Comparison of Transbronchial Biopsy and Open Lung Biopsy in Ventilated Patients with Diffuse Pulmonary Infiltrates after Hematopoietic Stem Cell Transplantation

比較經支氣管鏡肺切片及開肺切片在造血幹細胞移植後使用呼吸器病人的研究

洪禎佑(Chen-Yiu Hung) ； 王博南(Po-Nan Wang) ； 胡漢忠(Han-Chung Hu) ； 黃崇旂(Chung-Chi Huang) ； 謝孟哲(Meng-Jer Hsieh) ； 楊政達(Cheng-Ta Yang) ； 蔡熒煌(Ying-Hung Tsai) ； 高國晉(Kuo-Chin Kao)

《胸腔醫學》 27卷3期 (2012/06) Pp. 131-142

https://doi.org/10.29806/TM.201206.0001

摘要

前言：造血幹細胞移植後呼吸衰竭常常會造成嚴重的併發症和很高的死亡率。由於這一群病人相對是免疫力低下的族群，造成肺部浸潤的原因常常是多樣性且不易診斷。這個回溯性研究比較經支氣管鏡進行肺切片或開肺切片在這一類病人的病理診斷，治療改變，併發症和預後的分析。方法：這個研究收集了20位因瀰漫性肺部浸潤導致呼吸衰竭進到加護病房的病人接受了經支氣管鏡肺切片或開肺切片。我們記錄下病人基本資料，病理切片結果，治療的改變，併發症和預後的資料，同時利用Fisher's exact test和Mann-Whitney U test做變數分析。結果：瀰漫性肺泡破壞，瀰漫性肺泡出血，麴黴病（Aspergillosis），肺囊蟲肺炎（Pneumocystis jiroveci pneumonia），巨形細胞病毒肺炎（CMV pneumonitis）佔了多數病理診斷。開肺切片比經支氣管鏡肺切片有較高的診斷率和治療上的改變（82% versus 56%）。開肺切片只有一位個案有嚴重的皮下氣腫，顯示這個檢查的安全性是可以被接受的。結論：大多數瀰漫性肺部浸潤使用呼吸器的病人在切片之後得到一個特定的診斷並且有治療的改變。特別是在做完支氣管沖洗術的病人若沒有確定診斷，開肺切片比經支氣管鏡肺切片有較高的診斷率和治療上的改變。這篇研究顯示開肺切片都可以得到適當的檢體與支氣管鏡肺切片都有高的安全性。未來在評估這一類病人，開肺切片的角色仍需進ㄧ步前瞻性研究。（胸腔醫學2012；27：131-142）

關鍵字

經支氣管鏡肺切片 ； 開肺切片 ； 造血幹細胞移植 ； 治療改變 ； 併發症

並列摘要

Background: Establishing a specific diagnosis in ventilated patients with diffuse pulmonary infiltration after hematopoietic stem cell transplantation (HSCT) is challenging. The aim of this study was to review and compare our experience with transbronchial biopsy (TBBx) and open lung biopsy (OLB), with a focus on diagnostic yields, the influence of pathological results on altering therapy, and procedure-related complications.Patients and Methods: Data of 20 mechanically ventilated patients with diffuse pulmonary infiltrates receiving lung biopsy (TBBx or OLB) were recorded for analysis. The collected data included general information, pathological results, treatment alterations, complications and clinical outcomes. Characteristics of patients receiving TBBx or OLB were compared using Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables.Results: Twenty ventilated HSCT patients with diffuse pulmonary infiltrates receiving lung biopsy, including TBBx (N=9) or OLB (N=11), were enrolled. The most frequent pathologic results were diffuse alveolar damage (DAD) in 4 patients, diffuse alveolar hemorrhage (DAH) in 3 patients, aspergillosis in 3 patients, and Pneumocystis jiroveci pneumonia (PJP) in 3 patients. The rate of treatment alteration in OLB patients was higher than in TBBx patients, although the difference was not significant (82% versus 56%; p=0.34). One of the 11 OLB patients (9%) had subcutaneous emphysema due to chest tube dysfunction. The overall ICU survival rate of the patients receiving lung biopsy was 15% (3/20).Conclusion: TBBx and OLB had a high diagnostic yield rate for some selected ventilated HSCT patients with diffuse pulmonary infiltrates. Patients that underwent OLB had more adequate specimens, more pathological results, and greater rates of treatment alteration than those receiving TBBx, especially after a non-diagnostic BAL examination. The surgical complication rate of the OLB patients was low and acceptable. Further prospective, randomized controlled studies are warranted to define the specific role of OLB. (Thorac Med 2012; 27: 131-142)

並列關鍵字

transbronchial biopsy (TBBx) ； open lung biopsy (OLB) ； hematopoietic stem cell transplantation (HSCT) ； treatment alteration ； complication