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Barry B, Stewart D, Brownback KR. Acute Lung Injury in Immunocompromised Patients. Clin Chest Med 2025; 46:105-114. [PMID: 39890282 DOI: 10.1016/j.ccm.2024.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2025]
Abstract
Acute lung injury is a devastating complication when occurring in immunocompromised patients. The incidence appears to be increasing as more patients survive for longer in this susceptible state. Being aware of potential causes of acute lung injury may lead to earlier recognition and diagnosis. Infection is a common cause of acute lung injury and needs to be considered in the diagnostic algorithm. Management involves use of supportive ventilatory strategies and potentially pharmacologic therapies.
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Affiliation(s)
- Brogan Barry
- Department of Internal Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, MailStop 3007, Kansas City, KS 66160, USA
| | - Dane Stewart
- Department of Internal Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, MailStop 3007, Kansas City, KS 66160, USA
| | - Kyle R Brownback
- Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, MailStop 3007, Kansas City, KS 66160, USA.
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Lynch Y, Vande Vusse LK. Diffuse Alveolar Hemorrhage in Hematopoietic Cell Transplantation. J Intensive Care Med 2024; 39:1055-1070. [PMID: 37872657 DOI: 10.1177/08850666231207331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a morbid syndrome that occurs after autologous and allogeneic hematopoietic cell transplantation in children and adults. DAH manifests most often in the first few weeks following transplantation. It presents with pneumonia-like symptoms and acute respiratory failure, often requiring high levels of oxygen supplementation or mechanical ventilatory support. Hemoptysis is variably present. Chest radiographs typically feature widespread alveolar filling, sometimes with peripheral sparing and pleural effusions. The diagnosis is suspected when serial bronchoalveolar lavages return increasingly bloody fluid. DAH is differentiated from infectious causes of alveolar hemorrhage when extensive microbiological testing reveals no pulmonary pathogens. The cause is poorly understood, though preclinical and clinical studies implicate pretransplant conditioning regimens, particularly those using high doses of total-body-irradiation, acute graft-versus-host disease (GVHD), medications used to prevent GVHD, and other factors. Treatment consists of supportive care, systemic corticosteroids, platelet transfusions, and sometimes includes antifibrinolytic drugs and topical procoagulant factors. Therapeutic blockade of tumor necrosis factor-α showed promise in observational studies, but its benefit for DAH remains uncertain after small clinical trials. Even with these treatments, mortality from progression and relapse is high. Future investigational therapies could target the vascular endothelial cell biology theorized to contribute to alveolar bleeding and pathways that contribute to susceptibility, inflammation, cellular resilience, and tissue repair. This review will help clinicians navigate through the limited evidence to diagnose and treat DAH, counsel patients and families, and plan for future research.
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Affiliation(s)
- Ylinne Lynch
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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Nakagawa N, Ando T, Kawakami M, Hosoki K, Hiraishi Y, Mikami Y, Kage H. Diagnostic yield of flexible bronchoscopy for immunocompromised patients with lung infiltrates: A single-center, retrospective study. Respir Investig 2024; 62:726-731. [PMID: 38870553 DOI: 10.1016/j.resinv.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 05/21/2024] [Accepted: 05/26/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Pulmonary complications are associated with mortality in immunocompromised patients. The usefulness of bronchoscopy has been reported. However, clinical factors and procedures that influence diagnostic yield are still not established. MATERIALS AND METHODS We retrospectively analyzed 115 bronchoscopies performed on 108 immunocompromised patients, defined as those who take corticosteroids and/or immunosuppressants. We evaluated clinical factors, sampling procedures, final diagnosis, and severe complications of bronchoscopy. RESULTS The clinical diagnosis was obtained in 51 patients (44%). Of those, 33 cases were diagnosed as infectious diseases and 18 as non-infectious diseases. Nine out of 115 cases (7.8%) initiated new immunosuppressive treatment for an underlying disorder based on the negative microbiological results obtained with bronchoscopy. Collagen vascular disease was the most common underlying disorders (62 patients, 54%). Bronchoscopy was useful regardless of whether the patient was immunosuppressed to treat collagen vascular disease (P = 0.47). Performing transbronchial biopsy correlated with better diagnostic yield of bronchoscopy (54.7% vs 35.5%, P = 0.049). Other clinical factors, such as radiological findings, respiratory failure or antibiotic use at the time of bronchoscopy did not significantly influence diagnostic yield. Respiratory failure requiring intubation after bronchoscopy occurred only in one case (0.9%). CONCLUSIONS Our study implied the transbronchial biopsy may be a useful procedure for reaching a diagnosis in immunocompromised patients with pulmonary infiltrates. In addition, our data suggest the usefulness of bronchoscopy for immunocompromised patients due to the treatment of collagen vascular disease as well as other underlying disorders.
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Affiliation(s)
- Natsuki Nakagawa
- Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takahiro Ando
- Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Masanori Kawakami
- Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Hosoki
- Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yoshihisa Hiraishi
- Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yu Mikami
- Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hidenori Kage
- Department of Respiratory Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Thorat J, Bhat S, Sengar M, Baheti A, Bothra S, Bhaskar M, Tandon SP, Biswas SK, Salunke GV, Karimundackal G, Tiwari VK, Pramesh C, Sharma N, Kapu V, Eipe T, Bagal BP, Nayak L, Bonda A, Janu A, Shetty A, Jain H. Clinical Utility of Stepwise Bronchoalveolar Lavage Fluid Analysis in Diagnosing and Managing Lung Infiltrates in Leukemia/Lymphoma Patients With Febrile Neutropenia. JCO Glob Oncol 2024; 10:e2300292. [PMID: 38301183 PMCID: PMC10846792 DOI: 10.1200/go.23.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/28/2023] [Accepted: 11/20/2023] [Indexed: 02/03/2024] Open
Abstract
PURPOSE Febrile neutropenia (FN) is a serious complication in hematologic malignancies, and lung infiltrates (LIs) remain a significant concern. An accurate microbiological diagnosis is crucial but difficult to establish. To address this, we analyzed the utility of a standardized method for performing bronchoalveolar lavage (BAL) along with a two-step strategy for the analysis of BAL fluid. PATIENTS AND METHODS This prospective observational study was conducted at a tertiary cancer center from November 2018 to June 2020. Patients age 15 years and older with confirmed leukemia or lymphomas undergoing chemotherapy, with presence of FN, and LIs observed on imaging were enrolled. RESULTS Among the 122 enrolled patients, successful BAL was performed in 83.6% of cases. The study used a two-step analysis of BAL fluid, resulting in a diagnostic yield of 74.5%. Furthermore, antimicrobial therapy was modified in 63.9% of patients on the basis of BAL reports, and this population demonstrated a higher response rate (63% v 45%; P = .063). CONCLUSION Our study demonstrates that a two-step BAL fluid analysis is safe and clinically beneficial to establish an accurate microbiological diagnosis. Given the crucial impact of diagnostic delays on mortality in hematologic malignancy patients with FN, early BAL studies should be performed to enable prompt and specific diagnosis, allowing for appropriate treatment modifications.
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Affiliation(s)
- Jayashree Thorat
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Surabhi Bhat
- Hematological Cancer Consortium, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Akshay Baheti
- Department of Radio-diagnosis, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Sweta Bothra
- Department of Radio-diagnosis, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Maheema Bhaskar
- Department of Pulmonary Medicine, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Sandeep Prakashnarain Tandon
- Department of Pulmonary Medicine, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Sanjay K. Biswas
- Department of Microbiology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Gaurav V. Salunke
- Department of Microbiology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | | | - Virendra Kumar Tiwari
- Department of Thoracic Surgical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - C.S. Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Neha Sharma
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Venkatesh Kapu
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Thomas Eipe
- Department of Clinical Pharmacology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Bhausaheb Pandurang Bagal
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Lingaraj Nayak
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Avinash Bonda
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Amit Janu
- Department of Radio-diagnosis, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Alok Shetty
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
| | - Hasmukh Jain
- Department of Medical Oncology, Tata Memorial Centre, Affiliated with Homi Bhabha National University, Mumbai, India
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Schwartz B, Dupont V, Dury S, Carsin-Vu A, Thomas Guillard, Caillard S, Frimat L, Sanchez S, Schvartz B, Bani-Sadr F, Damien Jolly, Philippe Rieu, Antoine Goury. Aetiology, clinical features, diagnostic studies, and outcomes of community-acquired pneumonia in kidney transplant recipients admitted to hospital: a multicentre retrospective French cohort study. Clin Microbiol Infect 2022; 29:542.e1-542.e5. [PMID: 36574948 DOI: 10.1016/j.cmi.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/06/2022] [Accepted: 12/18/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To assess the aetiology, clinical features, diagnostic studies and outcomes of community-acquired pneumonia (CAP) in a French cohort of hospitalized kidney transplant recipients. METHODS We performed a retrospective, multicentre study in kidney transplant recipients admitted to ten French centres for CAP from January 2016 to December 2018. CAP discharge diagnoses were clinically and radiologically validated. We assessed a descriptive analysis of all confirmed CAP including medical ward and intensive care unit admissions. RESULTS One hundred sixty-five CAP episodes in 132 patients were included. Median time from transplantation to admission was 6.4 (interquartile range, 1.6-12.3) years, with corticosteroid exposure in 112/165 (67.9%) cases. Sputum culture was performed in 47/165 (28.5%) cases including 7/47 (14.9%) positive samples. Bronchoscopy was performed in 87/165 (52.7%) cases with pathogens identified in 39/87 (44.8%) cases. Microbiological studies led to identifying a respiratory pathogen in 64/165 (38.8%) CAP episodes including 11/64 (17.2%) polymicrobial cases. Among these 64 episodes, 75 microorganisms were identified; 46/75 (61.3%) were core respiratory pathogens and 29/75 (38.7%) were opportunistic or drug-resistant organisms including Pneumocystis jirovecii 9/75 (12%), Pseudomonas aeruginosa 5/75 (6.7%), multidrug-resistant Enterobacteriaceae 4/75 (5.3%), and Aspergillus 4/75 (5.3%). Patients required intensive care unit admission in 26/165 (15.8%) episodes, invasive ventilation in 20/165 (12.1%) cases, and 22/165 (13.3%) needed in-hospital dialysis. DISCUSSION CAP episodes occurred in kidney transplant recipients with a long history of immunosuppressive drug exposure. Diagnostic studies identified a microorganism in more than one-third of CAP episodes, including drug-resistant and opportunistic pathogens.
