Rabbat A, Chaoui D, Lefebvre A, et al. Is BAL useful in patients with acute myeloid leukemia admitted in ICU for severe respiratory complications

Department of Respiratory and Critical Care Medicine, Hôtel-Dieu Hospital, AP-HP, Université Paris Descartes, Paris, France.
Leukemia: official journal of the Leukemia Society of America, Leukemia Research Fund, U.K (Impact Factor: 10.43). 07/2008; 22(7):1361-7. DOI: 10.1038/leu.2008.100
Source: PubMed


In patients with hematological malignancy (HM) developing acute respiratory failure (ARF) bronchoalveolar lavage (BAL) is considered as a major diagnostic tool. However, the benefit/risk ratio of this invasive procedure is probably lower in the subset of patients with acute myeloid leukemia (AML). The study was to analyze the yield of BAL performed in HM patients (n=175) with AML or lymphoid malignancies (LM) admitted in intensive care unit (ICU) for ARF and pulmonary infiltrates. BAL was performed in 121 patients (53/73 AML patients (73%) and 68/102 LM patients (67%)) without a definite diagnosis at admission or contraindication for fiberoptic bronchoscopy. Life-threatening complications were noticed in 12/121 patients (10%). The overall diagnostic yield of BAL was 47% (25/53) in AML patients and 50% (34/68) in LM patients. A microorganism was recovered from BAL in 23% (12/53) of AML patients and 41% (28/68) of LM patients (P<0.005). BAL results induced significant therapeutic changes in 17% (9/53) of AML patients vs 35% (24/68) of LM patients (P=0.039). This study underlines the rather low diagnostic yield of BAL for infectious diagnosis and the low rate of therapeutic changes induced by its results in AML patients with ARF admitted in ICU.

