Investigation and management of pulmonary infiltrates following bone marrow transplantation: an eight year review

Impact of bronchoalveolar lavage on the management of immunocompromised hosts

BACKGROUND

Respiratory infections are an important cause of morbidity and mortality in immunocompromised individuals. Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is an important tool to detect infectious agents in immunocompromised patients with low respiratory tract infections (LRTI).

RESEARCH QUESTION

BAL changes the management of immunocompromised patients with suspected LRTI.

STUDY DESIGN AND METHODS

Immunocompromised patients with a suspicion of LRTI underwent diagnostic BAL. The primary composite outcome consisted of pre-defined modifications in the management of the immunocompromised patients following BAL. We quantified the impact of bronchoscopy up to 30 days after the procedure.

RESULTS

A total of 2666 visits from 1301 patients were included in the study and immunosuppression was classified as haematological (n = 1040; 544 patients), solid organ transplantation (n = 666; 107 patients) and other causes (n = 960; 650 patients). BAL led to a change in management in 52.36% (n = 1396) of all cases. This percentage, as well as the 30-day mortality differed significantly amongst the three groups. Age, C-reactive protein and aetiology of infection determined significantly the risk of 30-day mortality in all patients. In 1.89% (n = 50) of all cases, a combination of 2 respiratory viral agents was identified and 24.23% (n = 646) were diagnosed with a single respiratory viral agent.

INTERPRETATION

BAL leads to changes in management in the majority of immunosuppressed patients. There is a high prevalence of multimicrobial infections and respiratory viral infections in immunocompromised patients with respiratory symptoms. Individual virus infection is associated with diverse risk of a negative outcome.

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.

Utility of bronchoscopy in the definitive diagnosis of patients with haematological malignancies presenting with radiological abnormalities

INTRODUCTION

Patients with haematological malignancies usually have a plethora of respiratory complications. Bronchoscopy is one of the most important procedures used to diagnose respiratory complications. Despite enormous benefit, patients should be carefully selected for bronchoscopy as the process is invasive; however, there are only few reports evaluating the contributing factors of bronchoscopy that result in the definitive diagnosis of respiratory complications in these patients.

OBJECTIVE

This study aimed to elucidate and identify the contributing factors of bronchoscopy for definitive diagnosis in patients with haematological malignancies.

METHODS

We retrospectively analysed 275 patients with haematological malignancies who later showed respiratory complications, requiring consultation with pulmonologists. We found that 62 patients underwent bronchoscopy. Our data analysis focused on this particular subset of patients to identify the factors crucial for definitive diagnosis via bronchoscopy.

RESULTS

Bronchoscopy provided definitive diagnosis for 25 patients (diagnostic yield = 40.3%). We determined that nodular shadow was associated with high diagnostic yields by multivariate logistic regression [odds ratio (OR): 6.6 (2.1-23)]. Furthermore, in several bronchoscopic procedures, biopsy also contributed to definitive diagnosis of patients with nodular shadow [OR: 17 (1.5-180)]. Life-threatening complications were not observed due to bronchoscopy in our study.

CONCLUSIONS

Our study demonstrated that patients with haematological malignancies who showed lung nodular shadows are more likely to be definitively diagnosed by bronchoscopy, whereas transbronchial biopsy may also be beneficial for these patients.

Microbiologic yield of bronchoalveolar lavage specimens from stem cell transplant recipients

PURPOSE

Stem cell transplant (SCT) recipients commonly undergo bronchoalveolar lavage (BAL) collection as an infectious pulmonary work-up. Previous studies report the utility and overall diagnostic yield of fiberoptic bronchoscopy with BAL in this vulnerable population, though none focused purely on microbiologic yield or made comparisons with less invasive means of pathogen detection. We sought to determine and elaborate on the microbiologic yield of BAL in SCT recipients, assess a correlation between BAL studies and less invasive means of pathogen detection, and assess the utility of repeating a BAL within 30 days.

METHODS

Between January 1, 2009, and July 31, 2013, we reviewed medical records of 125 SCT recipients who underwent 179 BALs. In addition to demographic information and details pertaining to their SCT, a comprehensive review of their microbiologic data was performed and recorded.

RESULTS

Our study showed an overall BAL microbiologic yield of 40%, despite 92% of patients receiving broad-spectrum antimicrobial therapy at the time of the BAL procedure.

