For which patient(s) with a pulmonary infiltrate of uncertain cause would you favor VATS over open wedge excision?

A. An AIDS patient with a diffuse infiltrate who is ambulatory but requires supplemental oxygen. Bronchoalveolar lavage is negative.

B. A 64-year-old previously healthy man with increasing shortness of breath, a diffuse infiltrate, and restrictive lung disease as shown by pulmonary function studies

D. A 44-year-old man with fever, left-sided infiltrate, and shortness of breath.

DISCUSSION: Lung biopsy by VATS or minithoracotomy is often indicated in the work-up of a pulmonary infiltrate that has not been successfully diagnosed by less invasive studies. This procedure probably is not indicated for cancer patients with acute pneumonitis, as broad-spectrum antibiotics frequently are successful treatments. For those who do require the procedure, the choice between VATS and thoracotomy is determined by the severity of illness. In those who are critically ill and ventilator dependent, changing the tube to an endobronchial tube for thoracoscopy may be risky, and in these cases an anterior thoracotomy with single-lumen ventilation is indicated. These patients, who are frequently heavily sedated and are likely to remain so for some time postoperatively, are unlikely to benefit from the greatest advantage of VATS, the reduction of postoperative pain. It is, then, the ambulatory patient with a chronic interstitial process who benefits the most from the VATS approach.