Incidence rate and factors related to post-bronchoalveolar lavage fever in children

Complications and discomfort after research bronchoscopy in the MicroCOPD study

Background

Data on discomfort and complications from research bronchoscopy in chronic obstructive pulmonary disease (COPD) and asthma is limited. We present complications and discomfort occurring within a week after bronchoscopy, and investigate personal and procedural risk factors.

Methods

239 subjects with COPD, asthma or without lung disease underwent research bronchoscopies as part of a microbiome study of the lower airways (the MicroCOPD study). Bronchoscopy was done in the supine position with oral scope insertion with the option of light conscious alfentanil sedation. Sampling consisted of protected specimen brushes, bronchoalveolar lavage, small volume lavage and for some, endobronchial biopsies. Bleeding, desaturation, cough, haemodynamic changes, dyspnoea and other events that required an unplanned intervention or early termination of bronchoscopy were prospectively recorded. Follow-up consisted of a telephone interview where subjects rated discomfort and answered questions about fever sensation and respiratory symptoms in the week following bronchoscopy.

Results

An unplanned intervention or early termination of bronchoscopy was required in 25.9% of bronchoscopies. Three subjects (1.3%) experienced potentially severe complications, of which all recovered without sequelae. COPD subjects experienced more dyspnoea than controls. Sedation and lower age was associated with less unplanned intervention or premature termination. About half of the subjects (47.7%) reported fever. Discomfort was associated with postprocedural fever, dread of bronchoscopy, higher score on the COPD Assessment Test and never-smoking. In subjects undergoing more than one bronchoscopy, the first bronchoscopy was often predictive for complications and postprocedural fever in the repeated bronchoscopy.

Conclusion

Research bronchoscopies were not associated with more complications or discomfort in COPD subjects. 47.7% experienced postbronchoscopy fever sensation, which was associated with discomfort.

Ibuprofen does not prevent postbronchoscopy fever in children undergoing broncho-alveolar lavage

BACKGROUND

Fiber-optic bronchoscopy (FOB) of the lower airways is a routine examination performed for investigating varying respiratory complaints in children. A common side effect is a transient high fever on the day of the FOB. Such episodes are usually unrelated to an infectious process but may cause clinical uncertainty and parental anxiety. We have previously shown that a single dose of systemic dexamethasone significantly reduces the rate of fever postbronchoscopy (FPB).

RESEARCH QUESTION

To prospectively analyze the effect of a prophylactic dose of ibuprofen upon the FPB.

STUDY DESIGN AND METHODS

Children presenting for elective FOB and broncho-alveolar lavage (BAL) were randomized, in a double-blind fashion, to receive a single dose of ibuprofen syrup 10 mg/kg or placebo prior to the procedure. Parents were contacted the next day to record the presence or absence of fever.

RESULTS

Sixty-one children were included in the final analysis. Thirty-one children were in the treatment group and 30 in the placebo group. FPB occurred in 40 children (65%). There was no difference in the rate of FPB between placebo (63%) and treatment (67%) groups (P = .717). Fifty (82%) children had a positive BAL culture. Among them, 38 had FPB (76%) compared with only 2 of 11 (18%) of those with negative culture (P = .00026, relative risk 4.18). About 80% of positive cultures grew Haemophilus influenza. There was no significant difference between the number of BALs with a positive culture between the treatment and placebo groups (87% vs 77%, P = .35).

CONCLUSION

FPB occurs in around twothirds of children when BAL is performed. Fever occurred significantly more frequently when BAL culture is positive. A single standard dose of the nonsteroidal anti-inflammatory drug ibuprofen administered before a FOB does not prevent FPB.

Flexible Fiber-optic Bronchoscopy-directed Interventions in Children with Congenital Heart Diseases

Objective

In children, pulmonary and cardiac diseases are closely associated, and their integrated evaluation is important. Flexible fiber-optic bronchoscopy (FFB) can be used for both diagnostic and therapeutic purposes in pediatric cardiac intensive care units (PCICU). The objective of this study was to evaluate the utility of FFB in children with congenital heart disease (CHD).

Materials and methods

A retrospective, descriptive study was conducted at a tertiary care center in pediatric patients who underwent FFB in PCICU over a period of 6 years (2012-2017).