CONCLUSIONS

Although an initial BAL sample in this population provides crucial microbiologic information, repeating the procedure within 30 days may have minimal additional microbiologic yield. BAL continues to be an essential diagnostic tool in SCT recipients undergoing an infectious pulmonary work-up.

The clinical importance of bronchoalveolar lavage in allogeneic SCT patients with pneumonia

Patients who undergo allogeneic hematopoietic SCT (HSCT) are prone to pulmonary infections. Between 1998 and 2004, a total of 450 patients underwent HSCT at Karolinska University Hospital, Huddinge. Pneumonia was diagnosed in 167 patients (37%), including 42 children. Bronchoalveolar lavage (BAL) was performed on 68 occasions in 57 patients (six children). In 110 patients (36 children) with pneumonia, BAL was not performed. BAL contributed to the diagnosis in 43 cases (63%) and to relevant findings in 53 cases: bacteria (n=13, 24%), viruses (n=28, 53%) and fungi (n=12, 23%). In 25 cases BAL was negative. In 15 of these cases, BAL was performed >or=4 days after chest X-ray, and in four cases not in the same segment as the infiltrations. The median time between radiographic findings and positive BAL was 2 (0-15) days, and a negative BAL 6 (1-30) days (P<0.001). Antimicrobial treatment was administered to 79% patients with positive findings, and to 92% with negative findings at the time of BAL. No serious complications due to the procedure were reported. BAL resulted in a changed treatment in 32/68 (47%) episodes of pneumonia. To conclude, BAL is a safe and useful diagnostic procedure that should be performed early after the onset of pneumonia following allogeneic HSCT.

[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.

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.

Utility of Positive Bronchoalveolar Lavage in Predicting Respiratory Failure After Hematopoietic Stem Cell Transplantation: A Retrospective Analysis

Pulmonary complications occur frequently after hematopoietic stem cell transplantation (HSCT) and account for considerable mortality when associated with respiratory failure. Bronchoalveolar lavage (BAL) is commonly used in the diagnostic evaluation of pulmonary infiltrates in HSCT patients. Although the yield of BAL is well established in this setting, the impact on outcome is controversial. In addition, respiratory failure in HSCT patients is associated with high mortality. To determine if positive BAL predicted less respiratory failure and better survival, a retrospective review (between 1992 and 1998) of all HSCT patients who had bronchoscopy with BAL as part of their diagnostic evaluation for new pulmonary infiltrates was performed. Twenty-one patients met the inclusion criteria. Eleven patients (52%) had a positive BAL, defined as the isolation of infectious microorganisms or pulmonary hemorrhage in the lavage specimen. Most of the positive findings were pathogenic organisms (bacterial, fungal, and viral). Respiratory failure (defined as need for both intubation and mechanical ventilation) occurred in 11 of 21 patients (52%)-8 of 11 (73%) who had positive BAL compared with 3 of 10 (30%) who had negative BAL (P = .09). The overall mortality rate was 11 of 21 patients (52%). All deaths except one occurred as a direct result of respiratory failure. Although this study confirmed the high mortality rate in HSCT patients with respiratory failure, the BAL results were not predictive of outcome.

[The patient with leukemia in the intensive care unit]

Patients with leukemia are prone to critical illness at some time during their disease and their therapy that requires critical care. A number of these patients will have the opportunity to receive curative treatment and have an excellent probability of long-term remission if supported through a crisis. Complications that cause critical illness can be categorized as related to disease or those caused by therapy. The present review is focused on the description of the types of complications requiring intensive care, on specific aspects of the application of critical-care techniques, on organization of the intensive care unit in the context of leukemia and on ethical considerations.

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.

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.

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.

Bronchoalveolar lavage in immunocompromised patients with haematological malignancy--value of new microbiological methods

PURPOSE

To assess the usefulness of new culture-independent microbiological methods to analyse bronchoalveolar lavage (BAL) fluid from haematological patients with clinical pneumonia.

PATIENTS AND METHODS

Results of 135 BALs from 122 disease episodes in 99 patients treated between 1996 and 2002 were retrospectively analysed. Forty-three patients had undergone haematopoietic stem cell transplantation and 56 patients had been treated with conventional chemotherapy for haematological malignancy. In addition to conventional microbiological methods, polymerase chain reaction (PCR) tests for Pneumocystis carinii, cytomegalovirus (CMV), Legionella sp., mycobacterium, Mycoplasma pneumoniae, and Chlamydia pneumoniae and the Aspergillus antigen test were performed.

