1
|
[Clinical practice guidelines for bronchoalveolar lavage in Chinese children (2024)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:1-13. [PMID: 38269452 PMCID: PMC10817737 DOI: 10.7499/j.issn.1008-8830.2308072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/11/2023] [Indexed: 01/26/2024]
Abstract
Bronchoalveolar lavage (BAL) has become an important technique in the diagnosis and treatment of respiratory diseases in children. In order to standardize the clinical application of BAL in children, the Branch of Pediatric Critical Care Physicians of Chinese Medical Association, in collaboration with other institutions, has developed the "Clinical practice guidelines for bronchoalveolar lavage in Chinese children (2024)" based on the principles of the World Health Organization guidelines and the formulation/revision principles of the Chinese clinical practice guidelines (2022 edition). This guideline provides 30 recommendations to guide the operational procedures of BAL in children.
Collapse
|
2
|
Kaya AG, Öz M, Dilegelen U, Ecer D, Erol S, Çiftçi F, Çiledağ A, Kaya A. IS FLEXIBLE BRONCHOSCOPY A SAFE PROCEDURE FOR CRITICAL CARE PATIENTS WITH RESPIRATORY FAILURE? Acta Clin Croat 2023; 62:291-299. [PMID: 38549601 PMCID: PMC10969639 DOI: 10.20471/acc.2023.62.02.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/30/2021] [Indexed: 04/02/2024] Open
Abstract
Flexible bronchoscopy (FB) plays an important role in critical care patients. But, critical care patients with respiratory failure are at an increased risk of developing complications. Considering the developments in intensive care unit care in recent years, we aimed to evaluate the use of FB in these patients. We retrospectively reviewed patients who underwent FB in critical care between 2014 and 2020. A total of 143 patients underwent FB during the study period. Arterial blood gas measurement on the FB day revealed a mean PaO2/FiO2 of 186.94±28.47. Eighty-one (56.6%) patients underwent an fiberoptic bronchoscopy procedure under conventional oxygen supplementation, 10 (7%) on noninvasive ventilation, 13 (9.1%) on high flow nasal cannula, and 39 (27.3%) on invasive mechanical ventilation. During and immediately after bronchoscopy, none of the patients experienced life-threatening complications. Fifty-five (38.5%) patients developed complications that could be controlled. Multivariate analysis indicated that increased Apache-II score and presence of cardiovascular disease were significantly associated with an increased complication risk. Although critical care patients with respiratory failure are more prone to complications, diagnostic and therapeutic bronchoscopy may be performed following appropriate patient selection, without leading to major complications.
Collapse
Affiliation(s)
- Aslıhan Gürün Kaya
- Ankara University, Faculty of Medicine, Department of Chest Diseases, Ankara, Turkey
| | - Miraç Öz
- Ankara University, Faculty of Medicine, Department of Chest Diseases, Ankara, Turkey
| | - Umut Dilegelen
- Ankara University, Faculty of Medicine, Department of Chest Diseases, Ankara, Turkey
| | - Duygu Ecer
- Ankara University, Faculty of Medicine, Department of Chest Diseases, Ankara, Turkey
| | - Serhat Erol
- Ankara University, Faculty of Medicine, Department of Chest Diseases, Ankara, Turkey
| | - Fatma Çiftçi
- Ankara University, Faculty of Medicine, Department of Chest Diseases, Ankara, Turkey
| | - Aydın Çiledağ
- Ankara University, Faculty of Medicine, Department of Chest Diseases, Ankara, Turkey
| | - Akın Kaya
- Ankara University, Faculty of Medicine, Department of Chest Diseases, Ankara, Turkey
| |
Collapse
|
3
|
Lieveld AWE, Heldeweg MLA, Schouwenburg J, Veldhuis L, Haaksma ME, van Haaften RM, Teunissen BP, Smit JM, Twisk J, Heunks L, Nanayakkara PWB, Tuinman PR. Monitoring of pulmonary involvement in critically ill COVID-19 patients - should lung ultrasound be preferred over CT? Ultrasound J 2023; 15:11. [PMID: 36842163 PMCID: PMC9968403 DOI: 10.1186/s13089-022-00299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/27/2022] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND It is unclear if relevant changes in pulmonary involvement in critically ill COVID-19 patients can be reliably detected by the CT severity score (CTSS) and lung ultrasound score (LUSS), or if these changes have prognostic implications. In addition, it has been argued that adding pleural abnormalities to the LUSS could improve its prognostic value. The objective of this study was to compare LUSS and CTSS for the monitoring of COVID-19 pulmonary involvement through: first, establishing the correlation of LUSS (± pleural abnormalities) and CTSS throughout admission; second, assessing agreement and