Surgical lung biopsy in children after hematopoietic cell transplantation

Pulmonary Complications in Children Following Hematopoietic Cell Transplantation: A Case Report and Review of the Diagnostic Approach

Pulmonary complications are common in children following hematopoietic cell transplantation (HCT) and contribute to their morbidity and mortality. Early diagnosis is essential for management and prevention of progression of lung injury and damage. In many cases, diagnosis can be challenging and may require diagnostic imaging and more invasive testing such as bronchoscopy and lung biopsy. We report the case of a 12-year-old girl who developed recurrent episodes of acute respiratory failure requiring intensive care unit admission in the post-HCT phase and describe the diagnostic and multidisciplinary approach for her management. In addition, we review the diagnostic approach of pulmonary complications post-HCT and highlight the utility and risks of bronchoscopy and lung biopsy in these children.

Therapeutic Impact and Complications Associated with Surgical Lung Biopsy after Allogeneic Hematopoietic Stem Cell Transplantation in Children

Hematopoietic stem cell transplantation (HSCT) in the pediatric population is associated with pulmonary complications in 25% of recipients. The role of surgical lung biopsy (SLB) remains unclear because of concerns about both the therapeutic impact and morbidity associated with the procedure. A retrospective review of consecutive allogeneic HSCT recipients at Dana-Farber and Boston Children's Hospital Cancer and Blood Disorders Center between 2006 and 2016 was performed. All recipients who underwent SLB during the study period were identified and charts reviewed for perioperative complications, histopathologic findings, and changes in therapy delivered. Pearson's chi-square test and Student's t-test (or appropriate nonparametric test) were used to evaluate the associations between perioperative complication and categorical and continuous variables, respectively. Five hundred fifty-five HSCTs were included, among which 48 SLBs (8.6%) were identified. Median follow-up time was 24 months (range, 0 to 139). Thirty-day postoperative morbidity was 16.7% and 30-day postoperative mortality 10.4% (n = 5). The overall 30-day postoperative complication rate (including mortality) was 20.8% (n = 10). No mortalities were directly attributable to SLB. Definitive diagnoses were identified in 70.8% of SLBs (n = 34), and therapeutic changes occurred in 79.2% (n = 38). Overall, 83.3% of SLBs (n = 40) either provided a diagnosis or led to a change in therapy. SLB has an acceptable risk of perioperative complications in this medically complicated and often severely ill population. In most HSCT patients, SLB aids in defining the etiology of pulmonary infiltrates and can inform therapeutic decisions in patients where noninvasive diagnostic modalities have failed to provide a definitive diagnosis.

Challenges and Clinical Implications of the Diagnosis of Cytomegalovirus Lung Infection in Children

PURPOSE OF REVIEW

Pulmonary cytomegalovirus (CMV) infection is a potential lethal disease in children, but it remains a diagnostic challenge. The differentiation between latent CMV infections with viral shedding and active infections is difficult and may lead to false positives in bronchoalvolar lavage (BAL) PCR detection. This review summarizes current diagnostic approaches for CMV lung infection in children including progress in the identification of underlying immune defects linked to this condition.

RECENT FINDINGS

There is increasing literature supporting that the combined assessment of host risk factors and lung disease pattern is essential for the diagnosis of pulmonary CMV infection in children. The most important host risk factor is an immunecompromised state that has expanded from primary or acquired immunodeficiency (e.g., HIV) to include a myriad of immune-dysregulation syndromes (e.g., CTLA4, PIK3 defects). Newborns, paricularly those born premature, are also a high-risk group. At the pulmonary level, active CMV infection is typically characterized by alveolar compromise leading to hypoxemia, ground-glass opacities, and intra-alveolar infiltrates with CMV inclusions in lung biopsy. The identification of active CMV lung infection should trigger additional evaluation of immune defects (primary or secondary) impairing T and NK cell function or innate antiviral responses as well as other immune dysregulation disorders. Lung CMV infections in children are more prevalent in immunocompromised hosts and premature newborns. Lung CMV infections should prompt further investigation into conditions altering immune mechanisms usually in place to contain CMV infections. Common clinical and radiological patterns such as hypoxemia and ground-glass pulmonary opacities may allow early identification and treatment of CMV lung infection and underlying causes in the pediatric population.

Bronchoalveolar lavage with pediatric flexible fibreoptic bronchoscope in pediatric haematopoietic stem cell transplant patients: Nursing considerations for operative complications

PURPOSE

Bronchoalveolar lavage (BAL) with pediatric flexible fibreoptic bronchoscopy (FB) is used for diagnostic and therapeutic purposes in pediatric haematopoietic stem cell transplant (HSCT) patients with pulmonary complications. The aim of our study was to evaluate complications in pediatric HSCT patients undergoing BAL/FB and to explore the nursing emphases on complications.

DESIGN AND METHODS

We performed a retrospective, case-controlled study to evaluate perioperative complications of HSCT children. BAL/FB was conducted for 42 children with HSCT who experienced pulmonary complications between January 2017 and January 2018 within a tertiary hospital. Forty patients diagnosed with general pneumonia were randomly selected during the same period and served as the control group. We analyzed the signs and symptoms of all patients and compared the operative complications between the two groups. Furthermore, we presented the methods used to manage complications.

RESULTS

The presence of cough, lung rales, and imaging findings in the HSCT patients was significantly different from that of the control group (p < 0.0001). The complication rate was 66.67% (28/42) in the HSCT group and 22.5% (9/40) in the control group, and the difference was significant (p < 0.0001). Twelve out of 42 HSCT patients experienced airway mucosal bleeding (28.57%), and six had transient fever (14.29%). The topical use of epinephrine diluted saline (1:10,000) was highly effective for controlling airway mucosal bleeding without causing fluctuations in blood pressure.

PRACTICE IMPLICATIONS

There were more perioperative complications in the HSCT patients than in the general pneumonia patients who underwent BAL/FB. Airway mucosal bleeding was a key focus of perioperative nursing in HSCT patients undergoing bronchoscopy as main complication. BAL with the use of epinephrine diluted saline (1:10,000) effectively decreased airway mucosal bleeding.