The Role of Surveillance Bronchoscopy Post-Lung Transplantation

Abstract

Surveillance bronchoscopies with transbronchial lung biopsies (TBBx) are often performed post-lung transplantation, but the clinical value and impact on outcomes remain controversial. Given the cost and risks associated with TBBx, some centers only perform bronchoscopy for specific clinical indications or events. Although the presence of specific histological features (especially acute cellular rejection or lymphocytic bronchiolitis) have been associated with higher risk of chronic lung allograft rejection, the routine use of mandated TBBx has not been shown to alter clinical outcomes. However, prospective, randomized studies have not been done. Further, there are limited published data regarding the value of performing follow-up TBBx to ensure resolution of prior rejection events. On the other hand, putative benefits of TBBx include the ability to fine tune immune suppression and detect infection and large airway stenoses that may require more aggressive measures to minimize development of strictures and thereby prevent downstream post obstructive bronchiectasis. This review discusses the technique of TBBx, histological criteria for allograft rejection (acute and chronic), complications associated with TBBx (particularly pneumothoraces, hypoxemia, and bleeding), and putative benefits associated with mandated surveillance TBBx in this complex patient population.

Bronchoscopic procedures and lung biopsies in pediatric lung transplant recipients

“…Uniquely among the recipients of organ transplants, the connection of the allograft via the airways to the outside environment provides a route for fibre‐optic bronchoscopy to simply undertake this. Bronchoscopy has proven itself to have a central role in LTx management …”

“…Bronchoscopy has proven itself to have a central role in LTx management. 1 In the pre-LTx period, bronchoscopic assessment of donor secretions, airway anatomy, and hemorrhage are important in providing microbiological specimens and understanding donor quality. Immediately post-LTx, bronchoscopic airway toileting, assessment of bronchial anastomotic healing, and patency is also required.…”

Altered Exosomal RNA Profiles in Bronchoalveolar Lavage from Lung Transplants with Acute Rejection

“…AR detection requires invasive lung biopsy, which has poor sensitivity (7) and inherent risks (8). Because of this, intense surveillance for AR is limited, reducing early recognition.…”

Surveillance Bronchoscopy: Is It Still Relevant?

“…When performing TBBX, consideration must be given to the potential for sampling error. 37 Cellular rejection is a heterogeneous process and therefore if insufficient amount of tissue is obtained rejection may be missed simply because an appropriate area of lung has not been sampled. Guidelines from the Lung Rejection Study Group (LRGS) recommend a minimum of five pieces of evaluable (2-3 mm; containing a minimum of 100 alveoli per high power field), wellexpanded alveolar parenchyma from two separate lobes to provide adequate sensitivity for diagnosing ACR.…”

“…The advent of serological PCR testing for cytomegalovirus (CMV) has allowed us to diagnose CMV infection without the need to perform biopsies. 37,55…”