measurement error between raters for LUSS, pleural abnormalities, and CTSS; third, evaluating the association of the LUSS (± pleural abnormalities) and CTSS with mortality at different timepoints. METHODS This is a prospective, observational study, conducted during the second COVID-19 wave at the AmsterdamUMC, location VUmc. Adult COVID-19 ICU patients were prospectively included when a CT or a 12-zone LUS was performed at admission or at weekly intervals according to local protocol. Patients were followed 90 days or until death. We calculated the: (1) Correlation of the LUSS (± pleural abnormalities) and CTSS throughout admission with mixed models; (2) Intra-class correlation coefficients (ICCs) and smallest detectable changes (SDCs) between raters; (3) Association between the LUSS (± pleural abnormalities) and CTSS with mixed models. RESULTS 82 consecutive patients were included. Correlation between LUSS and CTSS was 0.45 (95% CI 0.31-0.59). ICCs for LUSS, pleural abnormalities, and CTSS were 0.88 (95% CI 0.73-0.95), 0.94 (95% CI 0.90-0.96), and 0.84 (95% CI 0.65-0.93), with SDCs of 4.8, 1.4, and 3.9. The LUSS was associated with mortality in week 2, with a score difference between patients who survived or died greater than its SDC. Addition of pleural abnormalities was not beneficial. The CTSS was associated with mortality only in week 1, but with a score difference less than its SDC. CONCLUSIONS LUSS correlated with CTSS throughout ICU admission but performed similar or better at agreement between raters and mortality prognostication. Given the benefits of LUS over CT, it should be preferred as initial monitoring tool.
Collapse
Affiliation(s)
- Arthur W. E. Lieveld
- grid.509540.d0000 0004 6880 3010Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Location VU Medical Center, Postbox 7507, 1007MB Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Micah L. A. Heldeweg
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Jasper Schouwenburg
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Lars Veldhuis
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Mark E. Haaksma
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Rutger M. van Haaften
- grid.509540.d0000 0004 6880 3010Section Emergency Radiology, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Berend P. Teunissen
- grid.509540.d0000 0004 6880 3010Section Emergency Radiology, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Jasper M. Smit
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Jos Twisk
- grid.509540.d0000 0004 6880 3010Department of Epidemiology and Data Science, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Leo Heunks
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Prabath W. B. Nanayakkara
- grid.509540.d0000 0004 6880 3010Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Location VU Medical Center, Postbox 7507, 1007MB Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| |
Collapse
|
4
|
Purinergic signaling during Marek's disease in chickens. Sci Rep 2023; 13:2044. [PMID: 36739336 PMCID: PMC9899245 DOI: 10.1038/s41598-023-29210-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Purinergic receptors (PRs) have been reported as potential therapeutic targets for many viral infections including herpesviruses, which urges the investigation into their role in Marek's disease (MD), a herpesvirus induced cancer in chickens that is an important pathogen for the poultry industry. MD is caused by MD virus (MDV) that has a similar viral life cycle as human varicella zoster virus in that it is shed from infected epithelial skin cells and enters the host through the respiratory route. In this report, PR responses during natural MDV infection and disease progression was examined in MD-resistant white Leghorns (WL) and MD-susceptible Pure Columbian (PC) chickens during natural infection. Whole lung lavage cells (WLLC) and liver tissue samples were collected from chickens infected but showing no clinical signs of MD (Infected) or presenting with clinical disease (Diseased). RNA was extracted followed by RT-qPCR analysis with gene specific primers against members of the P1, P2X, and P2Y PR families. Differential expression (p < 0.05) was observed in breed and disease conditions. Some PRs showed tissue specific expression (P1A1, P2X1, and P2X6 in WLLC) whereas others responded to MDV infection only in MD-susceptible (PC) chickens (P1A2A, P2X1, P2X5, P2X7). P2Y PRs had differential expression in both chicken lines in response to MDV infection and MD progression. This study is the first to our knowledge to examine PR responses during MDV infection and disease progression. These results suggest PR signaling may an important area of research for MDV replication and MD.
