The consensus emphasizes that a comprehensive multidisciplinary discussion (MDD) is mandatory before performing a lung biopsy in patients with suspected interstitial lung disease. The pre-biopsy MDD should determine the diagnostic certainty of the current noninvasive assessment, evaluate whether biopsy findings would alter management, and support shared decision-making that incorporates patient preferences (Level of evidence: 3; Recommendation: strong).
A lung biopsy is recommended when a patient’s diagnosis remains uncertain after a full noninvasive evaluation or when histopathologic subtyping will directly inform treatment. This is a strong recommendation though based on lower-level evidence (Level 4; Recommendation: strong).
The consensus stratifies biopsy indications by HRCT pattern:
If HRCT shows a definite pattern of usual interstitial pneumonia (UIP) and secondary causes have been excluded, lung biopsy is strongly discouraged.
For probable UIP where nonspecific interstitial pneumonia (NSIP) or fibrotic hypersensitivity pneumonitis (HP) cannot be excluded, biopsy is a conditional consideration.
In indeterminate or non-UIP patterns with insufficient clinical evidence, lung biopsy is strongly recommended to obtain a definitive diagnosis (Level 4; Recommendation: conditional to strong depending on pattern).
Biopsy should target active lesions identified on HRCT (for example, ground-glass opacities or fine reticulation). Specimens should include the interface between diseased and normal parenchyma to permit assessment of pattern distribution. High-risk regions such as major vessels and severe bullae must be avoided. Multi-lobar sampling from at least two sites that differ in severity is recommended to capture heterogeneity (Level 4; Recommendation: strong).
TBLB is recommended as the first-line bronchoscopic approach for suspected granulomatous disease (such as sarcoidosis) and certain alveolar filling patterns. If TBLB is non-diagnostic, escalation to transbronchial lung cryobiopsy (TBLC) or surgical lung biopsy (SLB) is advised. TBLB is not recommended for predominantly fibrotic ILDs such as UIP or NSIP (Level 4; Recommendation: strong).
TBLC is recommended as the preferred modality in experienced centers, especially for patients who are poor candidates for or who decline SLB. The procedure should be standardized, performed under general anesthesia with prophylactic balloon placement for hemorrhage control, and integrated with imaging or navigational guidance to maximize diagnostic yield while limiting complications (Level 2; Recommendation: strong).
When TBLC is non-diagnostic and the patient’s cardiopulmonary reserve permits surgery, SLB is recommended. Video-assisted thoracoscopic surgery (VATS) is the preferred approach. SLB should sample at least two distinct lobes, prioritizing dependent segments of the upper lobes or the superior segments of the lower lobes; the lingula or right middle lobe should be sampled only if they contain the most representative lesions (Level 2; Recommendation: strong).
PTNB is recommended for ILD patients who present with solitary nodules, masses, or focal consolidations—particularly when malignancy must be excluded. PTNB is not recommended for routine histopathologic evaluation of diffuse fibrosing ILDs (Level 2; Recommendation: strong).
A structured shared decision-making model is recommended throughout biopsy selection and planning. Clinicians should counsel patients comprehensively on expected benefits, procedural risks, and alternative diagnostic strategies, and align the clinical plan with patient values (Level 4; Recommendation: strong).
Recognized risk factors for acute exacerbation of ILD (AE-ILD) include histologic or imaging UIP pattern, evidence of active disease, and reduced diffusing capacity for carbon monoxide (DLCO). Routine prophylactic use of glucocorticoids or antifibrotic agents for all patients is not recommended. Instead, the consensus recommends meticulous perioperative management to mitigate AE risk. If AE-ILD occurs after biopsy, prompt investigation of underlying causes is required; high-dose glucocorticoids with supportive therapy may be considered (Level 2; Recommendation: strong).
Pathology reports must follow current international standardized nomenclature. Reports should describe the predominant histologic patterns and their key features, highlight any findings pointing to a specific etiology, and explicitly state diagnostic limitations due to specimen quality. Pathologists are expected to provide a systematic microscopic description, a histopathologic classification, and, where possible, etiologic interpretation (Level 4; Recommendation: strong).
Post-biopsy MDD by the same team that participated in the pre-biopsy evaluation is central to forming an integrated diagnosis. Systematic correlation of histopathology with clinical and radiologic data is required. Any discordance should be investigated until consensus is reached. If an integrated diagnosis cannot be achieved, repeat MDD, referral to an expert center, or consideration of a repeat biopsy is recommended (Level 2; Recommendation: strong).
The consensus addresses special scenarios such as ILD complicated by lung cancer or connective tissue disease-associated ILD (CTD-ILD), and recommends tailoring biopsy decisions to the combined clinical, radiologic, and pathologic context. Specific procedural choices and sequencing should reflect these complexities; detailed algorithms were developed by the working group.
The consensus was developed under the leadership of the Respiratory Physicians Branch of the Chinese Medical Doctor Association and the ILD Group of the Chinese Thoracic Society, with participation from national experts in respiratory medicine, radiology, pathology, thoracic surgery, and rheumatology. The methodology included systematic literature searches, evidence grading, and anonymous Delphi voting to produce 15 recommendations each annotated with evidence level and recommendation strength.
This consensus provides clinicians with clear, practical guidance for safe and standardized lung biopsy decision-making and procedure selection in ILD, with the overall goal of improving diagnostic precision and patient outcomes. The document is intended for respiratory physicians, radiologists, pathologists, thoracic surgeons, and multidisciplinary teams involved in ILD care.