Use of first line bronchoalveolar lavage in the immunosuppressed oncology patient

The Incidence of Respiratory Infections and Risk Factors Among Cancer Patients Undergoing Chemotherapy at a Tertiary Care Hospital in Western Saudi Arabia

Introduction

Cancer patients receiving chemotherapy are prone to infections because of the treatment regimens' immunosuppression. 

Objectives

This study estimated the overall incidence of respiratory infections among patients undergoing chemotherapy and associated risk factors.

Methods

This study is a retrospective chart review of cancer patients at Princess Noorah Oncology Center in Western Saudi Arabia from January 2017 to December 2020. 

Results

This study included 196 patients, 53.1% males and 50.5% older than 50 years. The estimated incidence of respiratory infections among participants was 8.7%, and the most commonly detected organism was Klebsiella pneumoniae (35.3%). The risk factors significantly associated with infection were ICU admission (p=0.001), the use of mechanical ventilation (p=0.003), and the presence of hematologic malignancy (p=0.02).

Conclusion

Future multi-center studies should employ a prospective design, including laboratory confirmation of causative organisms. Such studies may better estimate the infection-associated burden on cancer patients undergoing chemotherapy.

Utility of bronchoscopy in immunocompromised paediatric patients: Systematic review

PURPOSE

The objective of this study was to describe the diagnostic yield and safety of bronchoalveolar lavage (BAL) in the evaluation of pulmonary lesions in immunocompromised children.

METHODS

We conducted a systematic review of literature published during the past 20 years, searching Medline, Medline EPub, EMBASE, and Scopus. Studies included involved paediatric patients (<18 years) on treatment for an oncological diagnosis or other immune compromise who underwent BAL for evaluation of pulmonary lesions. Only English language publications were included.

RESULTS

In all, 272 studies were screened and 19 included. All were observational studies with moderate (11/19) or serious (8/19) risk of bias. BAL yielded a potential pathogen in 43% of cases (496/1156). Two papers reported improved diagnostic yield with early BAL (less than 3 days of presentation). A change in patient management after BAL was reported in 53% of cases (275/519). Adverse events were reported in 19% of cases following BAL (193/993) but were generally mild with no procedure-related mortality reported.

CONCLUSION

BAL appears to be useful for evaluation of pulmonary lesions in immunocompromised children with generally acceptable safety, though included studies had at least moderate risk of bias. Future prospective studies may provide more definitive estimates of benefit, timing and risk of BAL in this population.

Etiology and Prognosis of Pneumonia in Patients with Solid Tumors: A Prospective Cohort of Hospitalized Cases

BACKGROUND

Data on the incidence, etiology, and prognosis of non-ventilator-associated pneumonia in hospitalized patients with solid tumors are scarce. We aimed to study the characteristics of non-ventilator-associated pneumonia in hospitalized patients with solid tumors.

MATERIALS AND METHODS

This was a prospective noninterventional cohort study of pneumonia in patients hospitalized in an oncology ward in a tertiary teaching hospital. Pneumonia was defined according to the American Thoracic Society criteria. Patients were followed for 1 month after diagnosis or until discharge. Survivors were compared with nonsurvivors.

RESULTS

A total of 132 episodes of pneumonia were diagnosed over 1 year (9.8% of admissions to the oncology ward). They were health care-related (67.4%) or hospital-acquired pneumonia (31.8%). Lung cancer was the most common malignancy. An etiology was established in 48/132 episodes (36.4%). Knowing the etiology led to changes in antimicrobial therapy in 58.3%. Subsequent intensive care unit admission was required in 10.6% and was linked to inappropriate empirical therapy. Ten-day mortality was 24.2% and was significantly associated with hypoxia (odds ratio [OR], 2.1). Thirty-day mortality was 46.2%. The independent risk factors for 30-day mortality were hypoxia (OR, 3.3), hospital acquisition (OR, 3.1), and a performance status >1 (OR, 2.6). Only 40% of patients who died within 30 days were terminally ill.

CONCLUSION

Pneumonia is a highly prevalent condition in hospitalized patients with solid tumors, even with nonterminal disease. Etiology is diverse, and poor outcome is linked to inappropriate empirical therapy. Efforts to get the empirical therapy right and reach an etiological diagnosis to subsequently de-escalate are warranted.

IMPLICATIONS FOR PRACTICE

The present study shows that pneumonia is a prevalent infectious complication in patients admitted to oncology wards, with a very high mortality, even in non-terminally ill patients. Etiology is diverse, and etiological diagnosis is reached in fewer than 40% of cases in nonintubated patients. Intensive care unit admission, a marker of poor outcome, is associated with inappropriate empirical therapy. These results suggest that, to improve prognosis, a more precise and appropriate antimicrobial empirical therapy for pneumonia in patients with solid tumors is necessary, together with an effort to reach an etiological diagnosis to facilitate subsequent de-escalation.