Collapse
|
5
|
Nesbitt N, Martin MJ, Escalante P. 65-Year-Old Man With Weight Loss and Dyspnea on Exertion. Mayo Clin Proc 2022; 97:1363-1368. [PMID: 35787863 PMCID: PMC9247626 DOI: 10.1016/j.mayocp.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 12/03/2021] [Accepted: 12/13/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Nathan Nesbitt
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Max J Martin
- Fellow in Pulmonary and Critical Care Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Patricio Escalante
- Advisor to resident and fellow and Consultant in Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
6
|
Menditto VG, Mei F, Fabrizzi B, Bonifazi M. Role of bronchoscopy in critically ill patients managed in intermediate care units - indications and complications: A narrative review. World J Crit Care Med 2021; 10:334-344. [PMID: 34888159 PMCID: PMC8613715 DOI: 10.5492/wjccm.v10.i6.334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/18/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023] Open
Abstract
Flexible bronchoscopy (FB) has become a standard of care for the triad of inspection, sampling, and treatment in critical care patients. It is an invaluable tool for diagnostic and therapeutic purposes in critically ill patients in intensive care unit (ICU). Less is known about its role outside the ICU, particularly in the intermediate care unit (IMCU), a specialized environment, where an intermediate grade of intensive care and monitoring between standard care unit and ICU is provided. In the IMCU, the leading indications for a diagnostic work-up are: To visualize airway system/obstructions, perform investigations to detect respiratory infections, and identify potential sources of hemoptysis. The main procedures for therapeutic purposes are secretion aspiration, mucus plug removal to solve atelectasis (total or lobar), and blood aspiration during hemoptysis. The decision to perform FB might depend on the balance between potential benefits and risks due to frailty of critically ill patients. Serious adverse events related to FB are relatively uncommon, but they may be due to lack of expertise or appropriate precautions. Finally, nowadays, during dramatic recent coronavirus disease 2019 (COVID-19) pandemic, the exact role of FB in COVID-19 patients admitted to IMCU has yet to be clearly defined. Hence, we provide a concise review on the role of FB in an IMCU setting, focusing on its indications, technical aspects and complications.
Collapse
Affiliation(s)
- Vincenzo G Menditto
- Department of Emergency Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona 60126, Italy
| | - Federico Mei
- Respiratory Diseases Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona 60126, Italy
| | - Benedetta Fabrizzi
- Cystic Fibrosis Regional Reference Center, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona 60126, Italy
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona 60126, Italy
| |
Collapse
|
7
|
Kang YR, Cha YK, Kim JS, Lee EK, Oh JY, Bak SH, Yoon HJ. Imaging findings of Stenotrophomonas maltophilia pneumonia: emphasis on CT findings between immunocompromised and immunocompetent patients. Acta Radiol 2020; 61:903-909. [PMID: 31698928 DOI: 10.1177/0284185119885117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Stenotrophomonas maltophilia (S. maltophilia) is a globally emerging, rare, waterborne, aerobic, gram-negative, multiple-drug-resistant organism, most commonly associated with respiratory tract infection in humans. Computed tomography (CT) findings in patients with S. maltophilia pneumonia are rarely reported. PURPOSE To compare CT findings between immunocompromised and immunocompetent patients, and to determine characteristic imaging findings of S. maltophilia pneumonia. MATERIAL AND METHODS CT findings of eight immunocompromised and 29 immunocompetent patients with proven S. maltophilia pneumonia were reviewed retrospectively. Different patterns of CT abnormalities between immunocompromised and immunocompetent patients were compared by Fisher's exact test. RESULTS Patchy ground-glass opacities (GGOs) were the most common CT findings, present in 36 (97.3%) of the 37 patients. Among the patients with patchy GGOs, consolidation was seen in 29 (78.4%) patients, and centrilobular nodules were noted in 15 (40.5%) patients. The transaxial distribution of the parenchymal abnormalities was predominantly randomly distributed in 30 (81.1%) cases. Regarding longitudinal plane involvement, the predominant zonal distributions were the diffuse distribution (n=23, 62.2%) and the lower lung zone (n=14, 37.8%). None of the patients showed upper lung zone predominance. The proportion of patients with parenchymal CT findings or associated findings in the immunocompromised patients was not significantly different from that of the immunocompetent patients. However, lower lung zone predominance on the longitudinal plane was significantly more common in immunocompetent patients than in immunocompromised patients (14/29 vs. 0/8, P=0.015). And diffuse distribution of parenchymal abnormalities on a longitudinal plane was significantly more frequent in immunocompromised patients than in immunocompetent patients (8/8 vs. 15/29, P=0.015). CONCLUSION The most common CT patterns of S. maltophilia pneumonia in immunocompromised and immunocompetent patients were patchy GGOs and consolidation. However, in immunocompetent patients, parenchymal abnormalities were more predominately distributed in lower lung zone than in immunocompromised patients; and in immunocompromised patients, parenchymal abnormalities were more diffusely distributed than in immunocompetent patients.
