. J Crit Care 2009;24:122-128. https://doi.org/10.1016/j.jcrc.2008.01.008
  9. Chuang ML, Lin IF, Tsai YH, Vintch JR, Pang LC. The utility of open lung biopsy in patients with diffuse pulmonary infiltrates as related to respiratory distress, its impact on decision making by urgent intervention, and the diagnostic accuracy based on the biopsy location. J Intensive Care Med 2003;18:21-28. https://doi.org/10.1177/0885066602239121
  10. Guerin C, Bayle F, Leray V, et al. Open lung biopsy in nonresolving ARDS frequently identifies diffuse alveolar damage regardless of the severity stage and may have implications for patient management. Intensive Care Med 2015;41:222-230. https://doi.org/10.1007/s00134-014-3583-2
  11. Kao KC, Tsai YH, Wu YK, et al. Open lung biopsy in early-stage acute respiratory distress syndrome. Crit Care 2006;10:R106. https://doi.org/10.1186/cc4981
  12. Papazian L, Doddoli C, Chetaille B, et al. A contributive result of open-lung biopsy improves survival in acute respiratory distress syndrome patients. Crit Care Med 2007;35:755-762. https://doi.org/10.1097/01.CCM.0000257325.88144.30
  13. Papazian L, Thomas P, Bregeon F, et al. Open-lung biopsy in patients with acute respiratory distress syndrome. Anesthesiology 1998;88:935-944. https://doi.org/10.1097/00000542-199804000-00013
  14. Patel SR, Karmpaliotis D, Ayas NT, et al. The role of open-lung biopsy in ARDS. Chest 2004;125:197-202. https://doi.org/10.1378/chest.125.1.197
  15. de Hemptinne Q, Remmelink M, Brimioulle S, Salmon I, Vincent JL. ARDS: a clinicopathological confrontation. Chest 2009;135:944-949. https://doi.org/10.1378/chest.08-1741
  16. Thille AW, Esteban A, Fernandez-Segoviano P, et al. Comparison of the Berlin definition for acute respiratory distress syndrome with autopsy. Am J Respir Crit Care Med 2013;187:761-767. https://doi.org/10.1164/rccm.201211-1981OC
  17. Cardinal-Fernandez P, Bajwa EK, Dominguez-Calvo A, Menendez JM, Papazian L, Thompson BT. The presence of diffuse alveolar damage on open lung biopsy is associated with mortality in patients with acute respiratory distress syndrome: a systematic review and meta-analysis. Chest 2016;149:1155-1164. https://doi.org/10.1016/j.chest.2016.02.635
  18. Lorente JA, Cardinal-Fernandez P, Munoz D, et al. Acute respiratory distress syndrome in patients with and without diffuse alveolar damage: an autopsy study. Intensive Care Med 2015;41:1921-1930. https://doi.org/10.1007/s00134-015-4046-0
  19. Kao KC, Hu HC, Chang CH, et al. Diffuse alveolar damage associated mortality in selected acute respiratory distress syndrome patients with open lung biopsy. Crit Care 2015;19:228. https://doi.org/10.1186/s13054-015-0949-y
  20. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet 1967;2:319-323.
  21. Phua J, Badia JR, Adhikari NK, et al. Has mortality from acute respiratory distress syndrome decreased over time? A systematic review. Am J Respir Crit Care Med 2009;179:220-227. https://doi.org/10.1164/rccm.200805-722OC
  22. Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994;149(3 Pt 1):818-824. https://doi.org/10.1164/ajrccm.149.3.7509706
  23. Katzenstein AL, Bloor CM, Leibow AA. Diffuse alveolar damage: the role of oxygen, shock, and related factors. A review. Am J Pathol 1976;85:209-228.