An Analysis of the Clinical Benefit of 37 Bronchoalveolar Lavage Procedures in Patients with Hematologic Disease and Pulmonary Complications

Objective Since pulmonary complications are a major cause of mortality in patients with hematologic diseases, their rapid detection and treatment are essential. Bronchoalveolar lavage (BAL) is widely performed to diagnose pulmonary infiltrates not evident with non-invasive investigations; however, reports on its clinical benefits for patients with hematologic diseases are limited. The aim of our study was to investigate the utility of diagnostic bronchoscopy with BAL for those patients. Methods We retrospectively reviewed the clinical records of 37 consecutive BAL procedures in 33 adult patients with hematological diseases and pulmonary infiltrates with at least 6 months of follow-up between August 2013 and September 2017 (total 747 BAL procedures). The BAL results, ensuing treatment modifications, treatment outcomes, survival times, and adverse events were evaluated. Results Microbiological findings were detected in 11 (29.7%), even though wide-spectrum antibiotics and antifungal drugs had been empirically administered to most patients (>70%) prior to the bronchoscopy procedure. Overall, 25 of the 37 BAL procedures (67.6%) had some impact on the diagnosis of pulmonary diseases. Patients without specific diagnostic findings from BAL had a significantly poorer survival than those with diagnostic findings via BAL (30-day survival: 33.3% vs. 92.0%; 180-day survival: 8.3% vs. 64.0%). Four patients (12.1%) experienced complications associated with bronchoscopy; there were no procedure-related deaths. Conclusion BAL seems still important for diagnosing pulmonary infiltrates and/or excluding some of the important respiratory tract pathogens in patients with hematological diseases; furthermore, negative specific diagnostic findings from BAL may be associated with poor prognoses.

The utility and safety of flexible bronchoscopy in critically ill acute leukemia patients: a retrospective cohort study

PURPOSE

Flexible bronchoscopy with bronchoalveolar lavage (BAL) is commonly performed in immunocompromised patients. Nevertheless, it remains unclear whether bronchoscopy with BAL leads to changes in medical management or is associated with procedural complications among critically ill acute leukemia (AL) patients.

METHODS

We evaluated 71 AL patients who underwent diagnostic bronchoscopy with BAL in the intensive care unit (ICU) between 1 January 2007 and 31 December 2012. We recorded baseline characteristics, vital signs (before, during, and after the procedure), changes in medical management following the procedure, and procedural complications. Using a multivariable logistic regression model, we explored the relationship between patient characteristics and whether bronchoscopy changed management or caused complications. Patient characteristics included as predictors in the regression model were age, sex, immunosuppression status (those undergoing active chemotherapy), and the Acute Physiology And Chronic Health Evaluation II score.

RESULTS

The most common indication for ICU admission was respiratory failure (51 patients, 72%), followed by sepsis (14 patients, 20%). Overall, the results obtained from bronchoscopy with BAL were associated with a change in management in 32 patients (45%), most commonly a change in antimicrobial therapy as a result of an infectious pathogen being identified (17 patients, 24%). Complications were documented in nine patients (13%) and included post-procedural hypoxia (six patients, 8%), the need for intubation (one patient, 9% of non-intubated patients), and tracheal perforation (one patient, 1%). No clinically significant changes in patient vital signs were observed during or immediately following the procedure. Patient characteristics did not predict whether bronchoscopy was associated with changes in medical management or procedural complications in multivariable analyses.

CONCLUSIONS

Flexible bronchoscopy with BAL is relatively safe and helps to guide medical management among patients with AL admitted to the ICU.

Diagnostic Approach to Life-Threatening Pulmonary Infiltrates

Diagnosis of pulmonary disease is typically based upon consideration of presenting symptoms, physical examination, and pulmonary function testing in combination with classification of radiographic features, to guide diagnostic tests and initiate empiric treatment. When diagnostic efforts and/or empiric treatment fails, thoracic surgeons have traditionally been called upon to perform surgical biopsy of the lung to aid in the diagnosis of indeterminate, life-threatening pulmonary disease. Such biopsy has been requested specifically in the case of diffuse lung disease among patients receiving treatment for solid-organ or hematologic cancers, particularly when symptoms of respiratory failure progress and when noninvasive diagnostic tests and empiric treatments fail to halt progression. In such circumstances, radiologists, pulmonologists, and thoracic surgeons may be consulted and asked to provide tissue specimens that will allow rapid, accurate diagnosis leading to specific treatment. It is imperative that biopsy take place before respiratory failure supervenes [1], and that the specimens provided to clinical laboratories, pathologists, and microbiologists are comprehensive and properly preserved.

Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF)

Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.

Factors that increase diagnostic yield of surgical lung biopsy in pediatric oncology patients

PURPOSE

Recent data demonstrate that surgical lung biopsy in immunocompromised children, including oncology patients, alters therapy in only 50% of cases. We hypothesized that there are factors identifiable preoperatively which can predict the patients who will or will not benefit from surgical biopsy.

METHODS

We reviewed the medical records of all children with malignancy who underwent surgical lung biopsy between 2004 and 2013 at a single institution, excluding those children who had previously undergone a solid organ or bone marrow transplant.

RESULTS

Eighty lung wedge biopsies were performed (median age 13 years, IQR 5.25-16; 63% male, n=50) 53 (66%) of which led to a change in patient management. The majority of biopsies were performed to diagnose a new mass or differentiate infection from metastases (mass group) (n=68, 85%), and 12 biopsies (15%) were performed to diagnose a known infection for antibiotic guidance (infection group). Children in the infection group were more likely to be febrile preoperatively, were more likely to be an inpatient preoperatively, and had a lower absolute neutrophil count at the time of biopsy. Patients in the infection group had higher postoperative mortality rates and higher rates of major complications.