RESULTS

Three (2.2%) quantitative and four (3.0%) special bacterial cultures gave an aetiological diagnosis. A respiratory virus was isolated in 10 episodes (8.2%). The diagnostic yield increased to 35.6% (48 of 135) by other methods. The P. carinii PCR test was positive in 21 of 24 patients with P. carinii pneumonia, being the only microbiological indication of P. carinii in four cases. The CMV PCR test was positive in 18 patients, but in 14 patients the clinical significance of the finding remained unproven. The Aspergillus antigen test was positive in seven of nine patients with aspergillosis, being the only microbiological indication of Aspergillus in three cases. The result of BAL indicated commencement of specific antimicrobial treatment in 27 episodes (22.1%).

CONCLUSION

The contribution of new culture-independent methods to the total diagnostic yield was of note. Among these methods, the P. carinii PCR and Aspergillus antigen tests proved the most valuable, while the CMV PCR test was not clinically useful.

Pulmonary infections in the late period after allogeneic bone marrow transplantation: chest radiography versus computed tomography

PURPOSE

To analyze the capabilities of chest roentgenogram (CXR) and computed tomography (CT) in the evaluation of pulmonary infectious disease in the late period (>100 days) after allogeneic bone marrow transplantation (BMT).

METHODS

Ninety-four matched CXR and CT examinations were performed for clinical suspicion of infectious lung disease. The time gap between CXR and CT was 48 h at maximum. The image pairs were correlated with the patients' clinical course and with the results of diagnostic bronchoalveolar lavage (BAL). An unremarkable clinical course over the subsequent seven days after imaging and/or negative microbiological culture served as the basis for excluding infectious lung disease. Positive microbiological culture and/or improvement of symptoms after antibiotic therapy were considered as evidence of infectious disease.

RESULTS

The correlation with the clinical course and/or BAL revealed a significantly higher sensitivity, negative predictive value, and accuracy for CT than for CXR (89% versus 58%, P < 0.0001; 78% versus 47%, P < 0.0001; 90% versus 68%, P < 0.0001, respectively). CT was significantly more diagnostic in BAL verified fungal and bacterial infections (P < 0.05).

CONCLUSION

CT is significantly superior to CXR in the evaluation of infectious pulmonary disease in the late phase after BMT. Therefore, an unremarkable CXR should be followed by a CT scan to reliably detect or to accurately exclude early pulmonary infection in these patients.

Pulmonary complications in bone marrow transplantation: a practical approach to diagnosis and treatment

Pulmonary complications occur in 40% to 60% of recipients of bone marrow trans-plants, account for more than 90% of mortality, and develop during identifiable phases. Phase 1 (Days 1-30) includes pulmonary edema; diffuse alveolar hemorrhage; and various bacterial, fungal, and viral infections; Phase 2 (Days 31-100) usually requires a distinction between cytomegalovirus pneumonitis and idiopathic pneumonia syndrome; and Phase 3 (Day 100+) includes complications that are due to chronic graft-versus-host disease and associated bronchiolitis obliterans. The spectrum of pulmonary complications has been influenced by changes in transplantation technique, prophylactic treatment for infections, and the use of new chemotherapeutic agents that contribute to lung injury. Nonetheless, infections remain a leading cause of morbidity and mortality. The most serious complications result in respiratory failure, for which the prognosis has not improved significantly over the last 2 decades. In this article, we describe our algorithmic approach to the diagnosis and management of these complications.

Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates

STUDY OBJECTIVE

To study the diagnostic role of flexible bronchoscopy (FB) in immunocompromised patients with pulmonary infiltrates.

DESIGN

Prospective, observational study.

SETTING

Tertiary care hospital.

PATIENTS

A total of 104 consecutive non-HIV-infected immunocompromised patients with lung infiltrates in whom FB was performed.

METHODS

The primary outcome measure was the diagnostic yield of FB, which was derived as the number of the diagnoses made using FB results divided by all final diagnoses. Final diagnoses were established using data from FB, surgical lung biopsy (SLB), and microbiology and serology testing, and by the clinical response to empiric therapy. We also studied the diagnostic yields of individual sampling procedures such as BAL, transbronchial biopsy (TBB), and protected-specimen brush (PSB) sampling.