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Affiliation(s)
- Benoît Schwartz
- Department of Nephrology, Reims University Hospitals, Reims, France
| | - Vincent Dupont
- Department of Nephrology, Reims University Hospitals, Reims, France; French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists (F-CRIN INI-CRCT), Reims, France; Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sandra Dury
- Department of Respiratory Diseases, Reims University Hospitals, Reims, France; EA7509 IRMAIC, University of Reims Champagne-Ardenne, Reims, France
| | - Aline Carsin-Vu
- Department of Radiology, Reims University Hospitals, Reims, France
| | - Thomas Guillard
- Université de Reims Champagne-Ardenne, INSERM, CHU de Reims, Laboratoire de Bactériologie-Virologie-Hygiène Hospitalière-Parasitologie-Mycologie, P3Cell, Reims, France; Laboratoire de Bactériologie-Virologie-Hygiène Hospitalière-Parasitologie-Mycologie, Reims University Hospitals, Hôpital Robert Debré, Reims, France
| | - Sophie Caillard
- Department of Nephrology and Transplantation, Strasbourg University Hospitals, Strasbourg, France; INSERM 1109, Fédération de Médecine Translationnelle, LabEx TRANSPLANTEX, Strasbourg, France
| | - Luc Frimat
- Department of Nephrology and Transplantation, Nancy University Hospitals, Vandoeuvre les Nancy, France; EA 4360, INSERM CIC-EC CIE6, Apemac, Vandoeuvre les N, France
| | - Stephane Sanchez
- Clinical Research and Methological Unit, Troyes Hospital, Troyes, France
| | - Betoul Schvartz
- Department of Nephrology, Reims University Hospitals, Reims, France
| | - Firouzé Bani-Sadr
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims University Hospitals, Reims, France
| | - Damien Jolly
- Department of Research and Public Health, Reims University Hospitals, Reims, France
| | - Philippe Rieu
- Department of Nephrology, Reims University Hospitals, Reims, France
| | - Antoine Goury
- Intensive Care Department, Reims University Hospitals, Reims, France.
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Bronchoalveolar Lavage Fluid-Isolated Biomarkers for the Diagnostic and Prognostic Assessment of Lung Cancer. Diagnostics (Basel) 2022; 12:diagnostics12122949. [PMID: 36552956 PMCID: PMC9776496 DOI: 10.3390/diagnostics12122949] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Lung cancer is considered one of the most fatal malignant neoplasms because of its late detection. Detecting molecular markers in samples from routine bronchoscopy, including many liquid-based cytology procedures, such as bronchoalveolar lavage fluid (BALF), could serve as a favorable technique to enhance the efficiency of a lung cancer diagnosis. BALF analysis is a promising approach to evaluating the tumor progression microenvironment. BALF's cellular and non-cellular components dictate the inflammatory response in a cancer-proliferating microenvironment. Furthermore, it is an essential material for detecting clinically significant predictive and prognostic biomarkers that may aid in guiding treatment choices and evaluating therapy-induced toxicities in lung cancer. In the present article, we have reviewed recent literature about the utility of BALF analysis for detecting markers in different stages of tumor cell metabolism, employing either specific biomarker assays or broader omics approaches.
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Pulmonary Complications of Pediatric Hematopoietic Cell Transplantation. A National Institutes of Health Workshop Summary. Ann Am Thorac Soc 2021; 18:381-394. [PMID: 33058742 DOI: 10.1513/annalsats.202001-006ot] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Approximately 2,500 pediatric hematopoietic cell transplants (HCTs), most of which are allogeneic, are performed annually in the United States for life-threatening malignant and nonmalignant conditions. Although HCT is undertaken with curative intent, post-HCT complications limit successful outcomes, with pulmonary dysfunction representing the leading cause of nonrelapse mortality. To better understand, predict, prevent, and/or treat pulmonary complications after HCT, a multidisciplinary group of 33 experts met in a 2-day National Institutes of Health Workshop to identify knowledge gaps and research strategies most likely to improve outcomes. This summary of Workshop deliberations outlines the consensus focus areas for future research.
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Mainardi AS, Siddon AJ, Bader AS, Hilbert J. Progressive Dyspnea and Hypoxemia With Diffuse Pulmonary Infiltrates in a Previously Healthy Woman. Chest 2021; 158:e327-e334. [PMID: 33280778 DOI: 10.1016/j.chest.2020.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/08/2020] [Accepted: 07/12/2020] [Indexed: 11/29/2022] Open
Abstract
CASE PRESENTATION A 50-year-old woman presented with 3 months of cough, dyspnea, and fatigue. She also reported new fevers, night sweats, and a rash on her face and torso. On presentation she was tachycardic and tachypneic, with oxygen saturation of 81% on 2 L/min of oxygen. She was in mild respiratory distress. Results of the physical examination were remarkable for tender left cervical and axillary adenopathy and bibasilar pulmonary crackles. She had an acneiform rash on her face, chest, and back, consisting of multiple nonblanching erythematous or violaceous macules and papules (Fig 1) and had conjunctival edema. Admission laboratory test results were significant for a WBC count of 56,000, of which 79.5% were lymphocytes. Hemoglobin and platelet levels were normal. She was admitted for further management.
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Affiliation(s)
- Anne S Mainardi
- Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT; Respiratory, Critical Care, and Sleep Medicine, University of Tennessee/Erlanger Health System, Chattanooga, TN.