CONCLUSION

In pediatric oncology patients, surgical lung biopsy has a lower diagnostic yield and higher complication rate when performed for antibiotic guidance. Prior to proceeding with biopsy in this high-risk patient population, surgeons and oncologists should carefully weigh the potential risks and benefits.

Clinical utility of bronchoalveolar lavage and respiratory tract biopsies in diagnosis and management of suspected invasive respiratory fungal infections in children

BACKGROUND

Bronchoscopy with bronchoalveolar lavage (BAL) and respiratory tract biopsies are important tools for diagnosing fungal infections in children with cancer and hematopoietic stem cell transplant (HSCT) recipients. Our objective was to evaluate the impact of BAL and respiratory tract biopsies on the management of suspected fungal infections in oncology and HSCT patients.

PROCEDURE

We retrospectively reviewed the medical records of oncology and HSCT patients with possible, probable, or proven fungal infection of the respiratory tract and determined whether BAL or biopsy following computed tomography (CT) prompted a change in management.

RESULTS

Among 101 patients (0.5-29 years of age), 24 underwent a BAL and 31 had biopsies (27 lung and 4 sinus). The remaining 46 patients had CT scans only. Of these, there were radiographic findings suggestive of a fungal infection in 38 patients (83%). Thirty of these 38 patients (79%) had a change in management. BAL provided a diagnosis in 6 of 24 patients (25%). There was a change in management in 2 of the 6 (33%). Respiratory tract biopsy provided a diagnosis in 12 of 31 patients (39%). Biopsy results led to a change in management in 4 of the 12 patients (33%). Significant postoperative morbidity attributed to biopsy occurred in 3 of 31 patients (10%); 2 patients had pneumothorax requiring chest tube and intubation and a patient had prolonged intubation.

CONCLUSION

BAL and biopsy in children with an oncological diagnosis or those undergoing HSCT only infrequently lead to changes in management in the era of empiric therapy with broad-spectrum anti-fungal agents.

Bronchoalveolar lavage and lung biopsy in patients with cancer and hematopoietic stem-cell transplantation recipients: a systematic review and meta-analysis

PURPOSE

The objective of this study was to describe the diagnostic yield and complication rate of bronchoalveolar lavage (BAL) and lung biopsy in the evaluation of pulmonary lesions in patients with cancer and recipients of hematopoietic stem-cell transplantation (HSCT).

METHODS

We conducted a systematic literature review and performed electronic searches of Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Studies were included if patients had cancer or were recipients of HSCT, and if they underwent BAL or lung biopsy for the evaluation of pulmonary lesions. Only English language publications were included.

RESULTS

In all, 14,148 studies were screened; 72 studies of BAL and 31 of lung biopsy were included. The proportion of procedures leading to any diagnosis was similar by procedure type (0.53 v 0.54; P = .94) but an infectious diagnosis was more common with BAL compared with lung biopsy (0.49 v 0.34; P < .001). Lung biopsy more commonly led to a noninfectious diagnosis (0.43 v 0.07; P < .001) and was more likely to change how the patient was managed (0.48 v 0.31; P = .002) compared with BAL. However, complications were more common with lung biopsy (0.15 v 0.08; P = .006), and procedure-related mortality was four-fold higher for lung biopsy (0.0078) compared with BAL (0.0018).

CONCLUSION

BAL may be the preferred diagnostic modality for the evaluation of potentially infectious pulmonary lesions because of lower complication and mortality rates; thus, choice of procedure depends on clinical suspicion of infection. Guidelines to promote consistency in the approach to the evaluation of lung infiltrates may improve clinical care of patients.

Diagnostic value of bronchoalveolar lavage in leukemic and bone marrow transplant patients: the impact of antimicrobial therapy

There is significant morbidity and mortality from pneumonia in leukemic and bone marrow transplant patients. We sought to explore the diagnostic yield of bronchoalveolar lavage (BAL) in these patients with new pulmonary infiltrates. A retrospective chart review of approximately 200 Non- human immunodeficiency virus (HIV) leukemic and Hematopoietic stem cell transplantation (HSCT) patients who underwent bronchoscopy at a single academic cancer center was performed. Antimicrobial use for less than 24 hours at the time of BAL was associated with a higher yield in this population (56.8% versus 32.8%, p<0.001). This supports performing bronchoscopy with BAL within 24 hours of antimicrobial therapy in leukemic and HSCT patients.

Diagnostic value of bronchoscopy in patients with hematologic malignancy and pulmonary infiltrates

Pulmonary infections are a major cause of morbidity and mortality in patients with hematologic malignancy. Bronchoscopy is at present still the traditional first investigation in immunosuppressed patients that have developed pulmonary infiltrates. There is limited data available on the validity of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) to determine the etiology of pulmonary infiltrates with concurrent hematologic malignancy. We retrospectively analyzed the microbiological results of 206 bronchoscopic examinations and treatment changes used in 187 patients with hematologic malignancy and pulmonary infiltrates. Bacteria, fungi, and viruses were found in 85 (41.3 %), 49 (23.8 %), and 55 (28.6 %) of cases, respectively, and overall yield of bronchoscopy was 65.0 %. We compared the microbiological findings with respect to neutropenia, hematopoietic stem cell transplantation (HSCT) status, and the type of malignancy. There were significantly more bacterial and viral infections detected in post-HSCT patients, and more viruses were detected in patients without neutropenia. Galactomannan (GM) was measured in 149 BAL samples. With a GM index threshold of ≥0.5, the sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) of the BAL GM assay were 93.94 %, 86.21 %, 65.96 %, and 98.04 %, respectively. Treatment was modified in 62 cases (30.1 %). There was no significant relationship of treatment modification with the underlying disease, HSCT, or neutropenia. Bronchoscopy with BAL is a valuable diagnostic tool to determine the etiology and appropriate treatment in patients with hematologic malignancy and pulmonary infiltrates. A BAL GM test is recommended when invasive pulmonary aspergillosis is suspected.

