Flexible bronchoscopy in the diagnosis of pulmonary infiltrates following autologous peripheral stem cell transplantation for advanced breast cancer

Diagnostic yield of flexible bronchoscopy for immunocompromised patients with lung infiltrates: A single-center, retrospective study

BACKGROUND

Pulmonary complications are associated with mortality in immunocompromised patients. The usefulness of bronchoscopy has been reported. However, clinical factors and procedures that influence diagnostic yield are still not established.

MATERIALS AND METHODS

We retrospectively analyzed 115 bronchoscopies performed on 108 immunocompromised patients, defined as those who take corticosteroids and/or immunosuppressants. We evaluated clinical factors, sampling procedures, final diagnosis, and severe complications of bronchoscopy.

RESULTS

The clinical diagnosis was obtained in 51 patients (44%). Of those, 33 cases were diagnosed as infectious diseases and 18 as non-infectious diseases. Nine out of 115 cases (7.8%) initiated new immunosuppressive treatment for an underlying disorder based on the negative microbiological results obtained with bronchoscopy. Collagen vascular disease was the most common underlying disorders (62 patients, 54%). Bronchoscopy was useful regardless of whether the patient was immunosuppressed to treat collagen vascular disease (P = 0.47). Performing transbronchial biopsy correlated with better diagnostic yield of bronchoscopy (54.7% vs 35.5%, P = 0.049). Other clinical factors, such as radiological findings, respiratory failure or antibiotic use at the time of bronchoscopy did not significantly influence diagnostic yield. Respiratory failure requiring intubation after bronchoscopy occurred only in one case (0.9%).

CONCLUSIONS

Our study implied the transbronchial biopsy may be a useful procedure for reaching a diagnosis in immunocompromised patients with pulmonary infiltrates. In addition, our data suggest the usefulness of bronchoscopy for immunocompromised patients due to the treatment of collagen vascular disease as well as other underlying disorders.

Utility of Transbronchial Biopsy in the Immunocompromised Host With New Pulmonary Radiographic Abnormalities

OBJECTIVE

To assess how often transbronchial biopsy (TBBx) added unique positive findings apart from other synchronous bronchoscopic sampling techniques including the bronchoalveolar lavage-immunocompromised host (BAL-ICH) panel that justified changes in management in an array of immunocompromised patients with new pulmonary radiographic abnormalities.

METHODS

We retrospectively reviewed all bronchoscopies performed at Mayo Clinic Rochester between January 2012 and December 2017; on the basis of the physician's selection of a BAL-ICH panel, we identified 192 immunocompromised patients who underwent bronchoscopy with both a BAL-ICH panel and TBBx. The results of the BAL-ICH panel and TBBx were compared and subsequent management decisions analyzed from clinical notes. We identified changes in immunosuppressive agents, antibiotics, chemotherapy, goals of care, and decisions on further evaluation and procedures. We assessed whether the TBBx findings added information not identified on the BAL-ICH panel and other bronchoscopic sampling methods performed during the same procedure that justified subsequent management changes.

RESULTS

Of 192 bronchoscopic procedures performed on immunocompromised patients with acute and subacute pulmonary radiographic abnormalities, management changes justified by the unique positive results of the TBBx occurred 28% (51/192) of the time. Those immunocompromised by solid malignant neoplasms and receiving active immunosuppressive therapy had management changes justified 62.1% (18/29) of the time by the TBBx results. No additional fungal organisms were identified on TBBx that were accounted for on the BAL-ICH panel.

CONCLUSION

Transbronchial biopsy may add information to other bronchoscopic findings in immunocompromised patients, especially those with solid malignant neoplasms receiving active immunosuppressive treatment. These potential benefits must be weighed against the risks inherent to the procedure.