| | - Alexa J Siddon
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Anna S Bader
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Janet Hilbert
- Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT
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Muthu V, Gandra RR, Dhooria S, Sehgal IS, Prasad KT, Kaur H, Gupta N, Bal A, Ram B, Aggarwal AN, Chakrabarti A, Agarwal R. Role of flexible bronchoscopy in the diagnosis of invasive fungal infections. Mycoses 2021; 64:668-677. [PMID: 33719109 DOI: 10.1111/myc.13263] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND There are sparse data on the role of flexible bronchoscopy (FB) in diagnosing invasive mould infections (IMIs). OBJECTIVE To investigate the safety and usefulness of FB in IMI. We evaluate the factors associated with a successful diagnosis of IMI using FB. Further, we compare subjects of invasive pulmonary aspergillosis (IPA) with pulmonary mucormycosis (PM). METHODS We retrospectively reviewed the clinical features, imaging data, bronchoscopy, microbiology and pathology details of subjects who underwent FB for suspected IMI. We categorised FB as diagnostic if it contributed to the diagnosis of IMI. We performed a multivariate analysis to identify the factors associated with a diagnostic bronchoscopy. RESULTS Of the 3521 FB performed over 18 months, 132 (3.7%) were done for suspected IMIs. We included 107 subjects for the final analysis. The risk factors for IMI included renal transplantation (29.0%), diabetes (27.1%), haematological malignancy (10.3%) and others. We found bronchoscopic abnormalities in 33 (30.8%) subjects, and these were more frequent in those with confirmed PM (67%) than IPA (27%). IMI was confirmed in 79 (14 proven, 48 probable and 17 possible) subjects. FB was diagnostic in 71%. We experienced major complications in three cases (2.7%), including one death. On multivariate analysis, the visualisation of endobronchial abnormalities during FB (OR [95%, CI], 8.5 [1.4-50.4]) was the only factor associated with a diagnostic FB after adjusting for age and various risk factors. CONCLUSIONS Flexible bronchoscopy is a useful and safe procedure in diagnosing IMIs. The presence of endobronchial abnormalities predicts a successful diagnostic yield on FB.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Raghava Rao Gandra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nalini Gupta
- Department of Cytology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Babu Ram
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Mehta RM, Biraris P, Aurangabadwalla R, Kalpakam H, Bhat R, Bajaj P. Use of an Extended Working Channel in High-Risk Transbronchial Biopsy: An Innovative Use of an Existing Modality to Minimize Bleeding and Hypoxia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 16:75-79. [PMID: 33155854 DOI: 10.1177/1556984520968100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Bleeding is one of the main complications of transbronchial lung biopsy (TBBx) more so with conditions such as azotaemia and coagulopathy. Baseline hypoxia worsens the consequences of TBBx bleeding and can lead to escalation of care. In our experience, TBBx performed through a guide sheath (GS) using it as an extended working channel (EWC) helps minimize bleeding risk. We hypothesized that the EWC produces a tamponade effect in the close vicinity of the biopsy site, both reducing bleeding risk and restricting bleeding to a smaller segment. In this study, we assessed the impact of an additional EWC in high-risk (HR) patients undergoing TBBx, to reduce bleeding and enhance safety. METHODS Retrospective study between January 2014 and December 2018 looking at the risk of bleeding following TBBx performed through a GS (EWC) in patients at high risk for bleeding-related complications. Bleeding incidence and consequent hypoxic events requiring escalation of care were noted. The specimen diagnostic yield was also analyzed. SPSS statistics were used-data are reported as mean and standard deviation for continuous variables, and number and percentage for discrete variables. RESULTS Eight hundred four TBBxs were performed during the study period, and 105 (13.1%) procedures were done in the HR individuals using a GS as an EWC. No significant bleeding requiring escalation of care was seen with the use of EWC-GS. Histopathology revealed adequate sampling in all cases. CONCLUSIONS A GS as an EWC was used to reduce the bleeding risk, consequent hypoxia, and prevent escalation of care in TBBx in HR patients. Adequate tissue was obtained without any complications. Though prospective, randomized, multicenter trials using an EWC in HR-TBBx are important, they are challenging to do due to the HR population under study.
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Affiliation(s)
- Ravindra M Mehta
- 75438 Department of Pulmonary, Critical Care and Sleep Medicine, Apollo Hospitals, Bangalore, India
| | - Pavankumar Biraris
- 75438 Department of Pulmonary, Critical Care and Sleep Medicine, Apollo Hospitals, Bangalore, India
| | - Rohan Aurangabadwalla
- 75438 Department of Pulmonary, Critical Care and Sleep Medicine, Apollo Hospitals, Bangalore, India
| | - Hariprasad Kalpakam
- 75438 Department of Pulmonary, Critical Care and Sleep Medicine, Apollo Hospitals, Bangalore, India
| | - Rajani Bhat
- 75438 Department of Pulmonary, Critical Care and Sleep Medicine, Apollo Hospitals, Bangalore, India
| | - Pooja Bajaj
- 75438 Department of Pulmonary, Critical Care and Sleep Medicine, Apollo Hospitals, Bangalore, India
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11
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Brioulet J, David A, Sagan C, Cellerin L, Frampas E, Morla O. Percutaneous CT-guided lung biopsy for the diagnosis of persistent pulmonary consolidation. Diagn Interv Imaging 2020; 101:727-732. [PMID: 32811758 DOI: 10.1016/j.diii.2020.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/15/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The primary objective of this study was to determine the diagnostic accuracy of percutaneous computed tomography (CT)-guided biopsy of persistent pulmonary consolidations. The secondary objective was to determine the complication rate and identify factors affecting diagnostic yield. MATERIALS AND METHODS Two radiologists retrospectively reviewed 98 percutaneous CT-guided biopsies performed in 93 patients (60 men, 33 women; mean age, 62±14.0 (SD) years; range: 18-88 years) with persistent pulmonary consolidations. Final diagnoses were based on surgical outcomes or 12 months clinical follow-up findings. Biopsy results were compared to the final diagnosis to estimate diagnostic yield. RESULTS A final diagnosis was obtained for all patients: 51/93 (54.8%) had malignant lesions, 12/93 (12.9%) specific definite benign lesions (including 9 infections, two pneumoconiosis and one lipoid pneumonia) and 30/93 (32.3%) non-specific benign lesions. CT-guided biopsy had an overall diagnostic yield of 60% (59/98) with a correct diagnosis for 50/51 malignant lesions (diagnostic yield of 98% for malignancy) and for 9/47 benign lesions (diagnostic yield of 19% for benign conditions). Major complications occurred in 4/98 (4%) of lung biopsies (four pneumothoraxes requiring chest tube placement). CONCLUSION Percutaneous CT-guided biopsy is an alternative to endoscopic or surgical biopsy for the diagnosis of persistent consolidation with a low risk of severe complication.
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Affiliation(s)
- J Brioulet
- Department of Radiology, Centre Hospitalier Universitaire de Nantes, Hôtel Dieu, 44093 Nantes Cedex 1, France.
| | - A David
- Department of Radiology, Centre Hospitalier Universitaire de Nantes, Hôtel Dieu, 44093 Nantes Cedex 1, France
| | - C Sagan
- Department of Pathology, Centre Hospitalier Universitaire de Nantes, Hôpital Laënnec, Saint-Herblain, 44000 Nantes, France
| | - L Cellerin
- Department of Pneumology, Centre Hospitalier Universitaire de Nantes, Hôpital Laënnec, Saint-Herblain, 44000 Nantes, France
| | - E Frampas
- Department of Radiology, Centre Hospitalier Universitaire de Nantes, Hôtel Dieu, 44093 Nantes Cedex 1, France; CRCINA, INSERM, CNRS, Université d'Angers, Université de Nantes, 44000 Nantes, France
| | - O Morla
- Department of Radiology, Centre Hospitalier Universitaire de Nantes, Hôtel Dieu, 44093 Nantes Cedex 1, France
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12
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Clinical Usefulness of Bronchoalveolar Lavage in the Management of Pulmonary Infiltrates in Adults with Hematological Malignancies and Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2020; 12:e2020025. [PMID: 32395214 PMCID: PMC7202335 DOI: 10.4084/mjhid.2020.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/04/2020] [Indexed: 01/04/2023] Open
Abstract
Introduction Pulmonary complications are frequent in patients with hematologic malignancies and stem cell transplantation. Regardless of the microbiological usefulness of bronchoalveolar lavage (BAL), little information exists on both its benefits as a guide for therapeutic decisions and its impact on patients’ clinical outcome. Methods A prospective observational single-center study was performed between July 2011 and July 2016. Consecutive episodes of pulmonary infiltrates were analyzed in subjects over 18 years of age who presented hematologic malignancies and underwent chemotherapy or stem cell transplantation. Results Ninety-six episodes of pulmonary infiltrates were analyzed. Acute leukemia was the most frequent underlying condition. Thirty-seven patients (38.5%) received a stem cell transplant. Sixty-one (62.9%) were neutropenic at the moment of inclusion in the study. A definitive etiologic diagnosis was obtained in 41 cases (42.7%), where infection accounted for the vast majority of cases (33 cases, 80.5%). Definitive diagnosis was reached by non-invasive methods in 13 cases (13.5%). BAL was performed in 47 cases and led to a diagnosis in 40.4% of the cases. BAL results led to therapeutic changes in 27 cases (57.4%), including the addition of new antimicrobials to empiric treatments in 10. Regarding BAL’s safety, two patients experienced minor adverse events and one a severe adverse event; no procedure-related deaths were observed. Conclusions Infection was the leading cause of pulmonary infiltrates in patients with hematologic malignancies and stem cell transplantation. BAL was a useful decision-making diagnostic tool, with minor adverse events.
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13
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Guo H, Chen X, Su C, Liu Y, Wang H, Sun C, Chen P, Jiang M, Xu Y, Wu S, Jia K, Zhao S, Li W, Chen B, Wang L, Yu J, Xiong A, Gao G, Wu F, Li J, Ye L, Bo B, Chen S, Ren S, He Y, Zhou C. Challenges and countermeasures of thoracic oncology in the epidemic of COVID-19. Transl Lung Cancer Res 2020; 9:337-347. [PMID: 32420073 PMCID: PMC7225133 DOI: 10.21037/tlcr.2020.02.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since December, 2019, a 2019 novel coronavirus disease (COVID-19) infected by the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) emerged in Wuhan, Hubei province, and the epidemic situation has continued to spread globally. The epidemic spread of COVID-19 has brought great challenges to the clinical practice of thoracic oncology. Outpatient clinics need to strengthen the differential diagnosis of initial symptoms, pulmonary ground-glass opacity (GGO), consolidation, interstitial and/or interlobular septal thickening, and crazy paving appearance. In the routine of oncology, the differential diagnosis of adverse events from COVID-19 is also significant, including radiation pneumonitis, checkpoint inhibitor pneumonitis (CIP), neutropenic fever, and so on. During the epidemic, indications of transbronchial biopsy (TBB) and CT-guided percutaneous thoracic biopsy are strictly controlled. For patients who are planning to undergo biopsy operation, screening to exclude the possibility of COVID-19 should be carried out. For confirmed or suspected patients, three-level protection should be performed during the operation. Disinfection and isolation measures should be strictly carried out during the operation. At last, more attention to the protection of cancer patients and give priority to the treatment of infected cancer patients.
