Fiberoptic Bonchoscopy with Transbronchial Lung Biopsy (TBLB)

Fiberoptic bronchoscopy (FOB) is performed liberally in the early post-operative period, as stated previously. Subsequently, surveillance bronchoscopies are performed at 3 to 4 weeks, at around 3 months, at around 6 months, then at one year, and then annually thereafter.50,51 FOB is also performed for clinical indications including symptoms (dyspnea, cough), signs (fever, adventitious breath sounds), the presence of radiographic infiltrates, and declining spirometry and/or oxygenation. TBLB is obtained using fluoroscopic guidance with a 2 mm fenestrated biopsy forceps. Taking 10 to 12 TBB specimens ensures a high diagnostic yield and rarely fails to provide adequate diagnosis.52 If there is a discrete infiltrate, the majority of the biopsies are taken there, with a few being taken from uninvolved areas. If there is a diffuse infiltrate or normal chest radiograph then, specimens are taken from all several bronchopulmonary segments. These samples should then be sent in formaldehyde for routine hematoxylin and eosin (H and E) staining. Gomori methenamine silver stains are obtained to detect the presence of fungi or Pneumocystis carinii, and acid fast staining to detect the presence of mycobacteria. In addition, immunoperoxidase staining (for detection of CMV infection), and connective tissue stains (for detection of OB) are obtained if clinically indicated.

Open Lung Biopsy

When FOB with TBLB is inconclusive in the face of continuing clinical and physiological deterioration despite empiric therapy, open lung biopsy may be necessary to determine the underlying pathology and guide specific therapy.44

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