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The Diagnostic Yield, Safety, and Impact of Flexible Bronchoscopy in Non-HIV Immunocompromised Critically Ill Patients in the Intensive Care Unit

  • Mazen O. Al-Qadi
  • Rodrigo Cartin-Ceba
  • Rahul Kashyap
  • Sumanjit Kaur
  • Steve G. Peters
BRONCHOSCOPY
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Abstract

Background

Flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) have major roles in the evaluation of parenchymal lung diseases in immunocompromised patients. Given the limited evidence, lack of standardized practice, and variable perception of procedural safety, uncertainty still exists on what constitutes the best approach in critically ill patients with immunocompromised state who present with pulmonary infiltrates in the era of prophylactic antimicrobials and the presence of new diagnostic tests.

Objective

To evaluate the diagnostic yield, safety and impact of FB and BAL on management decisions in immunocompromised critically ill patients admitted to the intensive care unit (ICU).

Methods

A prospective, observational study of 106 non-HIV immunocompromised patients admitted to the intensive care unit with pulmonary infiltrates who underwent FB with BAL.

Results

FB and BAL established the diagnosis in 38 (33%) of cases, and had a positive impact on management in 44 (38.3%) of cases. Escalation of ventilator support was not required in 94 (81.7%) of cases, while 18 (15.7%) required invasive and 3 (2.6%) required non-invasive positive pressure ventilation after the procedure. Three patients (2.6%) died within 24 h of bronchoscopy, and 46 patients (40%) died in ICU. Significant hypoxemia developed in 5% of cases.

Conclusion

FB can be safely performed in immunocompromised critically ill patients in the ICU. The yield can be improved when FB is done prior to initiation of empiric antimicrobials, within 24 h of admission to the ICU, and in patients with focal disease.

Keywords

Bronchoscopy Bronchoalveolar lavage Immunocompromised Critical care Intensive care 

Notes

Author Contributions

MOA, RCC, SGP: performed the literature searches, contributed in the study design, the acquisition, analysis and interpretation of data, and writing of the manuscript. RK: participated in data collection, analysis and interpretation. SK: participated in data collection. MOA, RCC, RK, SK, SGP: revised the manuscript.

Funding

This publication was supported by Grant Number UL1 TR000135 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NIH. The sponsors had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study, and the study was approved by the Mayo Foundation Institutional Review Board (IRB No. 13-004963). This article does not contain any studies with animals performed by any of the authors.