RESULTS

Overall, 128 diagnoses were made in 104 patients. The overall diagnostic yield of FB was 56.2% (95% confidence interval [CI], 47 to 64%). FB provided at least one diagnosis in 53 of 104 patients (51%; 95% CI, 40 to 62%). FB was more likely to establish the diagnosis when the lung infiltrate was due to an infectious agent (81%; 95% CI, 67 to 90%) than to a noninfectious process (56%; 95% CI, 43 to 67%; p = 0.011). The diagnostic yields of BAL (38%; 95% CI, 30 to 47%) and TBB (38%; 95% CI, 27 to 51%) were similar (p = 0.94). The diagnostic yield of PSB sampling was lower (13%; 95% CI 6 to 24%; p = 0.001) than that of BAL. The combined diagnostic yield of BAL and TBB (70%; 95% CI, 57 to 80%) was higher than that of BAL alone (p < 0.001). Finally, the diagnostic yield of FB with PSB sampling, BAL, and TBB was similar to that of FB with BAL and TBB. The complication rate from FB was 21% (95% CI, 15 to 31%). Minor bleeding (13%) and pneumothorax (4%) were the most common complications.

CONCLUSIONS

FB has a high diagnostic yield in immunocompromised patients with pulmonary infiltrates. Based on our results, we recommend performing TBB in these patients, whenever possible.

Improved survival of critically ill cancer patients with septic shock

OBJECTIVE

To identify predictors of 30-day mortality in critically ill cancer patients with septic shock.

DESIGN

Retrospective study over a 6-year period.

SETTING

Twelve-bed medical intensive care unit (ICU).

PATIENTS

Eighty-eight patients (55 men, 33 women) aged 55 (43.5-63) years admitted to the ICU for septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eighty (90.9%) patients had hematological malignancies and eight (9.1%) had solid tumors; 47 patients (53.4%) were neutropenic, 19 (21.6%) were hematopoietic stem cell transplantation (HSCT) recipients, and 27 (30.7%) were in remission. Microbiologically documented infections were found in 60 (68.2%) patients. The Simplified Acute Physiologic Score II (SAPS II) and Logistic Organ Dysfunction (LOD) scores at ICU admission were 66 (47-89) and 7 (5-10), respectively, and the LOD score on day 3 was 8 (4-10). Sixty-eight (78.1%) patients received invasive mechanical ventilation (MV), 12 (13.6%) noninvasive MV, 22 (25%) dialysis. Thirty-day mortality was 65.5% (57/88). By multivariable analysis, mortality was higher when time to antibiotic treatment was >2 h [odds ratio (OR), 7.05; 95% confidence interval (95% CI), 1.17-42.21] and when DLOD (day 3-day 1 LOD score/day 3 LOD score) was high (OR, 3.47; 95% CI, 1.44-8.39); mortality was lower when admission occurred between 1998 and 2000 (OR, 0.23; 95% CI, 0.05-0.98) and when initial antibiotics were adapted (OR, 0.24; 95% CI, 0.06-0.09).

CONCLUSIONS

Earlier ICU admission and antibiotic treatment of critically ill cancer patients with septic shock is associated with higher 30-day survival. The LOD score change on day 3 as compared to admission is useful for predicting survival.

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

Flexible bronchoscopy is an important tool in the diagnosis of pulmonary complications following bone marrow transplantation. However, the value of this procedure in autologous peripheral stem cell transplant (APSCT) recipients with pulmonary complications is not well defined. We retrospectively evaluated the diagnostic yield of 27 consecutive bronchoscopies done on 23 APSCT recipients following high-dose chemotherapy for breast cancer. FB resulted in a positive diagnosis in 16 cases (59%). Broncheoalveolar lavage (BAL) was performed on all patients, and transbronchial biopsies (TBB) were carried out in 14. TBB were diagnostic in 10 (71%), with pulmonary drug toxicity as the most common finding (n = 8), followed by metastatic breast cancer (n = 2). BAL was diagnostic in six (22%): bacterial pneumonia (n = 3), aspergillosis (n = 2), Pneumocystis carinii pneumonia (n = 1) and Influenza B (n = 1). The procedure was well tolerated with no major complications except a small pneumothorax in one patient that did not require chest tube insertion. In conclusion, flexible bronchoscopy is a useful tool in the evaluation of pulmonary complications following APSCT for breast cancer. TBB can be done safely with relatively high diagnostic yield. Pulmonary drug toxicity is the most common pathological finding.

