Ann Thorac Surg 2006;82:267
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
Alessandro Brunelli, MD
Unit of Thoracic Surgery "Umberto I" Regional Hospital, Via S. Margherita 23, Ancona 60129, Italy
(Email: alexit_2000{at}yahoo.com).
As a number of specific diseases can produce the syndrome of adult respiratory distress syndrome (ARDS) and have specific therapies independent of ARDS, it is not clear that this syndrome is a homogeneous entity that can be treated uniformly. Theoretically, every effort should be made to achieve a specific diagnosis in these patients to institute an appropriate treatment that could improve their outcome. Previous studies have shown that lung biopsy was able to achieve a specific diagnosis in as much as 60% of patients with ARDS, ultimately leading to the institution of new therapies or discontinuation of unneeded ones.
Therefore lung biopsy would appear as a logical approach in these patients, whenever less invasive diagnostic procedures resulted nondiagnostic. Nonetheless, resecting lung parenchyma in these high-risk subjects is not without consequences. Persistent air leak is one of the most common occurrences. Therefore, identifying potentially modifiable factors associated with prolonged air leak in patients with ARDS submitted to lung biopsy would be of great importance to enhance the safety of the procedure without adding undue harm.
In this regard the study of Cho and colleagues [1] represents a unique contribution. The authors found that a lung protective ventilator strategy that limited peak airway pressure was strongly and reliably associated with reduced incidence of postoperative air leak. The authors should be commended for using bootstrap as a measure of reliability in their analysis.
This article was intriguing in many aspects. The institution of future prospective randomized trials on costs and benefits of lung biopsy in ARDS patients is certainly warranted. If these trials demonstrate a benefit for these patients, thoracic surgeons will be faced with an increasing number of procedures often performed at the intensive care unit bedside of critically ill patients. However, complications and mortality in these subjects may be daunting and, therefore, many could be reluctant to operate on them, mostly for the fear of being involved in malpractice litigation. Furthermore, an abrupt increase in surgical volume may be a critical issue in certain understaffed teams.
Finally, as an effort to minimize air leaks, the efficacy and safety of sealants or suture buttressing materials should be ideally tested in these subjects in prospective trials. In fact, they may be of great help in a situation in which both the barotraumas and the diseased parenchyma play a crucial role in delaying healing.
The authors must be commended on a well written, interesting, and scientifically sound article that adds on the topic of postoperative air leak and will contribute to stimulate further debate on the management of ARDS patients.
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References
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- Cho MH, Malhotra A, Donahue DM, et al. Mechanical ventilation and air leaks after lung biopsy for acute respiratory distress syndrome Ann Thorac Surg 2006;82:261-267.[Abstract/Free Full Text]
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