Collapse
Affiliation(s)
- Yeo Ryang Kang
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Yoon Ki Cha
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Jeung Sook Kim
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Eun Kyoung Lee
- Department of Radiology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Jin Young Oh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - So Hyeon Bak
- Department of Radiology, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Hyun Jung Yoon
- Department of Radiology, Veterans Health Service Medical Center, Seoul, Republic of Korea
| |
Collapse
|
8
|
Clinical Usefulness of Bronchoalveolar Lavage in the Management of Pulmonary Infiltrates in Adults with Hematological Malignancies and Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2020; 12:e2020025. [PMID: 32395214 PMCID: PMC7202335 DOI: 10.4084/mjhid.2020.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/04/2020] [Indexed: 01/04/2023] Open
Abstract
Introduction Pulmonary complications are frequent in patients with hematologic malignancies and stem cell transplantation. Regardless of the microbiological usefulness of bronchoalveolar lavage (BAL), little information exists on both its benefits as a guide for therapeutic decisions and its impact on patients’ clinical outcome. Methods A prospective observational single-center study was performed between July 2011 and July 2016. Consecutive episodes of pulmonary infiltrates were analyzed in subjects over 18 years of age who presented hematologic malignancies and underwent chemotherapy or stem cell transplantation. Results Ninety-six episodes of pulmonary infiltrates were analyzed. Acute leukemia was the most frequent underlying condition. Thirty-seven patients (38.5%) received a stem cell transplant. Sixty-one (62.9%) were neutropenic at the moment of inclusion in the study. A definitive etiologic diagnosis was obtained in 41 cases (42.7%), where infection accounted for the vast majority of cases (33 cases, 80.5%). Definitive diagnosis was reached by non-invasive methods in 13 cases (13.5%). BAL was performed in 47 cases and led to a diagnosis in 40.4% of the cases. BAL results led to therapeutic changes in 27 cases (57.4%), including the addition of new antimicrobials to empiric treatments in 10. Regarding BAL’s safety, two patients experienced minor adverse events and one a severe adverse event; no procedure-related deaths were observed. Conclusions Infection was the leading cause of pulmonary infiltrates in patients with hematologic malignancies and stem cell transplantation. BAL was a useful decision-making diagnostic tool, with minor adverse events.
Collapse
|
9
|
Morton C, Puchalski J. The utility of bronchoscopy in immunocompromised patients: a review. J Thorac Dis 2019; 11:5603-5612. [PMID: 32030281 DOI: 10.21037/jtd.2019.09.72] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Bronchoscopy is an important tool for the diagnosis of pulmonary disorders in immunocompromised patients. The addition of biopsies to bronchoalveolar lavage improves the diagnostic yield of non-infectious etiologies, although the underlying etiology of the immunocompromised state must be considered and may be influential. Certain unknowns remain, including timing of bronchoscopy and its impact on medical management and mortality. The ongoing role of non-invasive testing for infectious complications prior to bronchoscopy also remains to be defined. This review addresses the role of bronchoscopy in immunocompromised states related to underlying hematologic malignancies, prescription drug use or chemotherapy, and other disorders that predispose patients to infectious or non-infectious pulmonary diseases.
Collapse
Affiliation(s)
- Christopher Morton
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan Puchalski
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
10
|
Stanzani M, Sassi C, Battista G, Lewis RE. Beyond biomarkers: How enhanced CT imaging can improve the diagnostic-driven management of invasive mould disease. Med Mycol 2019; 57:S274-S286. [PMID: 31292659 DOI: 10.1093/mmy/myy125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/17/2018] [Accepted: 10/30/2018] [Indexed: 12/15/2022] Open
Abstract
CT imaging remains an essential diagnostic test for identification, staging and management of invasive mould infection (IMI) in patients with hematological malignancies. Yet the limited specificity of standard CT imaging can drive excessive antifungal use in patients, especially when more definitive diagnosis cannot be established through microbiology or invasive diagnostic procedures. CT pulmonary angiography (CTPA) is a complimentary, non-invasive approach to standard CT that allows for direct visualization of pulmonary arteries inside infiltrates for signs of angioinvasion, vessel destruction and vessel occlusion. Experience from several centers that are using CTPA as part of a standard diagnostic protocol for IMI suggests that a positive vessel occlusion sign (VOS) is the most sensitive and a specific sign of IMI in both neutropenic and non-neutropenic patients. CTPA is particularly useful in patients who develop suspected breakthrough IMI during antifungal prophylaxis because, unlike serum and/or BAL galactomannan and polymerase chain reaction (PCR) testing, the sensitivity is not reduced by antifungal therapy. A negative VOS may also largely rule-out the presence of IMI, supporting earlier discontinuation of empirical therapy. Future imaging protocols for IMI in patients with hematological malignancies will likely replace standard chest X-rays in favor of early low radiation dose CT exams for screening, with characterization of the lesions by CTPA and routine follow-up using functional/metabolic imaging such as 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (FDG-PET/CT) to assess treatment response. Hence, enhanced CT imaging techniques can improve the diagnostic-driven management of IMI management in high-risk patients with hematological malignancies.