Results

Total 71 bronchoscopies were done in 58 patients with CHD with median age and weight of 2.5 months and 3.4 kg, respectively. Total of 20 different cardiac lesions were present among patients who underwent FFB. While 38 (53.5%) and 30 (42.3%) procedures were performed in pre-op and postoperative patients, respectively, 3 intraoperative bronchoscopies were also performed. The main indications for FFB were persistent atelectasis (42/71), prolonged oxygen requirement (13/71), stridor (8/71), and suspected airway anomaly (6/71). Tracheobronchitis was the commonest bronchoscopy finding (51/71, 71.8%) followed by tracheobronchomalacia (27/71, 38.3%). Cause of stridor detected in 7/8 cases. Associated preoperative and postoperative respiratory complications were detected and necessary interventions were done. These included slide tracheoplasty (5/58), tracheostomy (5/58), antibiotic change based on bronchoalveolar lavage (BAL) cultures (11/71), and continued positive pressure ventilation (4/71). Nonconsequential complications were transient hypoxemia (10/71), bleeding (2/71), and transient bradycardia (1/71).

Conclusion

Bedside FFB is a safe and a valuable diagnostic tool that also helps in guiding interventions in children with cardiac diseases.

How to cite this article

Sachdev A, Chhawchharia R, Gupta D, Gupta N, Joshi R, Agarwal N. Flexible Fiber-optic Bronchoscopy-directed Interventions in Children with Congenital Heart Diseases. Indian J Crit Care Med 2020;24(5):340-343.

Direct-from-blood RNA sequencing identifies the cause of post-bronchoscopy fever

Background

Antibiotic resistance is rising at disturbing rates and contributes to the deaths of millions of people yearly. Antibiotic resistant infections disproportionately affect those with immunocompromising conditions, chronic colonization, and frequent antibiotic use such as transplant patients or those with cystic fibrosis. However, clinicians lack the diagnostic tools to confidently diagnose and treat infections, leading to widespread use of empiric broad spectrum antimicrobials, often for prolonged duration.

Case presentation

A 22 year-old Caucasian female with cystic fibrosis received a bilateral orthotopic lung transplantation 5 months prior to the index hospitalization. She underwent routine surveillance bronchoscopy and was admitted for post-procedure fever. A clear cause of infection was not identified by routine methods. Imaging and bronchoscopic lung biopsy did not identify an infectious agent or rejection. She was treated with a prolonged course of antimicrobials targeting known colonizing organisms from prior bronchoalveolar lavage cultures (Pseudomonas, Staphylococcus aureus, and Aspergillus). However, we identified Stenotrophomonas maltophilia in two independent whole blood samples using direct-pathogen sequencing, which was not identified by other methods.

Conclusions

This case represents a common clinical conundrum: identification of infection in a high-risk, complex patient. Here, direct-pathogen sequencing identified a pathogen that would not otherwise have been identified by common techniques. Had results been clinically available, treatment could have been customized, avoiding a prolonged course of broad spectrum antimicrobials that would only exacerbate resistance. Direct-pathogen sequencing is poised to fill a diagnostic gap for pathogen identification, allowing early identification and customization of treatment in a culture-independent, pathogen-agnostic manner.

Flexible bronchoscopy in children: Utility and complications

Background and objectives

The flexible bronchoscope has become widely used by pediatric pulmonologists as a diagnostic and therapeutic tool. Nevertheless, there are several gaps in our knowledge to help refine its use and reduce its complications. In this study, we aimed to evaluate the utility and complications of pediatric bronchoscopy.

Design and setting

We conducted a retrospective review of bronchoscopy cases between March 2006 and April 2015 at a tertiary care medical center (King Fahad Medical City). One-hundred forty nine patients were studied.

Patients and methods

We evaluated how bronchoscopy contributed to the patients' diagnosis, assessed the accuracy of bronchoalveolar lavage white blood cell count (BAL WBC) to differentiate between infectious and non-infectious conditions, assessed the ability of clinical factors to predict high risk of desaturation during bronchoscopy, and finally summarized the reported procedural complications.

Results

We found pediatric bronchoscopy was a crucial diagnostic (confirming, ruling out, and discovering unexpected diagnosis) and therapeutic tool. The accuracy of BAL WBC counts is poor (AUC (95% CI) = 0.609 (0.497–0.712)); however, using two cutoff values (≤10 WBCs (sensitivity = 84.44% and specificity = 29.27%) to rule out, and ≥400 WBCs (sensitivity = 33.33% and specificity 81.49%) to rule in infection) helped in early differentiation between infectious and non-infectious conditions. From the factors that we test, none we found predictive of desaturation. The most common procedural complication was desaturation (pooled incidence (95% CI) = 13 (8–19)%) followed by cough, mild airway bleeding, and spasm.

Conclusions

Flexible bronchoscopy is an important and relatively safe diagnostic and therapeutic tool in pediatric medicine, and utilization of this service should be encouraged after a careful consideration of which patient needs this procedure and a rigorous estimate of its pros and cons.