Evaluation of human body fluids for the diagnosis of fungal infections

Invasive fungal infections are a major cause of morbidity and mortality in immunocompromised patients. Because the etiologic agents of these infections are abundant in nature, their isolation from biopsy material or sterile body fluids is needed to document infection. This review evaluates and discusses different human body fluids used to diagnose fungal infections.

Current issues in the clinical management of invasive aspergillosis--the AGIHO, DMykG, ÖGMM and PEG web-based survey and expert consensus conference 2009

The objectives of this study were to identify unsolved issues in the management of invasive aspergillosis, identify controversies and achieve consensus. The German Speaking Mycological Society (Deutschsprachige Mykologische Gesellschaft, DMykG) invited other German infectious diseases (ID) and mycological societies to submit unsolved issues concerning the diagnosis and treatment of invasive aspergillosis. Based on these contributions, a digital web-based questionnaire of 12 questions on Aspergillus spp. was designed to be completed by experts of the participating societies. Controversial results were identified by a mathematical model and were discussed at a consensus conference during the 43rd Annual Meeting of the DMykG in Cologne, Germany. Forty-two individuals completed the questionnaire. Analysis showed a strong consensus on effective preventive measures, choice of antifungal agents for pre-emptive, empiric and targeted treatment, as well as the evaluation of early chest CT control scans as a measure of treatment response assessment. Opinions on the indication for a pulmonary biopsy of a halo sign in high-risk neutropenic patients and on the role of Aspergillus spp. PCR as well as galactomannan from serum in the assessment of treatment duration diverged in spite of discussion such that a consensus could not be reached. Using a recently published two-step approach - web-based survey plus classical panel discussion - expert consensus was achieved on 10 of 12 questions concerning the diagnosis and treatment of invasive aspergillosis.

Does high-resolution CT has diagnostic value in patients presenting with respiratory symptoms after hematopoietic stem cell transplantation?

BACKGROUND

Hematopoietic stem cell transplantation (SCT) can be complicated by a variety of live-threatening infectious and non-infectious pulmonary complications. The management of these complications is critically dependent on the most probable diagnosis, which is in part based on imaging work-up.

METHODS

Systematic review of the literature related to the diagnostic value of high-resolution computed tomography (HRCT) in patients who underwent SCT and developed respiratory symptoms.

RESULTS

Literature review did not reveal systematic cohort studies that included patients with respiratory symptoms post-SCT who underwent HRCT and had a well-defined outcome. Most studies selected participants based on their final diagnosis instead of the indication for diagnostic testing in practice. Nevertheless, several papers clearly indicated a potential role for HRCT when complications after SCT occur. A variety of articles described the role of certain HRCT findings in the diagnosis of specific infectious complications, but less data were available for non-infectious complications.

CONCLUSION

We believe more diagnostic studies are needed to determine the value of HRCT for a specific diagnosis in SCT-recipients who present with respiratory symptoms at the transplant clinic. Currently, radiologists should be cautious since HRCT interpretation in these patients is not unambiguous.

Minimally Invasive Diagnostic Strategy in Immunocompromised Patients with Pulmonary Infiltrates

Acute respiratory failure (ARF) is the main reason for ICU admission in patients with haematological malignancies. High mortality rates of up to 50% are reported in this situation, and mortality is highest when mechanical ventilation is needed. Rapid and accurate diagnostic methods are needed in these vulnerable patients to ensure the prompt initiation of effective treatment. However, the broad array of possible cause of ARF raises diagnostic challenges. In this review, we discuss the DIRECT strategy, which identifies the most plausible diagnosis in each patient based on the type of immune deficiency and clinical presentation. We will focus on non-invasive laboratory tests developed in recent years, discussing their sensitivity and specificity. We also discuss the usefulness in cancer patients with specific organ dysfunctions of biomarkers introduced over the past few years.

Epidemiology of Acute Respiratory Failure in Patients with HM (ICU Only)

Pulmonary complications are common in hematological patients, particularly those receiving a hematological stem cell transplant (HSCT), and a significant percentage of them will require intensive care unit (ICU) admission. Acute respiratory failure in these patients is a threatening event, with a very poor outcome, particularly when mechanical ventilation (MV) is required. For many years, oncologists and intensivists had a pessimistic vision of the dismal outcome of those hematological patients requiring admission to the ICU. The bleak experience in this population led some authors to suggest early withdrawal of support, or even withholding the option of mechanical ventilation altogether. However, over the last years this vision seems to be changing. Great progress has been made in stem cell transplantation that can be ascribed to a better understanding of the human leukocyte antigen (HLA) system for donor selection, more effective and less toxic immunosupression for prevention and treatment of graft-versus host disease (GVHD), and significant advances in infectious disease therapy. Also improvements in ventilatory and supportive care, such as the early implantation of noninvasive ventilation (NIV), may avoid intubation in a significant percentage of patients suffering from acute respiratory failure. As a result of all this, the proportion of both hematological patients requiring management in the ICU and those requiring MV is decreasing. Also the survival rate of HSCT recipients admitted to the ICU has been steadily improving. In this chapter we will report on the epidemiology of acute respiratory failure in patients with hematological malignancies.