Collapse
Affiliation(s)
- Marta Stanzani
- Institute of Hematology, "Lorenzo e Ariosto Seràgnoli" Department of Hematology and Clinical Oncology S'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Claudia Sassi
- Division of Radiology, Department of Experimental and Diagnostic Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Battista
- Division of Radiology, Department of Experimental and Diagnostic Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Russell E Lewis
- Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| |
Collapse
|
11
|
Mohan A, Madan K, Hadda V, Tiwari P, Mittal S, Guleria R, Khilnani GC, Luhadia SK, Solanki RN, Gupta KB, Swarnakar R, Gaur SN, Singhal P, Ayub II, Bansal S, Bista PR, Biswal SK, Dhungana A, Doddamani S, Dubey D, Garg A, Hussain T, Iyer H, Kavitha V, Kalai U, Kumar R, Mehta S, Nongpiur VN, Loganathan N, Sryma PB, Pangeni RP, Shrestha P, Singh J, Suri T, Agarwal S, Agarwal R, Aggarwal AN, Agrawal G, Arora SS, Thangakunam B, Behera D, Jayachandra, Chaudhry D, Chawla R, Chawla R, Chhajed P, Christopher DJ, Daga MK, Das RK, D'Souza G, Dhar R, Dhooria S, Ghoshal AG, Goel M, Gopal B, Goyal R, Gupta N, Jain NK, Jain N, Jindal A, Jindal SK, Kant S, Katiyar S, Katiyar SK, Koul PA, Kumar J, Kumar R, Lall A, Mehta R, Nath A, Pattabhiraman VR, Patel D, Prasad R, Samaria JK, Sehgal IS, Shah S, Sindhwani G, Singh S, Singh V, Singla R, Suri JC, Talwar D, Jayalakshmi TK, Rajagopal TP. Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations. Lung India 2019; 36:S37-S89. [PMID: 32445309 PMCID: PMC6681731 DOI: 10.4103/lungindia.lungindia_108_19] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.
Collapse
Affiliation(s)
- Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - GC Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - SK Luhadia
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - RN Solanki
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - KB Gupta
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Swarnakar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - SN Gaur
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Pratibha Singhal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Irfan Ismail Ayub
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shweta Bansal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prashu Ram Bista
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shiba Kalyan Biswal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ashesh Dhungana
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Doddamani
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Dilip Dubey
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Avneet Garg
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tajamul Hussain
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Hariharan Iyer
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Venkatnarayan Kavitha
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Umasankar Kalai
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Swapnil Mehta
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Noel Nongpiur
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - N Loganathan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - PB Sryma
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Prasad Pangeni
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prajowl Shrestha
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jugendra Singh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tejas Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sandip Agarwal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ritesh Agarwal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gyanendra Agrawal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Suninder Singh Arora
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Balamugesh Thangakunam
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - D Behera
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jayachandra
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhry
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Chawla
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Chawla
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prashant Chhajed
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Devasahayam J Christopher
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - MK Daga
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ranjan K Das
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - George D'Souza
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Raja Dhar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sahajal Dhooria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Aloke G Ghoshal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Goel
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Bharat Gopal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rajiv Goyal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neeraj Gupta
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - NK Jain
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Jindal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - SK Jindal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Surya Kant
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Katiyar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - SK Katiyar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Parvaiz A Koul
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jaya Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Raj Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Lall
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Mehta
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Nath
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - VR Pattabhiraman
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Dharmesh Patel
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rajendra Prasad
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - JK Samaria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shirish Shah
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Girish Sindhwani
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sheetu Singh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Virendra Singh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rupak Singla
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - JC Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Talwar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - TK Jayalakshmi
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - TP Rajagopal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
12
|
Choo R, Naser NSH, Nadkarni NV, Anantham D. Utility of bronchoalveolar lavage in the management of immunocompromised patients presenting with lung infiltrates. BMC Pulm Med 2019; 19:51. [PMID: 30808314 PMCID: PMC6390608 DOI: 10.1186/s12890-019-0801-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/04/2019] [Indexed: 02/08/2023] Open
Abstract
Background Bronchoalveolar lavage (BAL) is utilized for diagnosing lung infiltrates in immunocompromised. There is heterogeneity in the data and reported diagnostic yields range from 26 to 69%. Therefore, selection criteria for BAL to maximize yield and minimize complications are unclear. Objectives of this study were to determine the diagnostic yield and complication rate of BAL in immunocompromised patients presenting with lung infiltrates, and identify factors impacting these outcomes. Exploratory aims included characterization of pathogens, rate of treatment modification and mortality. Methods Retrospective study from January 2012 to December 2016. Patients on mechanical ventilation were excluded. Positive diagnostic yield was defined as confirmed microbiological or cytological diagnosis. Results A total of 217 patients were recruited (70.1% male and mean age: 51.7 ± 14.6 years). Diagnostic yield was 60.8% and complication rate 14.7%. Complications (hypoxemia and endobronchial bleeding) were all sell-limiting. Treatment modification based on BAL results was 63.3%. In 97.0% an infectious aetiology was identified. HIV infection (OR 5.304, 95% CI 1.611–17.458, p = 0.006) and severe neutropenia (OR 4.253, 95% CI 1.288–14.045, p = 0.018) were associated with positive yield. Leukemia (OR 0.317, 95% CI 0.102–0.982, p = 0.047) was associated with lower yield. No factors impacted complication rate. Overall mortality (90-day) was 17.5% and in those with hematologic malignancy, it was 28.3%. Conclusion BAL retains utility in diagnosis of immunocompromised patients with lung infiltrates. However, patients with hematologic malignancy have a high mortality and alternative sampling should be considered because of poor results with BAL. Trial registration ClinicalTrials.gov identifier NCT01374542. Registered June 16, 2011.
