A43-25 Case Report: Open Lung Biopsy Leading to Pneumomediastinum With Airway Compromise

Intro The diagnosis of interstitial lung disease (ILD) requires a multidisciplinary approach due to its wide spectrum of potential etiologies. Recent advances in ILD therapy underscore the importance of early diagnosis, as timely initiation of treatment can improve survival. With increased accessibility and improved resolution of high-resolution computed tomography (HRCT), lung biopsy is less frequently required; however, it remains necessary when imaging and clinical features are inconclusive.This case describes a patient who developed pneumomediastinum following lung biopsy via video-assisted thoracoscopic surgery (VATS), further complicated by air dissection into the subcutaneous tissues of the chest and neck—altogether placing them at risk for airway compromise. Case A 72-year-old man with COPD (former 25 pack year smoker), chronic hypoxic respiratory failure, and ankylosing spondylitis presented with worsening dyspnea and increased oxygen requirements following a recent hospitalization for shortness of breath unresponsive to outpatient antibiotics. HRCT of the chest was obtained to further characterize his lung disease and revealed findings suggestive of ILD. A lung biopsy, resulting in four wedge resections of right-sided friable lung tissue, was subsequently performed via VATS. The procedure was complicated by pneumomediastinum that enlarged over the next four days, leading to subcutaneous emphysema and air tracking into the neck. On postoperative day four, he developed severe respiratory distress requiring transfer to the intensive care unit for close monitoring. Pathology demonstrated acute organizing lung injury with features consistent with organizing pneumonia but no evidence of ILD. The persistent air leak lasted eight days and was believed to primarily result from bronchiole injury and subsequent air tracking along bronchovascular structures. The patient improved without requiring intubation and was discharged on hospital day 17. Discussion This case highlights the potential for severe and progressive complications of VATS lung biopsy. When tissue diagnosis is required for ILD evaluation, several biopsy modalities are available, and selection should be individualized. VATS surgical lung biopsy remains the gold standard, with a diagnostic yield exceeding 88%; however, it carries higher rates of morbidity, mortality, and cost. In contrast, CT-guided biopsy and transbronchial cryobiopsy are safer alternatives for high-risk patients, although with lower diagnostic yield and accuracy. A U.S. study of more than 30,000 ILD lung biopsies (2000-2011) reported in-hospital mortality below 2% for elective procedures, which increased to 16% for nonelective cases. This case underscores the importance of judicious patient selection and thoughtful choice of biopsy modality to optimize outcomes and minimize procedural risk.