Fiberoptic bronchoscopy in allogeneic bone marrow transplantation: findings in the era of serum cytomegalovirus antigen surveillance

STUDY OBJECTIVES

Pulmonary complications occur in half of allogeneic bone marrow transplantation (BMT) patients. The incidence of these complications has been reduced by prophylaxis against Pneumocystis carinii pneumonia, preemptive therapy in patients at high risk for cytomegalovirus (CMV) reactivation, and, more recently, screening for serum CMV antigen. Since fiberoptic bronchoscopy (FOB) has historically been the primary diagnostic test to evaluate BMT patients with pulmonary disease, a review was performed to determine the impact, if any, that current prophylaxis and screening policies may have had on FOB utility.

DESIGN

The records of 174 adult patients undergoing BMT between January 1997 and December 1999 were reviewed to determine the diagnostic yield of FOB and the frequency by which FOB altered management.

RESULTS

Sixty-one patients underwent 76 bronchoscopies. FOB was diagnostic in 32 patients (42.1% of cases) and directly changed management in 24 patients (31.6% of cases). Half of these changes included the withdrawal of an antimicrobial agent. The most common findings were infection (32 cases) and diffuse alveolar hemorrhage (6 cases). CMV was the most prevalent infection identified, but FOB resulted in the addition of antiviral therapy to only two patients. P carinii pneumonia was not diagnosed in any patient studied.

CONCLUSIONS

These data suggest a changing spectrum of pulmonary disease in BMT patients. FOB has limited impact on the diagnoses of CMV disease or P carinii pneumonia with current prophylaxis and screening strategies. It may be useful in identifying other infectious etiologies and in eliminating unnecessary antimicrobials.

Bronchoscopic invasive diagnostic techniques in the cancer patient

The cancer patient often presents with fever and pulmonary infiltrates, in particular during the course of chemotherapy or after bone marrow transplantation. In these conditions, specific diagnoses are mainly related to an infective cause, but noninfectious processes, malignant or not, are also found alone or in combination with infection. Identification of the pulmonary process can be achieved by bronchoscopic techniques, including bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB). BAL may help identify opportunistic organisms but also bacterial pneumonia, provided quantitative cultures are performed, and TBB has been shown to increase the diagnostic yield of BAL. These two procedures should then be combined, provided there is no contraindication.

Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures

BACKGROUND

The development of pulmonary infiltrates is a frequent life threatening complication in immunocompromised patients, requiring early diagnosis and specific treatment. In the present study non-invasive and bronchoscopic diagnostic techniques were applied in patients with different non-HIV immunocompromised conditions to determine the aetiology of the pulmonary infiltrates and to evaluate the impact of these methods on therapeutic decisions and outcome in this population.

METHODS

The non-invasive diagnostic methods included serological tests, blood antigen detection, and blood, nasopharyngeal wash (NPW), sputum and tracheobronchial aspirate (TBAS) cultures. Bronchoscopic techniques included fibrobronchial aspirate (FBAS), protected specimen brush (PSB), and bronchoalveolar lavage (BAL). Two hundred consecutive episodes of pulmonary infiltrates were prospectively evaluated during a 30 month period in 52 solid organ transplant recipients, 53 haematopoietic stem cell transplant (HSCT) recipients, 68 patients with haematological malignancies, and 27 patients requiring chronic treatment with corticosteroids and/or immunosuppressive drugs.

RESULTS

An aetiological diagnosis was obtained in 162 (81%) of the 200 patients. The aetiology of the pulmonary infiltrates was infectious in 125 (77%) and non-infectious in 37 (23%); 38 (19%) remained undiagnosed. The main infectious aetiologies were bacterial (48/125, 24%), fungal (33/125, 17%), and viral (20/125, 10%), and the most frequent pathogens were Aspergillus fumigatus (n=29), Staphylococcus aureus (n=17), and Pseudomonas aeruginosa (n=12). Among the non-infectious aetiologies, pulmonary oedema (16/37, 43%) and diffuse alveolar haemorrhage (10/37, 27%) were the most common causes. Non-invasive techniques led to the diagnosis of pulmonary infiltrates in 41% of the cases in which they were used; specifically, the diagnostic yield of blood cultures was 30/191 (16%); sputum cultures 27/88 (31%); NPW 9/50 (18%); and TBAS 35/55 (65%). Bronchoscopic techniques led to the diagnosis of pulmonary infiltrates in 59% of the cases in which they were used: FBAS 16/28 (57%), BAL 68/135 (51%), and PSB 30/125 (24%). The results obtained with the different techniques led to a change in antibiotic treatment in 93 cases (46%). Although changes in treatment did not have an impact on the overall mortality, patients with pulmonary infiltrates of an infectious aetiology in whom the change was made during the first 7 days had a better outcome (29% mortality) than those in whom treatment was changed later (71% mortality; p=0.001).