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Affiliation(s)
- Haoyue Guo
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Xiaoxia Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Chunxia Su
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Yu Liu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Hao Wang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Chenglong Sun
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Peixin Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Minlin Jiang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Yi Xu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Shengyu Wu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Keyi Jia
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Sha Zhao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Wei Li
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Bin Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Lei Wang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Jia Yu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Anwen Xiong
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Guanghui Gao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Fengying Wu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Jiayu Li
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Lingyun Ye
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Bing Bo
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Shen Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Shengxiang Ren
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Yayi He
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Caicun Zhou
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
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Utility of bronchoscopy in immunocompromised paediatric patients: Systematic review. Paediatr Respir Rev 2020; 34:24-34. [PMID: 32247829 DOI: 10.1016/j.prrv.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE The objective of this study was to describe the diagnostic yield and safety of bronchoalveolar lavage (BAL) in the evaluation of pulmonary lesions in immunocompromised children. METHODS We conducted a systematic review of literature published during the past 20 years, searching Medline, Medline EPub, EMBASE, and Scopus. Studies included involved paediatric patients (<18 years) on treatment for an oncological diagnosis or other immune compromise who underwent BAL for evaluation of pulmonary lesions. Only English language publications were included. RESULTS In all, 272 studies were screened and 19 included. All were observational studies with moderate (11/19) or serious (8/19) risk of bias. BAL yielded a potential pathogen in 43% of cases (496/1156). Two papers reported improved diagnostic yield with early BAL (less than 3 days of presentation). A change in patient management after BAL was reported in 53% of cases (275/519). Adverse events were reported in 19% of cases following BAL (193/993) but were generally mild with no procedure-related mortality reported. CONCLUSION BAL appears to be useful for evaluation of pulmonary lesions in immunocompromised children with generally acceptable safety, though included studies had at least moderate risk of bias. Future prospective studies may provide more definitive estimates of benefit, timing and risk of BAL in this population.
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15
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Evaluation of the clinical utility of reflex GMS and AFB stains on BAL specimens from lung transplant patients. J Am Soc Cytopathol 2020; 9:166-172. [PMID: 32179025 DOI: 10.1016/j.jasc.2020.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/15/2020] [Accepted: 01/30/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Bronchoalveolar lavage (BAL) has a useful role in the detection of infectious diseases. Grocott methenamine silver (GMS) and acid-fast bacilli (AFB) are ancillary stains that aid in the cytologic detection of fungal and mycobacterial organisms. However, the utility of these stains in conjunction with microbiological testing is unclear. MATERIALS AND METHODS BAL specimens from lung transplant patients between January 1, 2018, to December 31, 2018, were evaluated. Inclusion criteria included cases with both GMS and AFB stains and concurrent fungal and mycobacterial microbiology testing. The staining findings were correlated with concurrent microbiology findings, including cultures and immunofluorescent smears. RESULTS A total of 231 BAL specimens were identified. GMS stain was positive in 19.5% and AFB in 1.3%. Fungal microbiology was positive in 23.4% and mycobacterial microbiology in 6.1%. A total of 87.9% of cases had concordant findings between cytology stains and microbiology tests and 12.1% had discrepant findings. Notably of the discrepancies, 3.0% had positive GMS and negative fungal microbiology and 6.9% had positive fungal microbiology and negative GMS. No cases had positive AFB with negative mycobacterial microbiology whereas 4.8% had positive mycobacterial microbiology and negative AFB stain. CONCLUSIONS We show that staining for AFB on BAL material in lung transplant patients had limited benefit when concurrent microbiology was performed. GMS staining shows a small benefit. We recommend reflex testing for fungal organisms but not mycobacterial organisms in lung transplant patients.
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16
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Morton C, Puchalski J. The utility of bronchoscopy in immunocompromised patients: a review. J Thorac Dis 2019; 11:5603-5612. [PMID: 32030281 PMCID: PMC6988056 DOI: 10.21037/jtd.2019.09.72] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/20/2019] [Indexed: 01/04/2023]
Abstract
Bronchoscopy is an important tool for the diagnosis of pulmonary disorders in immunocompromised patients. The addition of biopsies to bronchoalveolar lavage improves the diagnostic yield of non-infectious etiologies, although the underlying etiology of the immunocompromised state must be considered and may be influential. Certain unknowns remain, including timing of bronchoscopy and its impact on medical management and mortality. The ongoing role of non-invasive testing for infectious complications prior to bronchoscopy also remains to be defined. This review addresses the role of bronchoscopy in immunocompromised states related to underlying hematologic malignancies, prescription drug use or chemotherapy, and other disorders that predispose patients to infectious or non-infectious pulmonary diseases.
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Affiliation(s)
- Christopher Morton
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan Puchalski
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA
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17
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Diagnostic Performance and Safety of Bronchoalveolar Lavage in Thrombocytopenic Haematological Patients for Invasive Fungal Infections Diagnosis: A Monocentric, Retrospective Experience. Mediterr J Hematol Infect Dis 2019; 11:e2019065. [PMID: 31700590 PMCID: PMC6827601 DOI: 10.4084/mjhid.2019.065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/14/2019] [Indexed: 01/11/2023] Open
Abstract
Background Although bronchoalveolar lavage (BAL) measurements of galactomannan antigen (GM) seems to be more sensitive than serum testing to detect invasive fungal infection (IFI), a consensus on the most appropriate diagnostic threshold of the BAL GM test is still unclear. Moreover, there is uncertainty as to whether BAL is a safe procedure in patients with hematological malignancies (HM) and thrombocytopenia. Objectives Based on this background, 102 adult patients with HM and associated thrombocytopenia were retrospectively analyzed with the dual aim of 1) determining whether BAL is a safe and feasible procedure; and, 2) identifying the most appropriate threshold for GM positivity in the diagnosis of IFI. Patients/Methods each BAL was considered as one case/patient. One hundred twelve BALs were carried out in 102 HM patients: at the time of the BAL, the median platelet count (PLTs) in all patients was 47×109/L (1–476), and 31 patients (27%) had PLTs< 20×109/L. Results complications from the BAL were infrequent (3.5%) and mild. No bleeding was reported. The BAL GM cut off of >0.8 was associated with the best diagnostic accuracy (sensitivity 72.97% and specificity 80%). Antifungal treatment of patients with BAL GM >0.8 resulted in a clinical-radiological improvement in 35/41 patients (85%). Conclusions BAL was a safe procedure also in thrombocytopenic patients, permitting an IFI diagnosis not otherwise identifiable using EORTC/MSG criteria. Our data suggest that a BAL GM value of>0.8 represents the most useful cut-off in terms of sensibility and specificity. Further prospective studies on a more significant number of patients are needed to confirm these results.
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18
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Valvani A, Martin A, Devarajan A, Chandy D. Postobstructive pneumonia in lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:357. [PMID: 31516903 DOI: 10.21037/atm.2019.05.26] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Postobstructive pneumonia can complicate lung cancer, particularly in more advanced stages of the disease, producing significant clinical decline and a poorer prognosis. It can lead to complications such as empyema, lung abscess and fistula formation. Postobstructive pneumonia can also be the first manifestation of an underlying malignancy. There are multiple challenges in the management of these patients. Recognition and treatment of this entity can be complex and includes the use of imaging, administration of broad-spectrum antibiotics to cover the wide variety of microorganisms involved and the use of different interventional modalities to relieve the obstruction. Existing literature on postobstructive pneumonia is scarce. In this article, we review the pathophysiology, different diagnostic methods and the therapeutic options to treat this condition. The utility and efficacy of the various modalities that are currently available in clinical practice to the interventional pulmonologist are described in some detail.