Collapse
Affiliation(s)
- Randall Choo
- Duke-NUS Medical School, Singapore, Singapore.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, S169856, Singapore, Singapore
| | - Naser Salman Hamza Naser
- Salmaniya Medical Complex, Manama, Bahrain.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, S169856, Singapore, Singapore
| | | | - Devanand Anantham
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, S169856, Singapore, Singapore.
| |
Collapse
|
13
|
Choo R, Anantham D. Role of bronchoalveolar lavage in the management of immunocompromised patients with pulmonary infiltrates. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:49. [PMID: 30906753 DOI: 10.21037/atm.2019.01.21] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pulmonary infiltrates are a significant cause of morbidity and mortality in immunocompromised patients and remain a diagnostic challenge due to the broad range of etiologies that include infection and malignancy. Empiric therapy may be sub-optimal and can adversely impact outcome. Therefore, a confirmed diagnosis is necessary and flexible bronchoscopy with bronchoalveolar lavage (BAL) may be a useful diagnostic tool. Samples are obtained for microbiological and cytological testing, but the procedure carries risk of complications including the adverse events related to moderate sedation. A review of published literature on BAL in immunocompromised patients from the year 2000 was undertaken focusing on diagnostic yield, complication rate, mortality as well as factors impacting these outcomes. Studies in which the majority of patients were supported on mechanical ventilation were excluded. A total of 23 studies (7 prospective and 16 retrospective) met inclusion criteria. This covered 3,395 procedures in 3,192 patients with a mean age of 47.4 years; 60.3% male gender. Diagnostic yield ranged from 26% to 69% with no clear association between diagnostic yield and etiology of immunosuppression or clinical/radiological presentation. Post BAL modification of treatment as an indicator for clinical utility ranged from 11% to 84%; and complication rate ranged from 1% to 52%. No specific factors were associated with increased adverse event rate. This review provides a summary of the data on the use of BAL for diagnosis of pulmonary infiltrates in immunocompromised patients, highlighting the heterogeneity of patients, significant variation in findings reported and the need for more data to optimize patient selection.
Collapse
Affiliation(s)
- Randall Choo
- Duke-NUS Medical School, Singapore.,Singapore Health Services, Singapore
| | - Devanand Anantham
- Singapore Health Services, Singapore.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| |
Collapse
|
14
|
Lachant DJ, Croft DP, McGrane Minton H, Hardy DJ, Prasad P, Kottmann RM. The clinical impact of pneumocystis and viral PCR testing on bronchoalveolar lavage in immunosuppressed patients. Respir Med 2018; 145:35-40. [PMID: 30509714 PMCID: PMC7126456 DOI: 10.1016/j.rmed.2018.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/21/2018] [Accepted: 10/21/2018] [Indexed: 11/25/2022]
Abstract
Introduction Pulmonary infiltrates in immunosuppressed patients are common. Yields from bronchoscopy with bronchoalveolar lavage (BAL) has been reported to be between 31 and 65%. The clinical impact of pneumocystis and viral Polymerase chain reaction (PCR) testing on BAL has not been extensively evaluated in a mixed immunosuppressed patient population. Methods We performed a retrospective chart review of immunosuppressed adults with pulmonary infiltrates who underwent BAL at the University of Rochester Medical Center. Only one BAL per patient was included. We compared the rate of positive PCR testing to conventional testing. We then investigated factors associated with positive PCR testing. Finally, we assessed for changes in antimicrobial therapy after bronchoscopy. Results Three hundred and fifty-nine patients underwent BAL with 249 patients having pneumocystis PCR testing and 142 having viral PCR testing. Pneumocystis identification occurred in 43 patients and viral species identification occurred in 56 patients. PCR testing increased pneumocystis identification compared to microscopy, 14% vs. 5%, p = 0.01, and viral identification compared to culture, 25% vs. 6%, p = 0.0001. Of the patients with positive pneumocystis PCR testing 49% had antibiotics stopped, 66% were started on anti-pneumocystis therapy, and only 6% did not receive treatment. There was no difference in the number of patients with antibiotics stopped based on viral PCR testing results. Discussion PCR testing increases BAL yield in immunosuppressed patients compared to conventional testing. Pneumocystis identified by PCR only may cause a self-limited infection and may not require antimicrobial therapy. PCR testing should be included in the evaluation of pulmonary infiltrates in immunosuppressed patients. Polymerase chain reaction testing has increased bronchoscopy yield. Pneumocystis is now being identified in non-HIV/AIDS with negative microscopy. Viruses are identified during bronchoscopy that were missed during nasal testing. Antimicrobial therapies are being changed based on testing results.