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Available from: Antoine Rabbat, May 06, 2014
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    • "The invasive strategy relies on fiberoptic bronchoscopy with BAL which remains the cornerstone of the diagnosis of pulmonary infiltrate in nonhypoxemic cancer patients. However, previous studies on the additional diagnostic yield of invasive techniques showed that bronchoscopy with BAL establishes the diagnosis in half of the patients at best and leads to therapeutic modification in only one-third of patients [13,30]. In addition, recent multicenter cohort and randomized controlled studies found that the additional diagnostic yield of BAL in combination with noninvasive tests is relatively low [6,7]. "
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    ABSTRACT: Although previous studies have reported etiologies, diagnostic strategies and outcomes of acute respiratory failure (ARF) in cancer patients, few studies investigated ARF in cancer patients presenting with diffuse pulmonary infiltrates. This was a retrospective observational study of 214 consecutive cancer patients with diffuse pulmonary infiltrates on chest radiography admitted to the oncology medical intensive care unit for acute respiratory failure between July 2009 and June 2011. After diagnostic investigations including bronchoalveolar lavage in 160 (75%) patients, transbronchial lung biopsy in 75 (35%), and surgical lung biopsy in 6 (3%), the etiologies of diffuse pulmonary infiltrates causing ARF were identified in 187 (87%) patients. The most common etiology was infection (138, 64%), followed by drug-induced pneumonitis (13, 6%) and metastasis (12, 6%). Based on the etiologic diagnoses, therapies for diffuse pulmonary infiltrates were subsequently modified in 99 (46%) patients. Diagnostic yield (46%, 62%, 85%, and 100%; P for trend < 0.001) and frequency of therapeutic modifications (14%, 37%, 52%, and 100%; P for trend < 0.001) were significantly increased with additional invasive tests. Patients with therapeutic modification had a 34% lower in-hospital mortality rate than patients without therapeutic modification (38% versus 58%, P = 0.004) and a similar difference in mortality rate was observed up to 90 days (55% versus 73%, Log-rank P = 0.004). After adjusting for potential confounding factors, therapeutic modification was still significantly associated with reduced in-hospital mortality (adjusted OR 0.509, 95% CI 0.281 - 0.920). Invasive diagnostic tests, including lung biopsy, increased diagnostic yield and caused therapeutic modification that was significantly associated with better outcomes for diffuse pulmonary infiltrates causing ARF in cancer patients.
    Full-text · Article · Jul 2013 · Critical care (London, England)
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    • "Bronchoalveolar lavage is an invasive diagnostic procedure to identify the cause of ARF in patients with cancer. However, the diagnostic yield of BAL in patients with cancer is not commonly satisfied [4,17]. Recent studies have shown no difference in diagnostic yield between BAL and noninvasive methods when used in patients with malignancies and ARF [12,18]. "
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    ABSTRACT: Background This retrospective study evaluated the utility and safety of surgical lung biopsy (SLB) in cancer patients with acute respiratory distress syndrome (ARDS). Methods All cases of critically ill patients with cancer and diagnosed with ARDS who underwent SLB in a tertiary care hospital from January 2002 to July 2009 were reviewed. Clinical data including patient baseline characteristics, surgical complications, pathological findings, treatment alterations, and survival outcomes were retrospectively collected and analyzed. Results A total of 16 critically ill patients with cancer diagnosed with ARDS who underwent SLB were enrolled. The meantime from ARDS onset to SLB was 3.0 ± 1.5 days. All SLB specimens offered a pathological diagnosis, and specific diagnoses were made in 9 of 16 patients. Biopsy findings resulted in a change in therapy in 11 of 16 patients. Overall, the SLB surgical complication rate was 19% (3/16). SLB did not directly cause the observed operative mortality. The ICU mortality rate was 38% (6/16). Patients who switched therapies after SLB had a trend toward decreased mortality than patients without a change in therapy (27% versus 60%; P = 0.299). Conclusions In selected critically ill cancer patients with ARDS, SLB had a high diagnostic yield rate and an acceptable surgical complication rate.
    Full-text · Article · May 2013 · Journal of Cardiothoracic Surgery
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    • "Intensive care reflects the administration proficiency and medical technology advancement of hospitals [9-11]. Close monitoring of pediatric patients [12], aged patients [13] and patients with unstable vital signs can greatly improve their survival rate [14-16]. ICU plays an unreplaceble role in saving the lives of victims after major disasters such as earthquakes, especially those with crush syndrome and complications [17-19]. "
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    ABSTRACT: The experience on management of crush injury after a devastating earthquake is lacking, and there are even less reports on the front-line critical care of these patients. A front-line intensive care unit (ICU) was set up in a tent after the disastrous Wenchuan earthquake (May, 12, 2008, China), where 32 patients suffering from crush injury were treated from May 12 to May 26. This study summarized our experience on management of 32 crush injury patients in a front-line tent ICU. We retrospectively analyzed the clinical data of 32 crush injury patients treated in our frontline tent ICU. Using limited equipment, we observed the arterial blood gas parameters, blood routine, alanine aminotransferase, lactate dehydrogenase, creatine kinase, creatinine, blood urea nitrogen, and urine protein of patients. We also closely watched for changes in crush injury symptoms, urine output, and the dangerous complications of crush injury. Eighteen of the 32 patients developed traumatic shock, 9 had acute renal failure, 6 had acute heart failure, 2 had stress ulcers and 4 had multiple organ dysfunction syndrome (MODS). The symptoms of 17 patients met the criteria of crush syndrome; hemodialysis and prompt surgical intervention were given to them when necessary. Prompt treatment in our tent ICU improved the symptoms of patients to different degrees. The limb distension and sensory dysfunction were improved and the urine output was increased or even restored to the normal level in some patients. Serological parameters were improved in most patients after admission. Five (15.63%) patients underwent amputation due to severe infection in our group. Six (18.75%) patients died, 4 due to MODS and 2 due to acute renal failure. Severe crushing injuries and life-threatening complications are major causes of death after major disasters like earthquakes. Prompt treatment and close monitoring of the severe complications are of great importance in saving patients' lives. Establishment of a well-equipped front-line ICU close to the epicentre of the earthquake allows for prompt on the spot rescue of critical patients with crush injury, greatly decreasing the mortality rate and complications and avoiding amputation. There should be sufficient equipment to meet the needs of more patients.
    Full-text · Article · Nov 2009 · Critical care (London, England)
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