Interstitial lung diseases are a heterogeneous group with diffuse parenchymal lung disease. Because most patients with interstitial lung diseases have impaired pulmonary function, the risks of thoracic surgery are an important issue when considering surgical lung biopsy. The nonintubated video-assisted thoracoscopic surgery lung biopsy for interstitial lung disease is a safe and feasible option in carefully selected patients with interstitial lung disease.
Key points
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Thoracoscopic lung biopsy has been performed using a conventional positive-pressure ventilator under general anesthesia, but the complications associated with general anesthesia and positive-pressure ventilators are not negligible.
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Perioperative surgical outcomes for the nonintubated video-assisted thoracoscopic surgery (VATS) lung biopsy for interstitial lung disease are comparable with the intubated technique.
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Nonintubated VATS lung biopsy for interstitial lung disease is a safe and feasible option in carefully selected patients with interstitial lung disease.
Introduction
Interstitial lung diseases (ILDs) are a heterogeneous group with diffuse parenchymal lung disease. Although rare, they are classified with similar clinical, radiological, physiologic, or pathologic signs. Pathologic examination is required if clinical symptoms, blood tests, or high-resolution computed tomography (HRCT) images alone are not enough to diagnose ILD. This may be important because treatment options and prognosis differ greatly between the various types of ILD. Methods for pathologic examinations include transbronchial lung biopsy (TBLB) and surgical lung biopsy. Surgical lung biopsy is usually performed by video-assisted thoracoscopic surgery (VATS) under general anesthesia and provides excellent diagnostic results. The diagnostic yield is up to 95% (range 85%–100%).
Because most patients with ILD have impaired pulmonary function, the risks of thoracic surgery are an important issue when considering surgical lung biopsy. These morbidity and mortality rates are not negligible.
General thoracic surgery has evolved from a traditional open thoracotomy to VATS. VATS has been widely accepted because of its smaller incision, shorter hospital stays, and less pain and bleeding after surgery. General thoracic surgery is generally performed under general anesthesia and mechanical 1-lung ventilation owing to severe pain and cardiopulmonary physiologic change. Efforts have been made to prevent the complications following thoracic surgery caused by general anesthesia and the use of a positive-pressure ventilator. The complications of general anesthesia and mechanical 1-lung ventilation are as follows. The ventilator-associated lung injury (more dangerous in patients with preexisting pulmonary disease) can be caused by positive-pressure ventilation. General anesthesia sometimes causes other complications, such as cardiac arrhythmia, transient hypoxemia, liver and kidney damage, impaired cognitive function, impaired preoperative immune surveillance, and mechanical airway injury.
Nonintubated VATS (NIVATS) is performed under spontaneous breathing and regional anesthesia without general anesthesia and positive-pressure mechanical ventilation. NIVATS was already introduced in the 1950s. This method was not used for a long time but has begun to reappear as a way to reduce postoperative complications related to general anesthesia and mechanical ventilation. NIVATS is expanding from simple procedures (pleural effusion, pleural biopsy, pneumothorax, ILD wedge biopsy) to complex procedures (anatomic lung resections, thymectomy, sleeve lobectomy). NIVATS may help achieve a shorter hospital stay and a reduction in postoperative morbidity rate compared with general anesthesia VATS in selected cases.
NIVATS was particularly applied to people with poor cardiorespiratory function. Recently, adoption of NIVATS is being progressively extended to patients without any substantial risk factor for general anesthesia and 1-lung ventilation. Indeed, in a recent survey from the European Society of Thoracic Surgeons, 20% affirmed to favor to the use of NIVATS regardless of a patient’s comorbidity profile. However, simple procedures, such as pneumothorax and ILD lung biopsy, have a short operative time and not many complications. Therefore, the shortening of the hospital stay and the reduction of complications, which are known as the advantages of NIVATS, are not significant compared with general anesthesia VATS in these procedures. However, if a patient has impaired cardiopulmonary function, NIVATS can be applied to improve patient safety.
Diagnosis
ILD is a generic term representing a heterogeneous group of diffuse parenchymal lung diseases classified together owing to several common features. The most common type of ILD is idiopathic pulmonary fibrosis (IPF). For diagnosis, a multidisciplinary team of experts is needed, which improves the accuracy of the diagnosis. Both the clinical context given by the pulmonary clinician and interpretation of chest HRCT by thoracic radiologist are very important. If these are not enough to diagnose, additional information can be obtained by bronchoalveolar lavage (BAL) and/or TBLB using bronchoscopy. Then, if the size of the specimen is not enough to diagnose, adequate large tissue should be obtained with surgical lung biopsy ( Table 1 )
| Author, Year | Subjects ( n ) | Context | Analgesia | Sedation Level | Wedge Number | Operative Time | Conversion to General Anesthesia | Diagnosis | Morbidity and Mortality | Observation Period |
|---|---|---|---|---|---|---|---|---|---|---|
| Ambrogi & Mineo, 2014 | 40 | 3-port (20) 1-port (20) | TEA (20) ICB (20) | Mild (midazolam or propofol) | 2.3 2.1 | 38 40 | 1 (5%) 1 (5%) | 33 (82.5%) | ARDS (1) Pneumonia (1) | 2002–2014 |
| Peng et al, 2017 | 43 | 1-port tubeless LMA (SIMV) | IV analgesia | BIS 40–60 | 2 | 22 ± 5 | 0 a | 38 (88.4%) | Atrial fibrillation (1) Pneumonia (1) Chest tube insertion (1) | 2014–2015 |
| Jeon et al, 2018 | 10 | 3-port Facial mask | TEA | BIS 60–80 | 2 | 33 | 0 | 10 (100%) | 0 | 2016 |
a Conversion to 2-port and chest tube or urinary catheterization in 3 cases.
Clinical evaluation by the pulmonary clinician includes examining the patient’s past medical history, physical examination, family history, and exposure to substances known to result in pulmonary injury. Clinical impression is obtained through various acquired clinical data. Image interpretation of the thoracic radiologist is crucial. HRCT chest scans are essential for ILD and should be taken with adequate inspiration and absent respiratory motion. Past chest imaging should be reviewed, and ILD can be narrowed down by combining these clinical and image data.
Because chest imaging is often seen in certain clinical situations, many disorders can be diagnosed with confidence without the need to obtain lung tissue. For example, in the case of a typical usual interstitial pneumonia (UIP) pattern on HRCT and a clinical context of idiopathic interstitial pneumonia (IIP), diagnosis of IPF does not require surgical lung biopsy. Connective tissue disease-associated ILD and ILD associated with a specific and clinically significant medication, environmental, occupational, avocational, or accidental exposure are also clinically diagnosed without pathologic lung tissue. However, if the imaging pattern is not typical within the clinical context, surgical lung biopsy should be considered ( Fig. 1 ).
