The safety and usefulness of routine bronchoscopy before stem cell transplantation and during neutropenia

Abstract

Summary:Fibreoptic bronchoscopy with bronchoalveolar lavage (BAL) is used for clinical investigation and research into pulmonary complications of stem cell transplantation. Adverse effects of BAL are common in neutropenic patients with lung disease; there are few data on its safety when used routinely in transplant recipients without lung impairment. We describe the complications and usefulness for infection surveillance of routine BAL pre-transplantation and during neutropenia. Thirtythree patients before autologous or allogeneic BMT or PBSCT (B1) and 24 during post-transplant neutropenia (B2) underwent BAL; patients with pulmonary disease were excluded. Subjects were monitored for adverse effects, and BAL fluid was examined for pathogens. Complications of B2 were compared with events seen in 35 neutropenic patients who did not undergo BAL (C).Eighteen percent B1 and 33% B2 subjects showed complications of BAL. Fever occurred in 12% B1 and 26% previously afebrile B2 subjects, compared to 11% of C (P = 0.3). Epistaxis occurred in one B2 subject and two C. Potentially pathogenic organisms were isolated from 18% B1 and 13% B2 BAL fluids; none caused later respiratory infection. Bronchoscopy and BAL pre-and post-transplant had acceptable safety for a research procedure, but were not clinically helpful for infection surveillance.

Therapeutic implication of BAL in patients with neutropenia

“…Additionally, most neutropenic patients with pneumonia receive antifungal drugs according to international guidelines [16,18,19,26]. It is known that previous antimicrobial treatment lowers the yield of BAL culture and is probably responsible for the low impact on treatment changes [4,5,7,9,30]. We could demonstrate as well, that positive bacterial BAL results were significantly less common in patients who underwent antibacterial prophylaxis than in patients who did not.…”

“…There exist some data that support a frequent use of BAL in immunocompromised patients with pulmonary infiltrates [8,14,21]. But, especially in severely ill patients with neutropenia, BAL is associated with a high rate of complications [2,11,30]. Therefore, the application of BAL in this setting should be considered carefully.…”

“…The diagnostic yield of BAL published for neutropenic patients with pneumonia ranged between 13% and 53% [3,5,9,11,21,27,30]. Nearly all of these data were collected in retrospective studies.…”

“…It has been shown in patients with different kinds of immunosuppression that BAL may provide a diagnostic yield in 13 to 60% of cases [2,8,14,15,24,25,29]; but there exists only a few data concerning BAL in patients with pneumonia during neutropenia [3,5,9,11,21,27,30]. Maschmeyer et al [19] recommended BAL in febrile neutropenic patients not responding to empirical antimicrobial therapy, in case of positive chest radiography findings.…”

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

“…5 Flexible fiber-optic bronchoscopy with bronchoalveolar lavage (BAL) has generally been considered to be a safe and accurate procedure for the evaluation of pulmonary complications in such patients. 3,6 In previous studies, however, the reported diagnostic yield has been highly variable and the identification of a pathogen using bronchoscopy does not seem to influence mortality. 7,8 In this study, we evaluated the incidence, etiology and outcome of pneumonia, and the safety and value of BAL for establishing the diagnosis in patients transplanted at the Karolinska University Hospital, Stockholm.…”