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Affiliation(s)
- Aashish Valvani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Alvaro Martin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Anusha Devarajan
- Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Dipak Chandy
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
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19
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de Heer K, Gerritsen MG, Visser CE, Leeflang MMG, Cochrane Airways Group. Galactomannan detection in broncho-alveolar lavage fluid for invasive aspergillosis in immunocompromised patients. Cochrane Database Syst Rev 2019; 5:CD012399. [PMID: 31107543 PMCID: PMC6526785 DOI: 10.1002/14651858.cd012399.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Invasive aspergillosis (IA) is a life-threatening opportunistic mycosis that occurs in some people with a compromised immune system. The serum galactomannan enzyme-linked immunosorbent assay (ELISA) rapidly gained widespread acceptance as part of the diagnostic work-up of a patient suspected of IA. Due to its non-invasive nature, it can be used as a routine screening test. The ELISA can also be performed on bronchoalveolar lavage (BAL), allowing sampling of the immediate vicinity of the infection. The invasive nature of acquiring BAL, however, changes the role of the galactomannan test significantly, for example by precluding its use as a routine screening test. OBJECTIVES To assess the diagnostic accuracy of galactomannan detection in BAL for the diagnosis of IA in people who are immunocompromised, at different cut-off values for test positivity, in accordance with the Cochrane Diagnostic Test Accuracy Handbook. SEARCH METHODS We searched three bibliographic databases including MEDLINE on 9 September 2016 for aspergillosis and galactomannan as text words and subject headings where appropriate. We checked reference lists of included studies for additional studies. SELECTION CRITERIA We included cohort studies that examined the accuracy of BAL galactomannan for the diagnosis of IA in immunocompromised patients if they used the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) classification as reference standard. DATA COLLECTION AND ANALYSIS Two review authors assessed study quality and extracted data. Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used for quality assessment. MAIN RESULTS We included 17 studies in our review. All studies except one had a high risk of bias in two or more domains. The diagnostic performance of an optical density index (ODI) of 0.5 as cut-off value was reported in 12 studies (with 1123 patients). The estimated sensitivity was 0.88 (95% confidence interval (CI) 0.75 to 1.00) and specificity 0.81 (95% CI 0.71 to 0.91). The performance of an ODI of 1.0 as cut-off value could be determined in 11 studies (with 648 patients). The sensitivity was 0.78 (95% CI 0.61 to 0.95) and specificity 0.93 (95% CI 0.87 to 0.98). At a cut-off ODI of 1.5 or higher, the heterogeneity in specificity decreased significantly and was invariably >90%. AUTHORS' CONCLUSIONS The optimal cut-off value depends on the local incidence and clinical pathway. At a prevalence of 12% a hypothetical population of 1000 patients will consist of 120 patients with IA. At a cut-off value of 0.5 14 patients with IA will be missed and there will be 167 patients incorrectly diagnosed with IA. If we use the test at a cut-off value of 1.0, we will miss 26 patients with IA. And there will be 62 patients incorrectly diagnosed with invasive aspergillosis. The populations and results were very heterogeneous. Therefore, interpretation and extrapolation of these results has to be performed with caution. A test result of 1.5 ODI or higher appears a strong indicator of IA.
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Affiliation(s)
- Koen de Heer
- FlevoziekenhuisDepartment of Internal MedicineAlmereNetherlands
- Academic Medical CenterDepartment of HematologyAmsterdamNetherlands
| | | | - Caroline E Visser
- Academic Medical CentreDepartment of Medical MicrobiologyAmsterdamNetherlands
| | - Mariska MG Leeflang
- Amsterdam University Medical Centers, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsP.O. Box 22700AmsterdamNetherlands1100 DE
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20
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Omar MM, Alhalafawy AS, Emara NM, El-Mahdy MAE, Abdelsalam E. The role of medical thoracoscopic lung biopsy in diagnosis of diffuse parenchymal lung diseases. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_41_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Katsumata Y, Terada J, Abe M, Suzuki K, Ishiwata T, Ikari J, Takeda Y, Sakaida E, Tsushima K, Tatsumi K. An Analysis of the Clinical Benefit of 37 Bronchoalveolar Lavage Procedures in Patients with Hematologic Disease and Pulmonary Complications. Intern Med 2019; 58:1073-1080. [PMID: 30568132 PMCID: PMC6522406 DOI: 10.2169/internalmedicine.1606-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective Since pulmonary complications are a major cause of mortality in patients with hematologic diseases, their rapid detection and treatment are essential. Bronchoalveolar lavage (BAL) is widely performed to diagnose pulmonary infiltrates not evident with non-invasive investigations; however, reports on its clinical benefits for patients with hematologic diseases are limited. The aim of our study was to investigate the utility of diagnostic bronchoscopy with BAL for those patients. Methods We retrospectively reviewed the clinical records of 37 consecutive BAL procedures in 33 adult patients with hematological diseases and pulmonary infiltrates with at least 6 months of follow-up between August 2013 and September 2017 (total 747 BAL procedures). The BAL results, ensuing treatment modifications, treatment outcomes, survival times, and adverse events were evaluated. Results Microbiological findings were detected in 11 (29.7%), even though wide-spectrum antibiotics and antifungal drugs had been empirically administered to most patients (>70%) prior to the bronchoscopy procedure. Overall, 25 of the 37 BAL procedures (67.6%) had some impact on the diagnosis of pulmonary diseases. Patients without specific diagnostic findings from BAL had a significantly poorer survival than those with diagnostic findings via BAL (30-day survival: 33.3% vs. 92.0%; 180-day survival: 8.3% vs. 64.0%). Four patients (12.1%) experienced complications associated with bronchoscopy; there were no procedure-related deaths. Conclusion BAL seems still important for diagnosing pulmonary infiltrates and/or excluding some of the important respiratory tract pathogens in patients with hematological diseases; furthermore, negative specific diagnostic findings from BAL may be associated with poor prognoses.
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Affiliation(s)
- Yusuke Katsumata
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Jiro Terada
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Mitsuhiro Abe
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Kenichi Suzuki
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Tsukasa Ishiwata
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Jun Ikari
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Yusuke Takeda
- Department of Hematology, Graduate School of Medicine, Chiba University, Japan
| | - Emiko Sakaida
- Department of Hematology, Graduate School of Medicine, Chiba University, Japan
| | - Kenji Tsushima
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Japan
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22
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Deshwal H, Avasarala SK, Ghosh S, Mehta AC. Forbearance With Bronchoscopy. Chest 2019; 155:834-847. [DOI: 10.1016/j.chest.2018.08.1035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/01/2018] [Accepted: 08/06/2018] [Indexed: 02/06/2023] Open
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Choo R, Naser NSH, Nadkarni NV, Anantham D. Utility of bronchoalveolar lavage in the management of immunocompromised patients presenting with lung infiltrates. BMC Pulm Med 2019; 19:51. [PMID: 30808314 PMCID: PMC6390608 DOI: 10.1186/s12890-019-0801-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/04/2019] [Indexed: 02/08/2023] Open
Abstract
Background Bronchoalveolar lavage (BAL) is utilized for diagnosing lung infiltrates in immunocompromised. There is heterogeneity in the data and reported diagnostic yields range from 26 to 69%. Therefore, selection criteria for BAL to maximize yield and minimize complications are unclear. Objectives of this study were to determine the diagnostic yield and complication rate of BAL in immunocompromised patients presenting with lung infiltrates, and identify factors impacting these outcomes. Exploratory aims included characterization of pathogens, rate of treatment modification and mortality. Methods Retrospective study from January 2012 to December 2016. Patients on mechanical ventilation were excluded. Positive diagnostic yield was defined as confirmed microbiological or cytological diagnosis. Results A total of 217 patients were recruited (70.1% male and mean age: 51.7 ± 14.6 years). Diagnostic yield was 60.8% and complication rate 14.7%. Complications (hypoxemia and endobronchial bleeding) were all sell-limiting. Treatment modification based on BAL results was 63.3%. In 97.0% an infectious aetiology was identified. HIV infection (OR 5.304, 95% CI 1.611–17.458, p = 0.006) and severe neutropenia (OR 4.253, 95% CI 1.288–14.045, p = 0.018) were associated with positive yield. Leukemia (OR 0.317, 95% CI 0.102–0.982, p = 0.047) was associated with lower yield. No factors impacted complication rate. Overall mortality (90-day) was 17.5% and in those with hematologic malignancy, it was 28.3%. Conclusion BAL retains utility in diagnosis of immunocompromised patients with lung infiltrates. However, patients with hematologic malignancy have a high mortality and alternative sampling should be considered because of poor results with BAL. Trial registration ClinicalTrials.gov identifier NCT01374542. Registered June 16, 2011.
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Affiliation(s)
- Randall Choo
- Duke-NUS Medical School, Singapore, Singapore.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, S169856, Singapore, Singapore
| | - Naser Salman Hamza Naser
- Salmaniya Medical Complex, Manama, Bahrain.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, S169856, Singapore, Singapore
| | | | - Devanand Anantham
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, S169856, Singapore, Singapore.