Collapse
Affiliation(s)
- Daniel J Lachant
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA.
| | - Daniel P Croft
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA
| | | | - Dwight J Hardy
- Department of Microbiology and Immunology, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA; Department of Pathology and Laboratory Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA
| | - Paritosh Prasad
- Division of Transplant Infectious Disease, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA; Division of Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA
| | - R Matthew Kottmann
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA
| |
Collapse
|
15
|
Ergan B, Nava S. The use of bronchoscopy in critically ill patients: considerations and complications. Expert Rev Respir Med 2018; 12:651-663. [PMID: 29958019 DOI: 10.1080/17476348.2018.1494576] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.
Collapse
Affiliation(s)
- Begum Ergan
- a Department of Pulmonary and Critical Care , School of Medicine, Dokuz Eylul University , Izmir , Turkey
| | - Stefano Nava
- b Department of Clinical , Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University , Bologna , Italy
| |
Collapse
|
16
|
Tang FF, Zhao XS, Xu LP, Zhang XH, Chen YH, Mo XD, Liu KY, Huang XJ. Utility of flexible bronchoscopy with polymerase chain reaction in the diagnosis and management of pulmonary infiltrates in allogeneic HSCT patients. Clin Transplant 2017; 32. [PMID: 29090481 PMCID: PMC7162290 DOI: 10.1111/ctr.13146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2017] [Indexed: 11/30/2022]
Abstract
Objectives Pulmonary infiltrates in allogeneic hematopoietic stem cell transplant (allo‐HSCT) patients are potentially life‐threatening and require early diagnosis and treatment. We aimed to retrospectively explore the clinical efficacy of polymerase chain reaction (PCR) in conjunction with flexible bronchoscopy (FB) in allo‐HSCT patients with pulmonary infiltrates. Patients and methods We retrospectively reviewed all patients undergoing FB after allo‐HSCT at the Peking University Institute of Hematology from January 2013 to December 2016. We used PCR to detect various viruses in FB specimens, particularly for 27 viruses. Results One hundred forty‐nine diagnostic FBs were performed in 130 patients. The overall diagnostic yield was 58%. Eighty‐nine percent of the patients with a positive FB result were diagnosed with a pulmonary infection. Viruses were the most common infectious diagnosis (70%), followed by fungi (48%), bacteria (38%), and Pneumocystis jirovecii (12%). Multivariate analyses showed that a chest computed tomography (CT) finding of diffuse pulmonary infiltrates (P = .012) and positive results in assisted microbiological and serological analyses (P = .000) predicted a positive FB result. FB results prompted a treatment modification in 61% of cases. Conclusions FB in conjunction with PCR is efficient in the rapid diagnosis and management of pulmonary infiltrates in allo‐HSCT patients.
Collapse
Affiliation(s)
- Fei-Fei Tang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Xiao-Su Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China
| |
Collapse
|
17
|
Harris B, Geyer AI. Diagnostic Evaluation of Pulmonary Abnormalities in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:317-331. [PMID: 28477642 PMCID: PMC7172342 DOI: 10.1016/j.ccm.2016.12.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pulmonary complications (PC) of hematologic malignancies and their treatments are common causes of morbidity and mortality. Early diagnosis is challenging due to host risk factors, clinical instability, and provider preference. Delayed diagnosis impairs targeted treatment and may contribute to poor outcomes. An integrated understanding of clinical risk and radiographic patterns informs a timely approach to diagnosis and treatment. There is little prospective evidence guiding optimal modality and timing of minimally invasive lung sampling; however, a low threshold for diagnostic bronchoscopy during the first 24 to 72 hours after presentation should be a guiding principle in high-risk patients.