Transbronchial biopsy in the management of pulmonary complications of hematopoietic stem cell transplantation

The utility of transbronchial biopsy in the management of pulmonary complications following hematopoietic stem cell transplantation has shown variable results. Herein, we examine the largest case series of patients undergoing transbronchial biopsy following hematopoietic stem cell transplantation. We performed a retrospective analysis of 130 transbronchial biopsy cases performed in patients with pulmonary complications post-hematopoietic stem cell transplantation. Logistic regression models were applied to examine diagnostic yield, odds of therapy change and complications. The most common histologic finding on transbronchial biopsy was a non-specific interstitial pneumonitis (n= 24 cases, 18%). Pathogens identified by transbronchial biopsy were rare, occurring in < 5% of cases. A positive transbronchial biopsy significantly increased the odds of a subsequent change in corticosteroid therapy (OR=3.12, 95% CI 1.18–8.23; p=0.02) but was not associated with a change in antibiotic therapy (OR=1.01, 95% CI 0.40–2.54; p=0.98) or changes in overall therapy (OR=1.92, 95% CI 0.79–4.70; p=0.15). Patients who underwent a transbronchial biopsy had increased odds of complications related to the bronchoscopy (OR=3.33, 95% CI 1.63–6.79; p=0.001). In conclusion, transbronchial biopsy may contribute to the diagnostic management of non-infectious lung injury post-hematopoietic stem cell transplantation, while its utility in the management of infectious pulmonary complications of HSCT remains low.

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.

Utility of flexible bronchoscopy in the evaluation of pulmonary infiltrates in the hematopoietic stem cell transplant population -- a single center fourteen year experience

INTRODUCTION

Pulmonary infiltrates are common within the hematopoietic stem cell transplant (HSCT) population and unfortunately portend an increased mortality. Bronchoscopy is often utilized as an initial diagnostic tool, but the literature supporting its diagnostic utility and effect on clinical management varies significantly. The aim of this study was to investigate the diagnostic ability, complication rate, and clinical impact of flexible bronchoscopy (FB) in evaluating pulmonary infiltrates in a large HSCT population.

PATIENTS AND METHOD

Retrospective review of all patients undergoing FB after HSCT in the Bone Marrow Transplant Unit from 1996 to 2009.

RESULTS

FB was performed 162times in 144patients with pulmonary infiltrates yielding positive results in 52.5%. The most common positive results were bacterial pneumonia (31%), fungal pneumonia (15%), and alveolar hemorrhage (11%). Treatment changes occurred in 44% of patients after FB. Treatment changes included antibiotic modification (59%), addition of corticosteroids (21%), antifungal modification (12%), and antiviral modification (7%). The overall complication rate associated with FB was 30%, although 84% of these complications were considered minor.

CONCLUSIONS

FB in patients with pulmonary infiltrates after HSCT should still be considered a valuable tool in the evaluation and management of pulmonary infiltrates in the HSCT population. Future prospective, multicenter randomized studies are needed to evaluate the overall clinical impact that bronchoscopic results and management changes have in this unique population.

Critical care of the hematopoietic stem cell transplant recipient

An estimated 50,000 to 60,000 patients undergo hematopoietic stem cell transplantation (HSCT) worldwide annually, of which 15.7% are admitted to the intensive care unit (ICU). The most common reason for ICU admission is respiratory failure and almost all develop single or multiorgan failure. Most HSCT recipients admitted to ICU receive invasive mechanical ventilation (MV). The overall short-term mortality rate of HSCT recipients admitted to ICU is 65%, and 86.4% for those receiving MV. Patient outcome has improved over time. Poor prognostic indicators include advanced age, poor functional status, active disease at transplant, allogeneic transplant, the severity of acute illness, and the development of multiorgan failure. ICU resource limitations often lead to triage decisions for admission. For HSCT recipients, the authors recommend (1) ICU admission for full support during their pre-engraftment period and when there is no evidence of disease recurrence; (2) no ICU admission for patients who refuse it and those who are bedridden with disease recurrence and without treatment options except palliation; (3) a trial ICU admission for patients with unknown status of disease recurrence with available treatment options.

Diagnostic approach of pulmonary disease in the HIV negative immunocompromised host

The advances in medicine have resulted in increasing number of immunocompromised patients with complications related to their underlying disease or the treatment of these conditions. Pulmonary infectious and non-infectious conditions are a major cause of morbidity and mortality in these patients, and represent a diagnostic challenge. This article reviews the major conditions causing pulmonary symptoms in the HIV negative immunocompromised host. It also discusses the role of the different diagnostic methods, including the recent advances in non-invasive studies, in reaching a diagnosis of pulmonary disease in this patient population.