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24
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Choo R, Anantham D. Role of bronchoalveolar lavage in the management of immunocompromised patients with pulmonary infiltrates. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:49. [PMID: 30906753 DOI: 10.21037/atm.2019.01.21] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pulmonary infiltrates are a significant cause of morbidity and mortality in immunocompromised patients and remain a diagnostic challenge due to the broad range of etiologies that include infection and malignancy. Empiric therapy may be sub-optimal and can adversely impact outcome. Therefore, a confirmed diagnosis is necessary and flexible bronchoscopy with bronchoalveolar lavage (BAL) may be a useful diagnostic tool. Samples are obtained for microbiological and cytological testing, but the procedure carries risk of complications including the adverse events related to moderate sedation. A review of published literature on BAL in immunocompromised patients from the year 2000 was undertaken focusing on diagnostic yield, complication rate, mortality as well as factors impacting these outcomes. Studies in which the majority of patients were supported on mechanical ventilation were excluded. A total of 23 studies (7 prospective and 16 retrospective) met inclusion criteria. This covered 3,395 procedures in 3,192 patients with a mean age of 47.4 years; 60.3% male gender. Diagnostic yield ranged from 26% to 69% with no clear association between diagnostic yield and etiology of immunosuppression or clinical/radiological presentation. Post BAL modification of treatment as an indicator for clinical utility ranged from 11% to 84%; and complication rate ranged from 1% to 52%. No specific factors were associated with increased adverse event rate. This review provides a summary of the data on the use of BAL for diagnosis of pulmonary infiltrates in immunocompromised patients, highlighting the heterogeneity of patients, significant variation in findings reported and the need for more data to optimize patient selection.
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Affiliation(s)
- Randall Choo
- Duke-NUS Medical School, Singapore.,Singapore Health Services, Singapore
| | - Devanand Anantham
- Singapore Health Services, Singapore.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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Stoller JK. Giants in Chest Medicine: Professor Atul C. Mehta, MBBS, FCCP. Chest 2019; 155:254-257. [DOI: 10.1016/j.chest.2018.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 10/16/2018] [Indexed: 10/27/2022] Open
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Kiranantawat N, McDermott S, Fintelmann FJ, Montesi SB, Price MC, Digumarthy SR, Sharma A. Clinical role, safety and diagnostic accuracy of percutaneous transthoracic needle biopsy in the evaluation of pulmonary consolidation. Respir Res 2019; 20:23. [PMID: 30704502 PMCID: PMC6357395 DOI: 10.1186/s12931-019-0982-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/08/2019] [Indexed: 01/18/2023] Open
Abstract
Background To determine the clinical role, safety, and diagnostic accuracy of percutaneous transthoracic needle biopsy in the evaluation of pulmonary consolidation. Methods A retrospective review of all computed tomography (CT)-guided percutaneous transthoracic needle biopsies (PTNB) at a tertiary care hospital over a 4-year period was performed to identify all cases of PTNB performed for pulmonary consolidation. For each case, CT Chest images were reviewed by two thoracic radiologists. Histopathologic and microbiologic results were obtained and clinical follow-up was performed. Results Thirty of 1090 (M:F 17:30, mean age 67 years) patients underwent PTNB for pulmonary consolidation (2.8% of all biopsies). A final diagnosis was confirmed in 29 patients through surgical resection, microbiology, or clinicoradiologic follow-up for at least 18 months after biopsy. PTNB had an overall diagnostic accuracy of 83%. A final diagnosis of malignancy was made in 20/29 patients, of which 19 were correctly diagnosed by PTNB, resulting in a sensitivity of 95% and specificity of 100% for malignancy. In all cases of primary lung cancer, adequate tissue for molecular testing was obtained. A benign final diagnosis was made in 9 patients, infection in 5 cases and non-infectious benign etiology in 4 cases. PTNB correctly diagnosed all cases of infection. Minor complications occurred in 13% (4/30) of patients. Conclusions Pulmonary consolidation can be safely evaluated with CT-guided percutaneous needle biopsy. Diagnostic yield is high, especially for malignancy. PTNB of pulmonary consolidation should be considered following non-diagnostic bronchoscopy.
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Affiliation(s)
- Nantaka Kiranantawat
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Department of Radiology, Songklanagarind Hospital, Prince of Songkhla University Hat Yai, Songkhla, 90110, Thailand
| | - Shaunagh McDermott
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
| | - Florian J Fintelmann
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Sydney B Montesi
- Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Melissa C Price
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Subba R Digumarthy
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Amita Sharma
- Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
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Valentini I, Lazzari Agli L, Michieletto L, Innocenti M, Savoia F, Del Prato B, Mancino L, Maddau C, Romano A, Puorto A, Corbetta L, Fois A. Competence in flexible bronchoscopy and basic biopsy technique. Panminerva Med 2018; 61:232-248. [PMID: 30394711 DOI: 10.23736/s0031-0808.18.03563-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Diagnostic bronchoscopy and tissue sampling techniques using forceps (endobronchial biopsy [EBB] and transbronchial biopsies [TBB]) or needle aspiration (transbronchial needle aspiration-TBNA), all performed with a flexible bronchoscope, are the basic elements of any interventional procedure. The flexible fibrobronchoscopy allows the visualization of the airways and is used both for diagnostic and therapeutic purposes. The working channel of both fibrobronchoscopes with optical fibers and videobronchoscopes, even if of relatively small diameter, allows the insertion of various diagnostic and therapeutic accessories. Fiber optic systems have been widely replaced by video cameras using a miniaturized charge-coupled device camera positioned at the end of the scope that provides electronic transmission of images to a monitor. The indications for both diagnostic and therapeutic fibrobronchoscopy derive from a correct evaluation of symptoms and objective signs of the patient and from the correct interpretation of imaging methods. Although bronchoscopy techniques keep evolving at a rapid pace, basic procedures such as bronchoalveolar lavage, transbronchial lung biopsy, and transbronchial needle aspiration still play a key role in pulmonary disease diagnostics, and therefore, these methods must still be part of the training of interventional pulmonologists. Trainees will acquire a thorough knowledge of thoracic anatomy and become skilled in the interpretation of thoracic imaging, after which they will be given a theoretical and practical training course on virtual reality simulators, on animal or cadaver models, the effectiveness of which has been fully demonstrated by scientific studies. Specific DOPS tests have been developed for a qualitative evaluation of procedures on simulators, on animal models and on the patient.
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Affiliation(s)
| | | | | | | | - Francesca Savoia
- Unit of Pneumology, ULSS 2 Marca Trevigiana, Treviso Hospital, Treviso, Italy
| | - Bruno Del Prato
- Department of Bronchial Endoscopy and Emergency Pneumology, Cardarelli Hospital, Naples, Italy
| | - Laura Mancino
- Institute for Oncological Study, Prevention, and Networking (ISPRO), Florence, Italy
| | - Cristina Maddau
- Unit of Pneumology, San Giuseppe Moscati Hospital, Avellino, Italy
| | | | - Antonella Puorto
- Clinic of Pneumology, Sassari University Hospital, Sassari, Italy
| | - Lorenzo Corbetta
- Unit of Interventional Pneumology, Careggi University Hospital, Florence, Italy
| | - Alessandro Fois
- Clinic of Pneumology, Sassari University Hospital, Sassari, Italy
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Lachant DJ, Croft DP, McGrane Minton H, Hardy DJ, Prasad P, Kottmann RM. The clinical impact of pneumocystis and viral PCR testing on bronchoalveolar lavage in immunosuppressed patients. Respir Med 2018; 145:35-40. [PMID: 30509714 PMCID: PMC7126456 DOI: 10.1016/j.rmed.2018.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/21/2018] [Accepted: 10/21/2018] [Indexed: 11/25/2022]
Abstract
Introduction Pulmonary infiltrates in immunosuppressed patients are common. Yields from bronchoscopy with bronchoalveolar lavage (BAL) has been reported to be between 31 and 65%. The clinical impact of pneumocystis and viral Polymerase chain reaction (PCR) testing on BAL has not been extensively evaluated in a mixed immunosuppressed patient population. Methods We performed a retrospective chart review of immunosuppressed adults with pulmonary infiltrates who underwent BAL at the University of Rochester Medical Center. Only one BAL per patient was included. We compared the rate of positive PCR testing to conventional testing. We then investigated factors associated with positive PCR testing. Finally, we assessed for changes in antimicrobial therapy after bronchoscopy. Results Three hundred and fifty-nine patients underwent BAL with 249 patients having pneumocystis PCR testing and 142 having viral PCR testing. Pneumocystis identification occurred in 43 patients and viral species identification occurred in 56 patients. PCR testing increased pneumocystis identification compared to microscopy, 14% vs. 5%, p = 0.01, and viral identification compared to culture, 25% vs. 6%, p = 0.0001. Of the patients with positive pneumocystis PCR testing 49% had antibiotics stopped, 66% were started on anti-pneumocystis therapy, and only 6% did not receive treatment. There was no difference in the number of patients with antibiotics stopped based on viral PCR testing results. Discussion PCR testing increases BAL yield in immunosuppressed patients compared to conventional testing. Pneumocystis identified by PCR only may cause a self-limited infection and may not require antimicrobial therapy. PCR testing should be included in the evaluation of pulmonary infiltrates in immunosuppressed patients. Polymerase chain reaction testing has increased bronchoscopy yield. Pneumocystis is now being identified in non-HIV/AIDS with negative microscopy. Viruses are identified during bronchoscopy that were missed during nasal testing. Antimicrobial therapies are being changed based on testing results.
