Conclusion
It is probable that approximately one third of the IPF patients would need SLB in order to obtain an accurate diagnosis. Several remarkable points should be considered when making a decision whether or not to perform the SLB. The mortality, which can occur shortly after the procedure, has probably been the major reason to refrain from performing SLB. The precise risk limits for complications of SLB procedure are not well known. Thus a thorough deliberation taking into consideration age, other diseases, medication, lung function and the stage of the pulmonary fibrosis are needed before proceeding to a procedure of SLB. As it has been noted in the new statement, in patients with severe physiologic impairment or substantial comorbidity, the risks of SLB may outweigh the benefits of establishing a secure diagnosis of IPF, and moreover, clinicians must spend adequate time with patients to discuss patients' values and preferences.
The accuracy of the histological diagnosis might be problematic, and thus it seems to be fundamental that SLB are analyzed by experienced pulmonary pathologists. It is probable that the histological diagnosis may become even more challenging than previously when only the patients with non-typical HRCT features are biopsied, and UIP may be at risk of remaining obscured by other concomitant diseases or confounding factors. Moreover, the challenge of pulmonary pathology will be greater because of the fact that more complex and less classical lung diseases will be investigated that will make classification of histological patterns more difficult and may limit the role of pathology as a routine predictor of prognosis. Evaluation of the pathological archives from previous decades might help in the training of pulmonary pathologists and for gathering experience from a large amount of samples including also the typical cases representing IPF/UIP. It is likely that more SLB may be needed for the diagnosis of NSIP and for the exclusion of IPF, especially after the preliminary results of the Panther-study which revealed a harmful effect of triple therapy treated IPF patients.
Since many IPF patients are at an older age and suffer from many other diseases, or their lung disease has already progressed to an advanced stage, SLB cannot be considered as a safe procedure for all individuals. Thus, there is a definite need for developing new diagnostic tools for the diagnosis of IPF and other ILDs. According to the current statement, BAL or TBB are no longer required for the diagnosis of IPF. A new BAL guideline has been recently published as has as a new BAL cell culture technique for diagnostic samples. Hopefully, BAL and TBB will gain greater acceptance in IPF diagnostics in the future with the development of more standardized techniques and innovative methodologies. Improvements in all methodological techniques including radiology and also the invasive procedures such as SLB, TBB and BAL could be predicted to make the diagnostics of IPF and other type of ILDs not only faster and safer but also more accurate, which will be important in the future due to a new classification of IIP including a category of unclassifiable ILD.