MAT # 18832209
Seeking pulmonologist who regularly performs transbronchial biopsies.
This case involves a 73yo woman with known interstitial lung disease (restrictive pattern on PFTs), suspected autoimmune/mixed connective tissue disease, pulmonary hypertension (dilated main pulmonary artery reported between 3.6 and 4.4 cm), Afib and OSA. She was reportedly active and independent prior to this event. Her course progressed from episodic dyspnea/hypoxia to prolonged respiratory failure with ventilator dependence, tracheostomy, PEG, and long-term institutional-level care.
She first presented 09/30/2025 with acute shortness of breath/cough; CTA reportedly showed no PE but did show pulmonary artery dilation and patchy ground-glass opacities; she was treated as pneumonia and discharged 10/02/2025.
She re-presented 11/02/2025 with worsening dyspnea/hypoxia and underwent the pivotal bronchoscopy on 11/03/2025 for “abnormal CT” and “diffuse parenchymal lung disease.” The bronchoscopy was performed under general anesthesia via endotracheal tube, with BAL performed in the RUL apical segment (B1) (30 mL returned, cloudy). Importantly, the pulmonologist performed a transbronchial lung biopsy using an “Erbe Cryo Probe” in the left upper lobe, guided by fluoroscopy. The report states the procedure was “accomplished with difficulty due to excessive bleeding,” with moderate bleeding listed as a complication; estimated blood loss 50 mL treated with epinephrine and IV fluids, therapeutic suctioning was performed, and residual clot remained in the LUL and RUL that could not be suctioned, though no active bleeding was noted at procedure end. Two biopsy passes were performed and one biopsy sample obtained.
Following this bronchoscopy/lung biopsy event, the patient experienced worsening respiratory status with radiographic progression (worsening ground-glass opacities/new consolidation reported shortly after), atrial fibrillation with RVR requiring rate control, and ongoing hematologic/respiratory complications. After discharge to rehab (11/26/2025), she returned (11/29/2025) with acute hypoxic respiratory failure requiring intubation (11/30/2025). Imaging then reportedly showed a mild acute PE with evidence of pulmonary hypertension and severe pulmonary edema/inflammation, and ultrasound showed bilateral DVTs.
She had a prolonged ICU course with multiple intubations/re-intubations and ultimately required tracheostomy (12/15/2025) and PEG, with discharge on 01/05/2026 to LTACH for chronic hypoxic respiratory failure and long-term support.
Pulmonology SOC issues for the expert to address:
1: Indication, timing, and risk/benefit of transbronchial lung biopsy in suspected autoimmune ILD/pulmonary hypertension
2: Whether the intraprocedural bleeding and residual airway clot were managed and documented appropriately (including escalation/monitoring afterward)
3: Whether the post-procedure clinical decline is more consistent with procedure-triggered hemorrhage/complication versus progression of underlying ILD.
Thank you for your opinion and welcome any questions.
Files:
Q: did the patient have an echo or right heart cath to assess the degree of pulmonary htn prior to the procedure? was the patient appropriately consented with risk of procedure - bleeding, ptx, exacerbation trigger, need to remain intubated/icu care, etc.
A: —
Do you believe there might have been medical error?
In patients with an interstitial lung disease of unclear etiology, it is fairly common to perform transbronchial bx to try to delineate the underlying cause to guide treatment decisions. Transbronchial cryobiospy has become more commonly employed due to the increased tissue volume acquired with these biopsies as opposed to traditional forceps biopsies which are small and hard to characterize the ILD with small biospies. In addition, there does appear to be less risk of complication from a bronchoscopic cryobiopsy as opposed to a surgical lung biopsy. It has been variably documented that the risk of bronchoscopic cryobiopsy causing severe or life-threatening bleeding (and pneumothorax though not germane to this case) is higher than with traditional forceps biopsy which has lead to variable adoption of this approach given this risk. If I patient has pulmonary HTN, the risk of severe or life threatening bleeding is elevated even further and would be a contraindication to proceeding with bronchoscopic cryobiopsy depending on the level of pulmonary HTN. It is also known that a patient with ILD of any cause, especially if coming in with what might be an evolving ILD exacerbation or viral/other infectious process, is at higher risk of any procedure further exacerbating that underlying ILD flare leading to progressive respiratory failure. It seems to me decisions were appropriate (assuming pt did not have severe pulmonary HTN) to proceed with bronchoscopy and consequent complications are known and expected possibilities - assuming discussed with patient as part of informed consent.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Detailed above - assuming no severe pulmonary HTN and other factors could have lead to decompensation beyond the bronchoscopy and bleed - ie, the underlying ILD itself, possible superimposed infection.
What makes you a good expert for this case?
20 year experience as an advanced bronchoscopist making cognitive decision on if procedure should be done, performing the procedures and dealing with the complications.
How often do you encounter cases similar to this one in your practice?
I rarely perform cryobx any longer due to a personal experience with a severe and life threatening bleed and I am not convinced in the current context of therapies the added diagnostic yield of cryobx does not warrant the risk to the patient.
Do you believe there might have been medical error?
No indication for high risk cryobiopsy. Too high risk of a procedure and biopsy for this consdition is almost never done now
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
bleeding as a complication of biopsy No indication for high risk cryobiopsy. Too high risk of a procedure and biopsy for this consdition is almost never done now
What makes you a good expert for this case?
I perform bronchoscopy often and we have elected against crytobiopsy because of the high risk nature of this procedure No indication for high risk cryobiopsy. Too high risk of a procedure and biopsy for this consdition is almost never done now
How often do you encounter cases similar to this one in your practice?
rare, No indication for high risk cryobiopsy. Too high risk of a procedure and biopsy for this consdition is almost never done now
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