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Affiliation(s)
- Daniel J Lachant
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA.
| | - Daniel P Croft
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA
| | | | - Dwight J Hardy
- Department of Microbiology and Immunology, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA; Department of Pathology and Laboratory Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA
| | - Paritosh Prasad
- Division of Transplant Infectious Disease, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA; Division of Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA
| | - R Matthew Kottmann
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, NY, USA
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Al-Qadi MO, Cartin-Ceba R, Kashyap R, Kaur S, Peters SG. The Diagnostic Yield, Safety, and Impact of Flexible Bronchoscopy in Non-HIV Immunocompromised Critically Ill Patients in the Intensive Care Unit. Lung 2018; 196:729-736. [PMID: 30306285 PMCID: PMC7102260 DOI: 10.1007/s00408-018-0169-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 10/03/2018] [Indexed: 11/25/2022]
Abstract
Background Flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) have major roles in the evaluation of parenchymal lung diseases in immunocompromised patients. Given the limited evidence, lack of standardized practice, and variable perception of procedural safety, uncertainty still exists on what constitutes the best approach in critically ill patients with immunocompromised state who present with pulmonary infiltrates in the era of prophylactic antimicrobials and the presence of new diagnostic tests. Objective To evaluate the diagnostic yield, safety and impact of FB and BAL on management decisions in immunocompromised critically ill patients admitted to the intensive care unit (ICU). Methods A prospective, observational study of 106 non-HIV immunocompromised patients admitted to the intensive care unit with pulmonary infiltrates who underwent FB with BAL. Results FB and BAL established the diagnosis in 38 (33%) of cases, and had a positive impact on management in 44 (38.3%) of cases. Escalation of ventilator support was not required in 94 (81.7%) of cases, while 18 (15.7%) required invasive and 3 (2.6%) required non-invasive positive pressure ventilation after the procedure. Three patients (2.6%) died within 24 h of bronchoscopy, and 46 patients (40%) died in ICU. Significant hypoxemia developed in 5% of cases. Conclusion FB can be safely performed in immunocompromised critically ill patients in the ICU. The yield can be improved when FB is done prior to initiation of empiric antimicrobials, within 24 h of admission to the ICU, and in patients with focal disease.
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Affiliation(s)
- Mazen O Al-Qadi
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, 06510, USA.
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rahul Kashyap
- Division of Critical Care, Department of Anesthesia, Mayo Clinic, Rochester, MN, USA
| | - Sumanjit Kaur
- Division of Critical Care, Department of Anesthesia, Mayo Clinic, Rochester, MN, USA
| | - Steve G Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Akl YMK, Zawam HME, ElKorashy RIM, Ismail MS, Hanna AKM. Role of fiberoptic bronchoscopy in the diagnosis of pulmonary infiltrates in patients with hematological malignancies. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2018. [DOI: 10.4103/ejb.ejb_107_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Mukhopadhyay S, Mehta AC. Utility of Core Needle Biopsies and Transbronchial Biopsies for Diagnosing Nonneoplastic Lung Diseases. Arch Pathol Lab Med 2018; 142:1054-1068. [DOI: 10.5858/arpa.2017-0558-ra] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Small lung biopsies (core needle biopsies and transbronchial biopsies) are the most common—and often the first—lung sample obtained when a radiologic abnormality is detected and tissue diagnosis is required. When a neoplastic diagnosis cannot be made but pathologic abnormalities are present, it is useful for pathologists to have a list (“menu”) of specific nonneoplastic diagnoses that can be made in these samples.
Objective.—
To provide surgical pathologists and pathology trainees with menus of nonneoplastic entities that can be diagnosed in small lung biopsies, and to briefly describe and illustrate some of these entities as they appear in small lung biopsies.
Data Sources.—
Published literature and the authors' experience with small lung biopsies for diagnosis of nonneoplastic lung diseases.
Conclusions.—
Although sampling error imposes some limitations, core needle biopsies and transbronchial lung biopsies can contribute to the diagnosis of a variety of nonneoplastic lung diseases and reduce the need for invasive surgical intervention.
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Affiliation(s)
| | - Atul C. Mehta
- From the Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute (Dr Mukhopadhyay) and the Department of Pulmonary Medicine, Respiratory Institute (Dr Mehta), Cleveland Clinic, Cleveland, Ohio
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Ergan B, Nava S. The use of bronchoscopy in critically ill patients: considerations and complications. Expert Rev Respir Med 2018; 12:651-663. [PMID: 29958019 DOI: 10.1080/17476348.2018.1494576] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.
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Affiliation(s)
- Begum Ergan
- a Department of Pulmonary and Critical Care , School of Medicine, Dokuz Eylul University , Izmir , Turkey
| | - Stefano Nava
- b Department of Clinical , Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University , Bologna , Italy
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Park J, Lee YJ, Lee J, Park SS, Cho YJ, Lee SM, Kim YW, Han SK, Yoo CG. Histopathologic heterogeneity of acute respiratory distress syndrome revealed by surgical lung biopsy and its clinical implications. Korean J Intern Med 2018; 33:532-540. [PMID: 29088909 PMCID: PMC5943661 DOI: 10.3904/kjim.2016.346] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 03/19/2017] [Accepted: 05/16/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND/AIMS Diffuse alveolar damage (DAD) is the histopathologic hallmark of acute respiratory distress syndrome (ARDS). However, there are several non-DAD conditions mimicking ARDS. The purpose of this study was to investigate the histopathologic heterogeneity of ARDS revealed by surgical lung biopsy and its clinical relevance. METHODS We retrospectively analyzed 84 patients with ARDS who met the criteria of the Berlin definition and underwent surgical lung biopsy between January 2004 and December 2013 in three academic hospitals in Korea. We evaluated their histopathologic findings and compared the clinical outcomes. Additionally, the impact of surgical lung biopsy on therapeutic alterations was examined. RESULTS The histopathologic findings were highly heterogeneous. Of 84 patients undergoing surgical lung biopsy, DAD was observed in 31 patients (36.9%), while 53 patients (63.1%) did not have DAD. Among the non-DAD patients, diffuse interstitial lung diseases and infections were the most frequent histopathologic findings in 19 and 17 patients, respectively. Although the mortality rate was slightly higher in DAD (71.0%) than in non-DAD (62.3%), the difference was not significant. Overall, the biopsy results led to treatment alterations in 40 patients (47.6%). Patients with non-DAD were more likely to change the treatment than those with DAD (58.5% vs. 29.0%), but there were no significant improvements regarding the mortality rate. CONCLUSIONS The histopathologic findings of ARDS were highly heterogeneous and classic DAD was observed in one third of the patients who underwent surgical lung biopsy. Although therapeutic alterations were more common in patients with non-DAD-ARDS, there were no significant improvements in the mortality rate.
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Affiliation(s)
- Jimyung Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung Soo Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Whan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chul-Gyu Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Ullmann AJ, Aguado JM, Arikan-Akdagli S, Denning DW, Groll AH, Lagrou K, Lass-Flörl C, Lewis RE, Munoz P, Verweij PE, Warris A, Ader F, Akova M, Arendrup MC, Barnes RA, Beigelman-Aubry C, Blot S, Bouza E, Brüggemann RJM, Buchheidt D, Cadranel J, Castagnola E, Chakrabarti A, Cuenca-Estrella M, Dimopoulos G, Fortun J, Gangneux JP, Garbino J, Heinz WJ, Herbrecht R, Heussel CP, Kibbler CC, Klimko N, Kullberg BJ, Lange C, Lehrnbecher T, Löffler J, Lortholary O, Maertens J, Marchetti O, Meis JF, Pagano L, Ribaud P, Richardson M, Roilides E, Ruhnke M, Sanguinetti M, Sheppard DC, Sinkó J, Skiada A, Vehreschild MJGT, Viscoli C, Cornely OA. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clin Microbiol Infect 2018; 24 Suppl 1:e1-e38. [PMID: 29544767 DOI: 10.1016/j.cmi.2018.01.002] [Citation(s) in RCA: 947] [Impact Index Per Article: 135.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
The European Society for Clinical Microbiology and Infectious Diseases, the European Confederation of Medical Mycology and the European Respiratory Society Joint Clinical Guidelines focus on diagnosis and management of aspergillosis. Of the numerous recommendations, a few are summarized here. Chest computed tomography as well as bronchoscopy with bronchoalveolar lavage (BAL) in patients with suspicion of pulmonary invasive aspergillosis (IA) are strongly recommended. For diagnosis, direct microscopy, preferably using optical brighteners, histopathology and culture are strongly recommended. Serum and BAL galactomannan measures are recommended as markers for the diagnosis of IA. PCR should be considered in conjunction with other diagnostic tests. Pathogen identification to species complex level is strongly recommended for all clinically relevant Aspergillus isolates; antifungal susceptibility testing should be performed in patients with invasive disease in regions with resistance found in contemporary surveillance programmes. Isavuconazole and voriconazole are the preferred agents for first-line treatment of pulmonary IA, whereas liposomal amphotericin B is moderately supported. Combinations of antifungals as primary treatment options are not recommended. Therapeutic drug monitoring is strongly recommended for patients receiving posaconazole suspension or any form of voriconazole for IA treatment, and in refractory disease, where a personalized approach considering reversal of predisposing factors, switching drug class and surgical intervention is also strongly recommended. Primary prophylaxis with posaconazole is strongly recommended in patients with acute myelogenous leukaemia or myelodysplastic syndrome receiving induction chemotherapy. Secondary prophylaxis is strongly recommended in high-risk patients. We strongly recommend treatment duration based on clinical improvement, degree of immunosuppression and response on imaging.