  24. Leaver SK, Evans TW. Acute respiratory distress syndrome. BMJ 2007;335:389-394. https://doi.org/10.1136/bmj.39293.624699.AD
  25. Wheeler AP, Bernard GR. Acute lung injury and the acute respiratory distress syndrome: a clinical review. Lancet 2007;369:1553-1564. https://doi.org/10.1016/S0140-6736(07)60604-7
  26. Calfee CS, Delucchi K, Parsons PE, et al. Subphenotypes in acute respiratory distress syndrome: latent class analysis of data from two randomised controlled trials. Lancet Respir Med 2014;2:611-620. https://doi.org/10.1016/S2213-2600(14)70097-9
  27. Wong AK, Walkey AJ. Open lung biopsy among critically ill, mechanically ventilated patients: a metaanalysis. Ann Am Thorac Soc 2015;12:1226-1230.
  28. Libby LJ, Gelbman BD, Altorki NK, Christos PJ, Libby DM. Surgical lung biopsy in adult respiratory distress syndrome: a meta-analysis. Ann Thorac Surg 2014;98:1254-1260. https://doi.org/10.1016/j.athoracsur.2014.05.029
  29. Brusselaers N, Vogelaers D, Blot S. The rising problem of antimicrobial resistance in the intensive care unit. Ann Intensive Care 2011;1:47. https://doi.org/10.1186/2110-5820-1-47
  30. Tabah A, Cotta MO, Garnacho-Montero J, et al. A systematic review of the definitions, determinants, and clinical outcomes of antimicrobial de-escalation in the intensive care unit. Clin Infect Dis 2016;62:1009-1017. https://doi.org/10.1093/cid/civ1199
  31. Tan SK, Burgener EB, Waggoner JJ, et al. Molecular and culture-based bronchoalveolar lavage fluid testing for the diagnosis of cytomegalovirus pneumonitis. Open Forum Infect Dis 2016;3:ofv212. https://doi.org/10.1093/ofid/ofw212
  32. Meersseman W, Lagrou K, Maertens J, et al. Galactomannan in bronchoalveolar lavage fluid: a tool for diagnosing aspergillosis in intensive care unit patients. Am J Respir Crit Care Med 2008;177:27-34. https://doi.org/10.1164/rccm.200704-606OC
  33. Jain P, Sandur S, Meli Y, Arroliga AC, Stoller JK, Mehta AC. Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates. Chest 2004;125:712-722. https://doi.org/10.1378/chest.125.2.712
  34. Flori P, Bellete B, Durand F, et al. Comparison between real-time PCR, conventional PCR and different staining techniques for diagnosing Pneumocystis jiroveci pneumonia from bronchoalveolar lavage specimens. J Med Microbiol 2004;53(Pt 7):603-607. https://doi.org/10.1099/jmm.0.45528-0
  35. Churg A, Wright JL, Tazelaar HD. Acute exacerbations of fibrotic interstitial lung disease. Histopathology 2011;58:525-530. https://doi.org/10.1111/j.1365-2559.2010.03650.x
  36. Bradley B, Branley HM, Egan JJ, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax 2008;63 Suppl 5:v1-v58. https://doi.org/10.1136/thx.2008.101691
  37. Richeldi L, du Bois RM, Raghu G, et al. Efficacy and safety of nintedanib in idiopathic pulmonary fibrosis. N Engl J Med 2014;370:2071-2082. https://doi.org/10.1056/NEJMoa1402584
  38. King TE Jr, Bradford WZ, Castro-Bernardini S, et al. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. N Engl J Med 2014;370:2083-2092. https://doi.org/10.1056/NEJMoa1402582

Cited by

  1. Predicting the Impact of Diffuse Alveolar Damage through Open Lung Biopsy in Acute Respiratory Distress Syndrome-The PREDATOR Study vol.8, pp.6, 2018, https://doi.org/10.3390/jcm8060829
  2. Video-Assisted Thoracoscopic Lung Biopsy in Critically Ill Patients With Hematologic Malignancy and Acute Respiratory Distress Syndrome: A Case Series Report vol.8, pp.None, 2018, https://doi.org/10.1177/2324709620912101