References

  1. 1.
    Kotloff RM, Ahya VN, Crawford SW (2004) Pulmonary complications of solid organ and hematopoietic stem cell transplantation. Am J Respir Crit Care Med 170:22–48CrossRefPubMedCentralGoogle Scholar
  2. 2.
    White P, Bonacum JT, Miller CB (1997) Utility of fiberoptic bronchoscopy in bone marrow transplant patients. Bone Marrow Transplant 20:681–687CrossRefPubMedCentralGoogle Scholar
  3. 3.
    Hiorns MP, Screaton NJ, Muller NL (2001) Acute lung disease in the immunocompromised host. Radiol Clin North Am 39:1137–1151CrossRefPubMedCentralGoogle Scholar
  4. 4.
    Conces DJ Jr (1998) Pulmonary infections in immunocompromised patients who do not have acquired immunodeficiency syndrome: a systematic approach. J Thorac Imaging 13(4):234–246CrossRefPubMedCentralGoogle Scholar
  5. 5.
    Oh YW, Effmann EL, Godwin JD (2000) Pulmonary infections in immunocompromised hosts: the importance of correlating the conventional radiologic appearance with the clinical setting. Radiology 217(3):647–656CrossRefPubMedCentralGoogle Scholar
  6. 6.
    Rañó A, Agustí C, Benito N, Rovira M, Angrill J, Pumarola T et al (2002) Prognostic factors of non-HIV immunocompromised patients with pulmonary infiltrates. Chest 122:253–261CrossRefPubMedCentralGoogle Scholar
  7. 7.
    Dunagan DP, Baker AM, Hurd DD, Haponik EF (1997) Bronchoscopic evaluation of pulmonary infiltrates following bone marrow transplantation. Chest 111:135–141CrossRefPubMedCentralGoogle Scholar
  8. 8.
    Fishman JA, Rubin RH (1998) Infection in organ-transplant recipients. N Engl J Med 338:1741–1751CrossRefPubMedCentralGoogle Scholar
  9. 9.
    Peikert T, Rana S, Edell E (2005) Safety, diagnostic yield, and therapeutic implications of flexible bronchoscopy in patients with febrile neutropenia and pulmonary infiltrates. Mayo Clin Proc 80(11):1414–1420CrossRefPubMedCentralGoogle Scholar
  10. 10.
    Goldstein RA, Rohatgi PK, Bergosfsky EH et al American Thoracic Society (1990) Clinical role of bronchoalveolar lavage in adults with pulmonary disease. Am Rev Respir Dis 142:481–486CrossRefPubMedCentralGoogle Scholar
  11. 11.
    Martin WJ II, Smith TF, Sanderson DR et al (1987) Role of bronchoalveolar lavage in the assessment of opportunistic pulmonary infections: utility and complications. Mayo Clin Proc 62:549–557CrossRefPubMedCentralGoogle Scholar
  12. 12.
    Stover DE, Zaman MB, Hajdu SI et al (1984) Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host. Ann Intern Med 101:1–7CrossRefPubMedCentralGoogle Scholar
  13. 13.
    Glazer M, Breuer R, Berkman N et al (1998) Use of fiberoptic bronchoscopy in bone marrow transplantation recipients. Acta Haematol 99:22–26CrossRefPubMedCentralGoogle Scholar
  14. 14.
    Marra R, Pagano L, Pagliari G et al (1993) The yield of bronchoal-veolar lavage in the etiological diagnosis of pneumonia in leukemia and lymphoma patients. Eur J Haematol 51:256 – 258CrossRefPubMedCentralGoogle Scholar
  15. 15.
    Von Eiff M, Zuhlsdorf M, Roos N et al (1995) Pulmonary infiltrates in patients with hematologic malignancies: clinical usefulness of non-invasive bronchoscopic procedures. Eur J Haematol 54:157–162CrossRefGoogle Scholar
  16. 16.
    Rano A, Agusti C, Jimenez P et al (2001) Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures. Thorax 56:379–387CrossRefGoogle Scholar
  17. 17.
    Eriksson B-M, Dahl H, Wang F-Z et al (1996) Diagnosis of pulmonary infections in immunocompromised patients by fiberoptic bronchoscopy with bronchoalveolar lavage and serology. Scand J Infect Dis 28:479–485CrossRefPubMedCentralGoogle Scholar
  18. 18.
    Huaringa AJ, Leyva FJ, Signes-Costa J et al (2000) Bronchoalveolar lavage in the diagnosis of pulmonary complications of bone marrow transplant patients. Bone Marrow Transplant 25:975–979CrossRefPubMedCentralGoogle Scholar
  19. 19.
    Pisani RJ, Wright AJ (1992) Clinical utility of bronchoalveolar lavage in immunocompromised hosts. Mayo Clin Proc 67:221–227CrossRefPubMedCentralGoogle Scholar
  20. 20.
    Cordonnier C, Bernaudin J-F, Fleury J et al (1985) Diagnostic yield of bronchoalveolar lavage in pneumonitis occurring after allogenic bone marrow transplantation. Am Rev Respir Dis 132:1118–1123Google Scholar
  21. 21.
    Young JA, Hopkin JM, Cuthbertson WP (1984) Pulmonary infiltrates in immunocompromised patients: diagnosis by cytological examination of bronchoalveolar lavage fluid. J Clin Pathol 37:390–397CrossRefPubMedCentralGoogle Scholar
  22. 22.
    Breuer R, Lossos IS, Lafair JS, Engelhard D (1990) Utility of bronchoalveolar lavage in the assessment of diffuse pulmonary infiltrates in nonAIDS immunocompromised patients. Respir Med 84(4):313–316CrossRefPubMedCentralGoogle Scholar
  23. 23.
    Jain P, Sandur S, Meli Y et al (2004) Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates. Chest 125(2):712–722CrossRefPubMedCentralGoogle Scholar
  24. 24.
    Azoulay E, Schlemmer B (2006) Diagnostic strategy in cancer patients with acute respiratory failure. Intensive Care Med 32(6):808–822CrossRefPubMedCentralGoogle Scholar
  25. 25.
    Aguilar-Guisado M, Jiménez-Jambrina M, Espigado I, Rovira M, Martino R, Oriol A et al (2011) Pneumonia in allogeneic stem cell transplantation recipients: a multicenter prospective study. Clin Transplant 25:E629–E638CrossRefPubMedCentralGoogle Scholar
  26. 26.
    De Pauw B, Walsh TJ, Donnelly JP, Stevens DA, Edwards JE, Calandra T et al (2008) Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis 46:1813–1821CrossRefPubMedCentralGoogle Scholar
  27. 27.
    Spitzer TR (2001) Engraftment syndrome following hematopoietic stem cell transplantation. Bone Marrow Transplant 27:893–898CrossRefPubMedCentralGoogle Scholar
  28. 28.
    Lucena CM, Torres A, Rovira M et al. (2014) Pulmonary complications in hematopoietic SCT: a prospective study. Bone Marrow Transplant.  https://doi.org/10.1038/bmt.2014.151 CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Cracco C, Fartoukh M, Prodanovic H et al (2013) Safety of performing fiberoptic bronchoscopy in critically ill hypoxemic patients with acute respiratory failure. Intensive Care Med 39(1):45–52CrossRefPubMedCentralGoogle Scholar
  30. 30.
    Shannon VR, Andersson BS, Lei X et al (2010) Utility of early versus late fiberoptic bronchoscopy in the evaluation of new pulmonary infiltrates following hematopoietic stem cell transplantation. Bone Marrow Transplant 45:647–665CrossRefPubMedCentralGoogle Scholar
  31. 31.
    Kottomann RM, Kelly J, Lyda E et al (2011) Bronchoscopy with bronchoalveolar lavage: determinants of yield and impact on management in immunosuppressed patients. Thorax 66(9):823CrossRefGoogle Scholar
  32. 32.
    Pue CA, Pacht ER (1995) Complications of fiberoptic bronchoscopy at a university hospital. Chest 107:430CrossRefPubMedCentralGoogle Scholar
  33. 33.
    Azoulay E, Mokart D, Lambert J et al (2010) Diagnostic strategy for hematology and oncology patients with acute respiratory failure: a randomized controlled trial. Am J Respir Crit Care Med 182(8):1038–1046CrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Section of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineYale University School of MedicineNew HavenUSA
  2. 2.Division of Pulmonary and Critical Care Medicine, Department of MedicineMayo ClinicRochesterUSA
  3. 3.Division of Critical Care, Department of AnesthesiaMayo ClinicRochesterUSA

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