Diagnostic strategy for hematology and oncology patients with acute respiratory failure: randomized controlled trial

RATIONALE

Respiratory events are common in hematology and oncology patients and manifest as hypoxemic acute respiratory failure (ARF) in up to half the cases. Identifying the cause of ARF is crucial. Fiberoptic bronchoscopy with bronchoalveolar lavage (FO-BAL) is an invasive test that may cause respiratory deterioration. Recent noninvasive diagnostic tests may have modified the risk/benefit ratio of FO-BAL.

OBJECTIVES

To determine whether FO-BAL in cancer patients with ARF increased the need for intubation and whether noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL.

METHODS

We performed a multicenter randomized controlled trial with sample size calculations for both end points. Patients with cancer and ARF of unknown cause who were not receiving ventilatory support at intensive care unit admission were randomized to early FO-BAL plus noninvasive tests (n = 113) or noninvasive tests only (n = 106). The primary end point was the number of patients needing intubation and mechanical ventilation. The major secondary end point was the number of patients with no identified cause of ARF.

MEASUREMENTS AND MAIN RESULTS

The need for mechanical ventilation was not significantly greater in the FO-BAL group than in the noninvasive group (35.4 vs. 38.7%; P = 0.62). The proportion of patients with no diagnosis was not smaller in the noninvasive group (21.7 vs. 20.4%; difference, -1.3% [-10.4 to 7.7]).

CONCLUSIONS

FO-BAL performed in the intensive care unit did not significantly increase intubation requirements in critically ill cancer patients with ARF. Noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL for identifying the cause of ARF. Clinical trial registered with www.clinicaltrials.gov (NCT00248443).

Utility of early versus late fiberoptic bronchoscopy in the evaluation of new pulmonary infiltrates following hematopoietic stem cell transplantation

Pulmonary infiltrates frequently complicate hematopoietic SCT (HSCT). The utility of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) in the evaluation of new pulmonary infiltrates, particularly as it relates to optimal timing of the procedure, is unclear. Based on this, we retrospectively reviewed 501 consecutive, adult, nonintubated patients who underwent 598 BALs for evaluation of new pulmonary infiltrates during the first 100 days following HSCT to determine whether diagnostic yields for infection, subsequent antimicrobial treatment modifications and patient outcomes differed following early vs late referrals for the procedure. The overall yield of BAL for clinically significant pathogens was 55%. Notably, the yield was 2.5-fold higher among FOBs performed within the first 4 days of presentation (early FOB) compared to those performed late, and highest (75%) when performed within 24 h of clinical presentation. Rates of FOB-guided adjustments in antimicrobial therapy (51%) did not differ significantly between early and late examinations. However, late FOB-related antibiotic adjustments were associated with 30-day pulmonary-associated deaths that were threefold higher (6 vs 18%, P=0.0351). Major FOB-related complications occurred in only three (0.6%) patients. We conclude that early referral for FOB in this patient setting is associated with higher diagnostic yields and may favorably impact survival.

[Diagnostic strategy for acute respiratory failure in patients with haematological malignancy]

INTRODUCTION

About 15% of patients with haematological malignancy develop acute respiratory failure (ARF), necessitating admission to intensive care where their mortality is of the order of 50%.

STATE OF THE ART

The prognosis of these patients is not determined by the pathological characteristics of the malignancy but by the cause of the acute respiratory failure. In effect, the need to resort to mechanical ventilation in the presence of dysfunction of other organs dominates the prognosis. Even if the use of non-invasive ventilation in these patients has reduced the need for intubation and reduced the mortality, its prolonged use in the most severely affected patients prevents the optimal diagnostic and therapeutic management.

PERSPECTIVES

Fibreoptic bronchoscopy with broncho-alveolar lavage (BAL) is considered the cornerstone of aetiological diagnosis but its diagnostic effectiveness is poor, at best 50%, and this has led to increasing interest in high resolution CT scanning and regularly reawakens a transitory enthusiasm for surgical lung biopsy. Furthermore, in hypoxaemic patients, fibreoptic bronchoscopy with BAL may be the origin of the resort to mechanical ventilation, and thus increased mortality. The place of recently developed non-invasive tools is under evaluation. In effect, though the individual performance of diagnostic molecular techniques on sputum, blood, urine or naso- pharyngeal secretions has been established, the combination of these tools as an alternative to BAL has not yet been reported.

CONCLUSION

This review deals with acute respiratory failure in patients with haematological malignancy. It includes a review of the recent literature and considers the current controversies, in particular the risk-benefit balance of fibreoptic bronchoscopy with BAL in severely hypoxaemic patients.

