The influence of diagnostic bronchoscopy on clinical outcomes comparing adult autologous and allogeneic bone marrow transplant patients
ABSTRACT To review our experience with diagnostic bronchoscopy in the evaluation of pulmonary infiltrates in adult hematopoietic stem cell transplantation (HSCT) recipients in the era of Pneumocystis prophylaxis and cytomegalovirus antigen testing. The study focused on diagnostic yields and the influence of bronchoscopic findings on pharmacologic therapy and mortality, comparing allogeneic (allo) HSCT patients to autologous (auto) HSCT patients.
Case series review.
Tertiary care academic urban medical centers.
All adult allo-HSCT and auto-HSCT patients undergoing bronchoscopy for the evaluation of pulmonary infiltrates from January 1997 to September 2001.
The review identified 169 bronchoscopies that had been performed on HSCT patients, representing 12.5% of all HSCT patients (allo-HSCT patients, 125 bronchoscopies; auto-HSCT patients, 44 bronchoscopies). Bronchoscopy was requested more often in allo-HSCT patients (18.7%) compared to auto-HSCT patients (6.6%). Findings at bronchoscopy provided a specific diagnosis more frequently in allo-HSCT patients (50%) compared to auto-HSCT patients (34%). For both allo-HSCT and auto-HSCT patients, most diagnoses were obtained by BAL alone, whereas transbronchial biopsy (TBBx) provided additional specific information in < 10% of cases. For select patients (n = 27), surgical lung biopsy following bronchoscopy provided unique diagnoses in 47 to 50% of cases. Information from bronchoscopy influenced clinical decisions more often in allo-HSCT patients (50%) than in auto-HSCT patients (36%), and allowed for the discontinuation or addition of antimicrobial, corticosteroid, or antineoplastic agents to treatment. Complications from bronchoscopy occurred in 9% of all HSCT patients (n = 15), and were associated with higher in-hospital mortality rates in allo-HSCT patients (82%; n = 9) compared to auto-HSCT patients (50%; n = 2). The overall in-hospital mortality rates for allo-HSCT and auto-HSCT patients having bronchoscopy was similar (38% vs 27%, respectively; p = 0.25), and establishing a specific diagnosis by bronchoscopy did not improve the in-hospital mortality rate for allo-HSCT or auto-HSCT patients.
Bronchoscopy may provide clinically useful information in the evaluation of adult allo-HSCT and auto-HSCT recipients with pulmonary infiltrates. The results of testing BAL fluid samples alone suggested an etiology in most cases, whereas the findings of TBBx provided unique diagnoses infrequently. Further studies are warranted to improve the utility of diagnostic bronchoscopy in the evaluation of HSCT patients.
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ABSTRACT: Diffuse alveolar hemorrhage (DAH) is characterized by diffuse pulmonary infiltrates on chest radiograph, hypoxemia, progressively bloodier return, or ≥20% hemosiderin-laden macrophages of bronchoalveolar lavage fluid, and the absence of cardiac or infectious causes. The incidence, clinical course, treatment, and prognosis of DAH in patients with hematologic malignancy, but without blood and marrow transplantation (BMT) have not been well described. DAH develops in approximately 4.4% of BMT recipients. Pre-transplant intensive chemotherapy, myeloablative conditioning regimen, total body irradiation, thoracic irradiation, and old age are risk factors for DAH in BMT recipients. The incidence of DAH does not differ between autologous and allogeneic recipients. Although the pathogenesis of DAH in the BMT recipient has not been clearly established, lung tissue injury, inflammation, and cytokine release are implicated. The onset of DAH is usually within the first 30 days following BMT, and the symptoms and findings include progressive dyspnea, cough, fever, hypoxemia, and diffuse consolidation on chest radiograph. Hemoptysis is uncommon. BMT recipients with DAH are often treated with high-dose corticosteroids. The majority of them receive invasive mechanical ventilation. The overall reported mortality rate of BMT recipients with DAH is 76%.
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ABSTRACT: The use of BAL to investigate the alveolar component of the patient’s lung has been widely developed since the mid 1970s; however the need for diagnostic BAL in patients with hematologic malignancies is considered to have decreased over the last 10 years. A major question in 2010 is therefore: what is the real value of BAL in everyday management of these patients? The aim of this chapter is to discuss clearly the various areas in which cytological examination of BAL fluid remains a particularly useful diagnostic tool in these patients. The diagnosis of pulmonary diseases associated with hematologic malignancies, such as pulmonary hemorrhage and pulmonary alveolar proteinosis, is based on BAL analysis not requiring pathologic examination of tissue samples. In primary lung lymphomas, BAL cytology is a particularly valuable first-line diagnostic procedure, and, in other situations, BAL cytology may make a major contribution to the diagnostic decision.