Procedure diagnostiche invasive nelle malattie infiltrative diffuse del polmone

Le malattie polmonari che, già all’esordio clinico e/o nel loro decorso, coinvolgono più di un lobo e caratterizzate dall’accumulo od infiltrazione nel lobulo polmonare secondario di sostanze o cellule non normalmente presenti in tale sede o presenti, comunque, in quantità anomala, possono essere definite con il termine di pneumopatie infiltrative diffuse (PID) [1].

Retrospective utility of bronchoscopy after hematopoietic stem cell transplant

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is thought to be the procedure of choice to evaluate pulmonary infiltrates in hematopoietic stem cell transplant (HSCT) recipients. We retrospectively reviewed 91 bronchoscopies performed on 190 in-patient HSCT recipients admitted or treated for pneumonia from January 1994 to December 2004. These yielded a diagnosis 49% of the time with an overall survival of 35 days post-bronchoscopy. We were unable to detect any survival benefit from an addition to the treatment regimen after a positive result from analysis of the BAL fluid or transbronchial biopsy. The most common bacteria isolated was Pseudomonas that was often resistant to the patient's current antibiotics, suggesting that in lieu of this diagnostic procedure, changes to better cover resistant Gram-negative bacteria are reasonable. Although transbronchial biopsies provided an additional diagnosis in one out of 21 biopsies performed, six of the seven complications in our series were directly related to the transbronchial biopsy. With approximately a 50% yield from a bronchoscopy, additional treatment given after only 20% of all bronchoscopies, and no detectable survival benefit with a bronchoscopy that yielded a diagnosis, the utility of a bronchoscopy in this patient population is questioned by these data.

Acute Lung Injury After Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) has emerged as a common therapeutic option for a variety of life-threatening disorders, especially hematologic malignancies. Pulmonary complications are reported in 30% to 60% of all recipients and represent a major cause of mortality. A major proportion of these complications are the direct result of infection. This article addresses early, noninfectious causes of acute lung injury in the HSCT recipient.

Pulmonary complications following hematopoietic stem cell transplantation: diagnostic approaches

Pulmonary complications are a significant cause of morbidity and mortality in hematopoietic stem cell transplant recipients. Pulmonary infiltrates in such patients pose a major challenge for clinicians because of the wide differential diagnosis of infectious and noninfectious conditions. It is rare for the diagnosis to be made by chest radiograph, and commonly these patients will need further invasive and noninvasive studies to confirm the etiology of the pulmonary infiltrates. This review describes the role of the different diagnostic tools available to reach a diagnosis in a timely manner in this patient population.

Diagnostic Invasive Procedures in Diffuse Infiltrative Lung Diseases

The diagnosis of infiltrative diffuse lung disease may require invasive procedures after all noninvasive tools have failed. The clinical context in which these diseases develop and the radiological patterns are crucial for defining the timing and the methods to be used. Immunocompromised hosts are usually acutely ill with fever, cough, shortness of breath, and often with progressive hypoxemia. In this context a prompt diagnosis is necessary to decrease mortality. Bronchoalveolar lavage [especially in cases that show ground-glass attenuation or alveolar opacification in high-resolution CT scan (HRCT)] is the most important invasive procedure allowing the identification of infectious agents, neoplastic elements and characteristic cytological and phenotypical profiles (for drug injury) in the majority of cases. Less frequently transbronchial lung biopsy, transbronchial needle aspiration and biopsy or surgical lung biopsy are necessary. In immunocompetent patients the clinical spectrum of diffuse lung disease is quite broad. Furthermore, in the last two decades HRCT, used in conjunction with clinical and other noninvasive investigative modalities, has increased the accuracy of diagnosis for some diseases without the need of surgical biopsy. Also in these patients bronchoalveolar lavage, frequently in combination with transbronchial lung biopsy, is sufficient to achieve a definitive diagnosis in the majority of cases. Surgical lung biopsy is, however, still relevant in cases with idiopathic interstitial pneumonias. In this article invasive diagnostic procedures in patients with diffuse lung infiltrates are discussed from the perspective of their clinical context and their imaging characteristics.