Diagnostic bronchoscopy in hematology and oncology patients with acute respiratory failure: prospective multicenter data

OBJECTIVE

To describe the diagnostic yields of test strategies with and without fiberoptic bronchoscopy and bronchoalveolar lavage (FO-BAL), as well as outcomes, in cancer patients with acute respiratory failure (ARF).

DESIGN

Prospective observational study.

SETTING

Fifteen intensive care units in France.

PATIENTS

In all, 148 cancer patients, including 45 bone marrow transplant recipients (27 allogeneic, 18 autologous) with hypoxemic ARF.

INTERVENTION

None.

RESULTS

Overall, 146 causes of ARF were identified in 128 patients (97 [66.4%] pulmonary infections). The cause of ARF was identified in 50.5% of the 101 patients who underwent FO-BAL and in 66.7% of the other patients. FO-BAL was the only conclusive test in 34 (33.7%) of the 101 investigated patients. Respiratory status deterioration after FO-BAL occurred in 22 of 45 (48.9%) nonintubated patients, including 16 (35.5%) patients who required ventilatory support. Hospital mortality was 55.4% (82 deaths) overall and was not significantly different in the groups with and without FO-BAL. By multivariate analysis, mortality was affected by characteristics of the malignancy (remission, allogeneic bone marrow transplantation), cause of ARF (ARF during neutropenia recovery, cause not identified), and need for life-sustaining treatments (mechanical ventilation and vasopressors).

CONCLUSION

In critically ill cancer patients with ARF, a diagnostic strategy that does not include FO-BAL may be as effective as FO-BAL without exposing the patients to respiratory status deterioration.

Invasive diagnostic procedures for pulmonary infiltrates in pediatric hematopoietic stem cell transplant recipients

To evaluate the role of BAL, CTB, and OLB in the management of pulmonary infiltrates in pediatric HSCT recipients, we conducted a retrospective review of clinical records of pediatric HSCT recipients. Data were analyzed using Chi-square for dichotomous and anova for continuous variables. Logistic regression was used to adjust confounding variables for diagnostic yield. Forty patients underwent 44 separate procedures. Infections were the prevailing cause of infiltrates with a positive diagnostic yield (96%). CTB and OLB were performed more often in patients with focal infiltrates compared with BAL (100%, 71% vs. 22%; p < 0.01). Adverse events were not significantly different across the three procedures. OLB more often yielded information that led to change in medical management (71% vs. 0%, 34%; p < 0.05) compared with CTB and BAL. Patients who had a positive diagnostic yield had no apparent survival advantage when compared with those in whom a procedure yielded no information. Logistic regression demonstrated that focal infiltrate was the only independently predictive variable for identifying a cause of pulmonary infiltrate. In conclusion, all three invasive diagnostic procedures were safe. Having a focal infiltrate was independently and significantly associated with having a positive diagnostic yield.

Diagnostic accuracy of bronchoalveolar lavage samples in immunosuppressed patients with suspected pneumonia: analysis of a protocol

BACKGROUND

Fast and accurate etiologic diagnosis of pneumonia in immunocompromised patients is essential for a good outcome. Utility of bronchoalveolar lavage (BAL) samples has already been established, but studies about them are scarce and limited to few countries. We aimed to evaluate the accuracy of a diagnostic protocol, emphasizing on local epidemiology, rapidity, and yield of different techniques.

METHODS

One year prospective study of 101 consecutive immunosuppressed patients admitted with suspected pneumonia to a university hospital. They all had bronchoscopic BAL (n=109) and respiratory sampling. Conventional microbiological studies, cytomegalovirus pp65 antigenemia and transbronchial biopsy (TBB), whenever considered pertinent, were done. Results were analyzed along with other diagnostic procedures, clinical course and final outcome.

RESULTS

HIV/AIDS infection was the most frequent cause of inclusion (n=80). Infections accounted for 79 out of 122 final diagnoses (64.8%). Our protocol identified 60 infectious and 3 noninfectious pathologies (general yield: 51.6%). Sensitivity in pulmonary infections was 75.9% (IC95%: 64.8-84.6%), specificity 86.0% (72.6-93.7%), positive predictive value 89.6% (79.1-95.3%), negative predictive value 69.4% (56.2-80.1%), accuracy 79.8% (71.7-86.2%). Mycobacterium spp. (n=27), bacteria (n=19), Pneumocystis jirovecii (n=18) and other fungi (histoplasmosis: 6, aspergillosis: 5, cryptococosis: 3) were the most common infectious pathogens. Direct microscopy allowed an early definite/presumptive diagnosis in 36/49 fungal and mycobacterial infections (73.5%). Up to 30% of mycobacterial infections were missed.

CONCLUSIONS

Systematical study of BAL samples has a high diagnostic yield in our immunocompromised patients with suspected pneumonia. As economical and epidemiological conditions of regions are different, it should be tried everywhere.

Evaluation of persistent pulmonary infiltrates in pediatric oncology patients

PURPOSE

To evaluate the role of bronchoalveolar lavage (BAL), computed-tomography-guided biopsy (CTB), and open lung biopsy (OLB) in the management of persistent pulmonary infiltrates in pediatric oncology patients.

METHODS

Retrospective review of clinical records of pediatric oncology patients who underwent BAL, CTB, and OLB over a 7-year period. Data was compared across the three procedures using chi-square analysis. Logistic regression was used to adjust potential confounding variables for diagnostic yield.