CONCLUSIONS

Non-invasive and bronchoscopic procedures are useful techniques for the diagnosis of pulmonary infiltrates in immunocompromised patients. Bronchial aspirates (FBAS and TBAS) and BAL have the highest diagnostic yield and impact on therapeutic decisions.

Yield of bronchoalveolar lavage in ventilated and non-ventilated children after bone marrow transplantation

A study was undertaken to retrospectively evaluate the yield of bronchoalveolar lavage (BAL) in a single-institution series of children after bone marrow transplantation (BMT) and to compare the yield of BAL between the ventilated and nonventilated patients. We reviewed charts of 52 consecutive children after BMT who underwent BAL. Thirty patients (41 BALs) were nonventilated (group 1) and 33 patients (45 BALs) were ventilated for respiratory failure (group 2). Eleven patients were included in both groups. BAL was performed a median of 255 and 28.5 days after BMT in groups 1 and 2, respectively (P < 0.001). Group 1:17 pathogens were isolated from 13 BALs; a single pathogen from 10 BALs. Group 2:15 pathogens were isolated from 14 BALs (31.1% positive). Viruses were isolated from 13 BALs in group 2. A severe complication of BAL occurred in only one patient from group 1 (1.1%). Open lung biopsies were performed in one patient in group 1 and eight patients in group 2. The histological findings correlated with the BAL findings in 66.7%. In conclusion, there was no difference in the yield of BAL between the groups. Therapy was changed in one third of the patients dictated by the BAL findings. The risk of severe complications was relatively low. A good correlation between open lung biopsy (OLB) and BAL was found.

Bronchoscopic evaluation of pulmonary infiltrates following bone marrow transplantation

STUDY OBJECTIVE

To determine the impact of fiberoptic bronchoscopy (FOB), including quantitative bacterial cultures obtained by BAL and protected specimen brushing on therapeutic decisions and outcome in bone marrow transplant (BMT) patients.

DESIGN

Retrospective review of all BMT patients undergoing FOB during a 4-year period.

SETTING

A tertiary care university hospital.

RESULTS

Three hundred five patients underwent BMT; 71 (23%) had FOB to assess pulmonary infiltrates. Allogeneic BMT recipients underwent FOB 3.37 times more often than autologous recipients (p < 0.001). Pathogens were identified in 31 (46%) patients undergoing FOB; bacteria were most commonly isolated although 86% of patients had received broad-spectrum empiric antibiotics. Therapy was changed in 20 (65%) patients when a microorganism was identified and in 9 (22%) with nondiagnostic results (p = 0.0026), but isolation of a presumed pathogen had no apparent effect on survival. There were 19 (27%) FOB complications, including bleeding in 8 (11%) patients and death in 2 (3%). Major complications were associated with prolonged prothrombin time (p = 0.006) and were more common (36% vs 14%; p < 0.05) in patients who had protected specimen brushing vs BAL alone. Mortality at 40 months in BMT patients not requiring FOB was 33% compared with 61% mortality in those undergoing FOB (p < 0.001); mortality was 96% in patients with respiratory failure requiring mechanical ventilation.

CONCLUSION

FOB is diagnostically useful in the evaluation of some BMT patients with pulmonary complications and often influences therapy, although no impact on survival was clearly demonstrated. FOB should be performed only after benefits of the procedure are weighed carefully against its increased risk in this select population.

Critical care of the patient with hematologic malignancy

Patients with leukemia, lymphoma, or multiple myeloma are prone to critical illness because of the diffuse nature of their disease and the disruption of protective mechanisms. Despite high morbidity rates, a number of these patients have an excellent probability of long-term remission if supported through a crisis. Complications that cause critical illness can be categorized as related to disease or those caused by therapy. Those with unique features or management strategies for the hematologic malignancy patient and are included in this discussion include: leukostasis, disseminated intravascular coagulation, tumor lysis syndrome, respiratory failure, and typhlitis. A case study of an acutely ill, newly diagnosed patient with several of these oncologic emergencies is used to exemplify typical clinical finds and management strategies.