Collapse
Affiliation(s)
- Bianca Harris
- Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Alexander I Geyer
- Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| |
Collapse
|
18
|
Abstract
http://onlinelibrary.wiley.com/doi/10.1111/resp.13049/abstract http://onlinelibrary.wiley.com/doi/10.1111/resp.13049/abstract
Collapse
Affiliation(s)
- Kyle R Brownback
- Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
19
|
Grønningsæter IS, Tsykunova G, Lilleeng K, Ahmed AB, Bruserud Ø, Reikvam H. Bronchiolitis obliterans syndrome in adults after allogeneic stem cell transplantation-pathophysiology, diagnostics and treatment. Expert Rev Clin Immunol 2017; 13:553-569. [DOI: 10.1080/1744666x.2017.1279053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Ida Sofie Grønningsæter
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Galina Tsykunova
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
| | - Kyrre Lilleeng
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
| | - Aymen Bushra Ahmed
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Medicine, Hematology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | |
Collapse
|
20
|
Brownback KR. When is a nodule more than a nodule? Eur J Haematol 2016; 96:3-4. [PMID: 25873325 DOI: 10.1111/ejh.12564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kyle R Brownback
- Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| |
Collapse
|
21
|
Oren I, Hardak E, Zuckerman T, Geffen Y, Hoffman R, Yigla M, Avivi I. Does molecular analysis increase the efficacy of bronchoalveolar lavage in the diagnosis and management of respiratory infections in hemato-oncological patients? Int J Infect Dis 2016; 50:48-53. [PMID: 27484225 DOI: 10.1016/j.ijid.2016.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES The identification of the specific pathogen responsible for a respiratory infection in patients with hematological malignancies (HM) would ensure relevant treatment and prevent toxicity associated with anti-infective therapy. This large-scale study aimed to explore the clinical impact of fiberoptic bronchoscopy with bronchoalveolar lavage (FOB-BAL) in conjunction with molecular analysis on the diagnosis and management of respiratory infections in hemato-oncological patients. METHODS All consecutive patients with HM and pulmonary infiltrates, who underwent FOB-BAL between January 2008 and January 2013, were included in the analysis. Clinical characteristics, FOB-BAL results, and treatment adjustments were recorded, and factors predicting a positive BAL were assessed. RESULTS Four hundred and twenty-five FOB-BAL procedures were analyzed. BAL revealed a specific diagnosis in 219 (51.5%) patients, 208 of them with a pulmonary infection. Infectious etiological agents found were mainly Aspergillus spp (n=142), bacterial species (n=44), and Pneumocystis jirovecii (n=34). Multivariate analysis showed that a lymphoproliferative disease, ≥2 symptoms (dyspnea/cough/hemoptysis/pleuritic pain), and less than 4 days between symptom appearance and FOB-BAL, predicted a positive FOB-BAL result. BAL results prompted a treatment modification in 48% of subjects. CONCLUSIONS FOB-BAL in conjunction with molecular assays is efficient in the rapid detection of life-threatening infections, allowing for adjustment of anti-infective therapy, which may result in better outcomes and reduce treatment-related toxicity.
Collapse
Affiliation(s)
- Ilana Oren
- Unit of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel; The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Emilia Hardak
- The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Division of Pulmonary Medicine, Rambam Health Care Campus, 8 Ha'Aliya Street, Haifa 31096, Israel.
| | - Tsila Zuckerman
- The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Yuval Geffen
- Clinical Microbiology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | - Ron Hoffman
- The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Mordechai Yigla
- The Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Division of Pulmonary Medicine, Rambam Health Care Campus, 8 Ha'Aliya Street, Haifa 31096, Israel
| | - Irit Avivi
- Department of Hematology and Bone Marrow Transplantation, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
22
|
Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Nguyen MH, Segal BH, Steinbach WJ, Stevens DA, Walsh TJ, Wingard JR, Young JAH, Bennett JE. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63:e1-e60. [PMID: 27365388 DOI: 10.1093/cid/ciw326] [Citation(s) in RCA: 1588] [Impact Index Per Article: 198.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 12/12/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
Collapse
Affiliation(s)
- Thomas F Patterson
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System
| | | | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, University of Manchester, United Kingdom
| | - Jay A Fishman
- Massachusetts General Hospital and Harvard Medical School
| | | | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Vicki A Morrison
- Hennepin County Medical Center and University of Minnesota, Minneapolis
| | | | - Brahm H Segal
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, and Roswell Park Cancer Institute, New York
| | | | | | - Thomas J Walsh
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | | | - John E Bennett
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
23
|
Role of bronchoalveolar lavage in the diagnosis of pulmonary infiltrates in immunocompromised patients. Curr Opin Infect Dis 2015; 27:322-8. [PMID: 24977681 DOI: 10.1097/qco.0000000000000072] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe the role of bronchoalveolar lavage (BAL) in the evaluation of pulmonary disease in immunocompromised patients. RECENT FINDINGS Recent discoveries in this field are largely in two areas: the array of diagnostic testing performed on BAL fluid and technical details that can enhance the yield from this procedure. Regarding diagnostic testing, the addition of new assays, including Aspergillus galactomannan antigen assay, respiratory viral panels, and Pneumocystis jirovecii PCR, has improved the diagnostic yield of BAL over conventional cultures and stains. To improve the diagnostic yield of the procedure itself, it should be done early in the clinical course, with the BAL in the anatomic area most affected, and with a preprocedural computed tomography of the chest to properly plan the procedure. SUMMARY Bronchoscopic evaluation with BAL can provide important diagnostic information in immunocompromised patients with pulmonary diseases and should be routinely performed when clinically indicated and able to be completed safely.
Collapse
|