RESULTS

There were 113 consecutive patients who underwent 140 separate procedures during their hospitalization. Thirty (26%) patients had a previous BMT. BALs were more likely to occur as the first line of investigation (98% vs. 47%, 45%; P < 0.01) and in patients with diffuse infiltrates (64% vs. 6%, 26%; P < 0.01) when compared to CTB and OLB, respectively. OLBs were performed less frequently in neutropenic patients (26% vs. 53%, 54%; P < 0.05), more often led to change in management directly because of procedure (61% vs. 12%, 33%; P < 0.01), and had higher diagnostic yield (61% vs. 24%, 36%; P < 0.01) when compared to CTB and BAL, respectively. Diagnostic yield of OLB was significantly higher regardless of diffuse or focal nature of infiltrate. Major adverse events after a procedure were not significantly different across the three procedures. Logistic regression demonstrated that having an OLB was independently associated with identifying the cause of pulmonary infiltrate.

CONCLUSION

OLB appears to be safe, has the best diagnostic yield, and leads to change in management more often than CTB or BAL in pediatric oncology patients with persistent pulmonary infiltrates.

Diagnostic strategy in cancer patients with acute respiratory failure

OBJECTIVE

Nearly 15% of cancer patients experience acute respiratory failure (ARF) requiring admission to the intensive care unit, where their mortality is about 50%. This review focuses on ARF in cancer patients. The most recent literature is reviewed, and emphasis is placed on current controversies, most notably the risk/benefit ratio of fiberoptic bronchoscopy and BAL in patients with severe hypoxemia.

BACKGROUND

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is the cornerstone of the causal diagnosis. However, the low diagnostic yield of about 50%, related to the widespread use of broad-spectrum antimicrobial therapy in cancer patients, has generated interest in high-resolution computed tomography (HRCT) and primary surgical lung biopsy. In patients with hypoxemia, bronchoscopy and BAL may trigger a need for invasive mechanical ventilation, thus considerably decreasing the chances of survival.

DISCUSSION

The place for recently developed, effective, noninvasive diagnostic tools (tests on sputum, blood, urine, and nasopharyngeal aspirates) needs to be determined. The prognosis is not markedly influenced by cancer characteristics; it is determined chiefly by the cause of ARF, need for mechanical ventilation, and presence of other organ failures. Although noninvasive ventilation reduces the need for endotracheal intubation and diminishes mortality rate, its prolonged use in patients with severe disease may preclude optimal diagnostic and therapeutic management. The appropriateness of switching to endotracheal mechanical ventilation in patients who fail noninvasive ventilation warrants evaluation.

CONCLUSION

This review discusses risks and benefits from invasive and non invasive diagnostic and therapeutic strategies in critically ill cancer patients with acute respiratory failure. Avenues for research are also suggested in order to improve survival in these very high risk patients.

Microbiologic features and outcome of pneumonia in transplanted patients

We prospectively evaluated lower respiratory tract infections in solid organ transplantation (SOT) patients to determine the microbiologic diagnosis and clinical outcomes. We diagnosed 83 cases of pneumonia, 38 of which were community acquired and 45 were nosocomial. Those with bilateral infiltrates or absence of improvement after 3 days of treatment underwent fiberoptic bronchoscopy. Bacterial pneumonia was the most frequent diagnosis and mixed infection predominated in the nosocomial group (11/45 nosocomial versus 1/38 community). Fiberoptic bronchoscopy with bronchoalveolar lavage had higher diagnostic yield in nosocomial pneumonia (77% versus 47%). Mortality differences between the 2 groups were 58% nosocomial versus 8% community-acquired infections (P < 0.001). SOT patients with nosocomial pneumonia, or those who needed mechanical ventilation, had a high mortality rate and benefits from the fiberoptic diagnostic techniques.

Natural history of pulmonary complications in children after bone marrow transplantation

We sought, in children after bone marrow transplantation (BMT), (1) to determine the natural history and incidence of pulmonary complications, (2) to evaluate the diagnostic yield of fiberoptic bronchoscopy and bronchoalveolar lavage (BAL); and (3) to determine the effect of bronchoscopy with lavage on patient outcome. The study design was a retrospective review in a tertiary care university hospital of all children undergoing BMT over a 5-year period. Patients were separated into 2 study groups: children with and without pulmonary complications. Pulmonary complications were defined as new or persistent pulmonary infiltrates on chest radiograph or chest computed tomography scan, respiratory symptoms, hypoxemia, or hemoptysis. Three hundred sixty-three pediatric patients underwent BMT between January 1, 1995, and December 31, 1999. Ninety patients (25%) developed pulmonary complications and were evaluated with bronchoscopy and BAL. Patients with pulmonary complications had a higher mortality (65% versus 44%; P < .01). The median posttransplantation survival for children with pulmonary complications was 258 days, compared with 1572 days in patients without pulmonary complications. The incidence of pulmonary complications was increased in patients with allogeneic BMT (P < .01). The time-dependent onset of severe (grade III to IV) graft-versus-host disease increased the relative risk of pulmonary complications by 2.0 (95% confidence interval, 1.1-3.7; P = .02). Pulmonary complications increased the time-dependent relative risk of mortality by 3.5 (95% confidence interval, 2.5-4.8). The diagnostic yield of bronchoscopy with lavage was 46% in patients undergoing BAL. Diagnostic bronchoscopy did not enhance either 30- or 100-day survival. Pathogen identification did not decrease mortality (P = .45). Pulmonary complications occur in 25% of children undergoing BMT and increase the risk of death in the first year after BMT. Although pathogen identification does not confer a survival advantage, rigorous, prospective screening may allow for earlier identification of pathogens and thereby provide a benefit to this uniquely vulnerable population.

Diffuse pulmonary infiltrates after bone marrow transplantation: the role of open lung biopsy

BACKGROUND

Diffuse pulmonary infiltrates is the major complication and cause of mortality after bone marrow transplantation. We analyzed the etiologies and prognostic factors in bone marrow recipients with diffuse pulmonary infiltrates and assessed the role of open lung biopsy in managing this complication.

METHODS

Medical records of patients with diffuse pulmonary infiltrates after bone marrow transplantation were reviewed. Possible prognostic factors were analyzed by multivariate logistic regression.

RESULTS

Sixty-eight (20%) of 341 bone marrow recipients had diffuse pulmonary infiltrates and 34 died. Thirty-five underwent open lung biopsy, resulting in therapeutic changes in 22 (63%) and clinical improvement in 16 (46%). The leading diagnoses were idiopathic interstitial pneumonitis (40%) and cytomegalovirus pneumonitis (20%). Cytomegalovirus pneumonitis caused radiographically observable interstitial infiltrates exclusively and was frequently associated with hepatitis. Idiopathic interstitial pneumonitis resulted in either diffuse ground-glass opacity or interstitial infiltrates. Three (9%) patients had miliary tuberculosis. Respiratory failure (p < 0.001) and acute graft-versus-host disease (p = 0.016) were the poor prognostic factors.

CONCLUSIONS

Among bone marrow recipients, we found diffuse pulmonary infiltrates in 20% and a mortality rate of 50%. Idiopathic interstitial pneumonitis and cytomegalovirus pneumonitis were the most common causes and should be suspected in patients with diffuse interstitial infiltrates. In endemic areas, miliary tuberculosis should be suspected in bone marrow recipients with diffuse reticulonodular lesions. Respiratory failure and acute graft-versus-host disease were poor prognostic factors. By establishing a correct diagnosis, open lung biopsy led to treatment changes in about two-thirds of these patients.

Pulmonary Infiltrates in the Non-HIV-Infected Immunocompromised Patient

Pulmonary complications remain a major cause of both morbidity and mortality in immunocompromised patients. When such individuals present with radiographic infiltrates, the clinician faces a diagnostic challenge. The differential diagnosis in this setting is broad and includes both infectious and noninfectious processes. Rarely are the radiographic findings classic for one disease, and most potential etiologies have overlapping clinical and radiographic appearances. In recent years, several themes have emerged in the literature on this topic. First, an aggressive approach to identifying a specific etiology is necessary; as a corollary, diagnostic delay increases the risk for mortality. Second, the evaluation of these infiltrates nearly always entails bronchoscopy. Bronchoscopy allows identification of some etiologies with certainty, and often allows for the exclusion of infectious agents even if the procedure is otherwise unrevealing. Third, early use of CT scanning regularly demonstrates lesions missed by plain radiography. Despite these advances, initial therapeutic interventions include the use of broad-spectrum antibiotics and other anti-infectives in order to ensure that the patients is receiving appropriate therapy. With the results of invasive testing, these treatments are then narrowed. Frustratingly, outcomes for immunocompromised patients with infiltrates remain poor.

Continuous veno-venous hemofiltration may improve survival from acute respiratory distress syndrome after bone marrow transplantation or chemotherapy

PURPOSE

Acute respiratory distress syndrome (ARDS) may result from immunologic activity triggered by irradiation and/or chemotherapy. Hemofiltration removes plasma water and soluble components below 25 kilodaltons. The authors hypothesized that early hemofiltration might attenuate the inflammatory component of ARDS, resulting in increased survival in immunocompromised children and young adults.

METHODS

Ten children (6 bone marrow transplantation, 3 chemotherapy, 1 lymphoma/hemophagocytosis) with ARDS (Pao2/Fio2 94 +/- 37 torr) received early continuous veno-venous hemodiafiltration as adjunctive therapy for respiratory failure, regardless of renal function. Six children had normal urine output and initial serum creatinine (range 0.1-1.2 mg/dL); four had renal insufficiency (initial creatinine 1.7-2.4 mg/dL). Hemofiltration was instituted coincident with intubation. Respiratory failure was precipitated by Enterobacter sepsis in two patients and by Aspergillus in one.

RESULTS

Hemodiafiltration was performed for 13 +/- 9 days. A high rate of clearance was achieved (52 +/- 17 mL/min/1.73 m2). Duration of mechanical ventilation was 14 +/- 9 days. Nine of the 10 children were successfully extubated; 8 survived.

CONCLUSIONS

Early hemofiltration may improve survival from ARDS following bone marrow transplantation or chemotherapy. Possible mechanisms include strict fluid balance, immunomodulation through filtration of inflammatory constituents, and immunomodulation through intensive extracellular water exchange that delivers biochemicals to organs of metabolism as well as the hemofilter.