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Affiliation(s)
- A J Ullmann
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J M Aguado
- Infectious Diseases Unit, University Hospital Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - S Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D W Denning
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; European Confederation of Medical Mycology (ECMM)
| | - A H Groll
- Department of Paediatric Haematology/Oncology, Centre for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - K Lagrou
- Department of Microbiology and Immunology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lass-Flörl
- Institute of Hygiene, Microbiology and Social Medicine, ECMM Excellence Centre of Medical Mycology, Medical University Innsbruck, Innsbruck, Austria; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R E Lewis
- Infectious Diseases Clinic, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - P Munoz
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - P E Verweij
- Department of Medical Microbiology, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - A Warris
- MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - F Ader
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France; Inserm 1111, French International Centre for Infectious Diseases Research (CIRI), Université Claude Bernard Lyon 1, Lyon, France; European Respiratory Society (ERS)
| | - M Akova
- Department of Medicine, Section of Infectious Diseases, Hacettepe University Medical School, Ankara, Turkey; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M C Arendrup
- Department Microbiological Surveillance and Research, Statens Serum Institute, Copenhagen, Denmark; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R A Barnes
- Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK; European Confederation of Medical Mycology (ECMM)
| | - C Beigelman-Aubry
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; European Respiratory Society (ERS)
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia; European Respiratory Society (ERS)
| | - E Bouza
- Department of Medical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain; Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R J M Brüggemann
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG)
| | - D Buchheidt
- Medical Clinic III, University Hospital Mannheim, Mannheim, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Cadranel
- Department of Pneumology, University Hospital of Tenon and Sorbonne, University of Paris, Paris, France; European Respiratory Society (ERS)
| | - E Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy; ESCMID Fungal Infection Study Group (EFISG)
| | - A Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India; European Confederation of Medical Mycology (ECMM)
| | - M Cuenca-Estrella
- Instituto de Salud Carlos III, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - G Dimopoulos
- Department of Critical Care Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece; European Respiratory Society (ERS)
| | - J Fortun
- Infectious Diseases Service, Ramón y Cajal Hospital, Madrid, Spain; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J-P Gangneux
- Univ Rennes, CHU Rennes, Inserm, Irset (Institut de Recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Garbino
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - W J Heinz
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - R Herbrecht
- Department of Haematology and Oncology, University Hospital of Strasbourg, Strasbourg, France; ESCMID Fungal Infection Study Group (EFISG)
| | - C P Heussel
- Diagnostic and Interventional Radiology, Thoracic Clinic, University Hospital Heidelberg, Heidelberg, Germany; European Confederation of Medical Mycology (ECMM)
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, London, UK; European Confederation of Medical Mycology (ECMM)
| | - N Klimko
- Department of Clinical Mycology, Allergy and Immunology, North Western State Medical University, St Petersburg, Russia; European Confederation of Medical Mycology (ECMM)
| | - B J Kullberg
- Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - C Lange
- International Health and Infectious Diseases, University of Lübeck, Lübeck, Germany; Clinical Infectious Diseases, Research Centre Borstel, Leibniz Center for Medicine & Biosciences, Borstel, Germany; German Centre for Infection Research (DZIF), Tuberculosis Unit, Hamburg-Lübeck-Borstel-Riems Site, Lübeck, Germany; European Respiratory Society (ERS)
| | - T Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; European Confederation of Medical Mycology (ECMM)
| | - J Löffler
- Department of Infectious Diseases, Haematology and Oncology, University Hospital Würzburg, Würzburg, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Lortholary
- Department of Infectious and Tropical Diseases, Children's Hospital, University of Paris, Paris, France; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Maertens
- Department of Haematology, ECMM Excellence Centre of Medical Mycology, University Hospital Leuven, Leuven, Belgium; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland; Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Centre of Expertise in Mycology Radboudumc/CWZ, ECMM Excellence Centre of Medical Mycology, Nijmegen, Netherlands; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - L Pagano
- Department of Haematology, Universita Cattolica del Sacro Cuore, Roma, Italy; European Confederation of Medical Mycology (ECMM)
| | - P Ribaud
- Quality Unit, Pôle Prébloc, Saint-Louis and Lariboisière Hospital Group, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - M Richardson
- The National Aspergillosis Centre, Wythenshawe Hospital, Mycology Reference Centre Manchester, Manchester University NHS Foundation Trust, ECMM Excellence Centre of Medical Mycology, Manchester, UK; The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester, UK; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - E Roilides
- Infectious Diseases Unit, 3rd Department of Paediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece; Hippokration General Hospital, Thessaloniki, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Ruhnke
- Department of Haematology and Oncology, Paracelsus Hospital, Osnabrück, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M Sanguinetti
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli - Università Cattolica del Sacro Cuore, Rome, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - D C Sheppard
- Division of Infectious Diseases, Department of Medicine, Microbiology and Immunology, McGill University, Montreal, Canada; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - J Sinkó
- Department of Haematology and Stem Cell Transplantation, Szent István and Szent László Hospital, Budapest, Hungary; ESCMID Fungal Infection Study Group (EFISG)
| | - A Skiada
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - M J G T Vehreschild
- Department I of Internal Medicine, ECMM Excellence Centre of Medical Mycology, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology, Cologne-Bonn, University of Cologne, Cologne, Germany; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; European Confederation of Medical Mycology (ECMM)
| | - C Viscoli
- Ospedale Policlinico San Martino and University of Genova (DISSAL), Genova, Italy; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM)
| | - O A Cornely
- First Department of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece; German Centre for Infection Research (DZIF) partner site Bonn-Cologne, Cologne, Germany; CECAD Cluster of Excellence, University of Cologne, Cologne, Germany; Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany; ESCMID Fungal Infection Study Group (EFISG); European Confederation of Medical Mycology (ECMM); ESCMID European Study Group for Infections in Compromised Hosts (ESGICH).
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Kara S, Sen N, Kursun E, Yabanoğlu H, Yıldırım S, Akçay Ş, Haberal M. Pneumonia in Renal Transplant Recipients: A Single-Center Study. EXP CLIN TRANSPLANT 2018. [PMID: 29528008 DOI: 10.6002/ect.tond-tdtd2017.p23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Pulmonary infections are a significant cause of morbidity and mortality in solid-organ transplant recipients despite enhanced facilities for perioperative care. The aim of this study was to evaluate the demographic characteristics, clinical course, and outcomes of renal transplant recipients with pneumonia. MATERIALS AND METHODS The medical records of all renal transplant recipients from January 2010 to December 2014 were retrospectively reviewed, and patients diagnosed with pneumonia according to Centers for Disease Control and Prevention criteria were evaluated. Pneumonia was classified as community acquired or nosocomial. Patient demographics, microbiologic findings, need for intensive care/mechanical ventilation over the course of treatment, and information about clinical follow-up and mortality were all recorded. RESULTS Eighteen (13.4%) of 134 renal transplant recipients had 25 pneumonia episodes within the study period. More than half (56%) of the pneumonia episodes developed within the first 6 months of transplant, whereas 44% developed after 6 months (all > 1 year). Eight cases (32%) were considered nosocomial pneumonia, and 17 (68%) were considered community-acquired pneumonia. Bacteria were the most common cause of pneumonia (28%), and fungi ranked second (8%). No viral or mycobacterial agents were detected. No patients required prolonged mechanical ventilation. No statistically significant difference was found in the need for intensive care or regarding mortality between patients with nosocomial and community-acquired pneumonia. Two patients (11%) died, and all remaining patients recovered. CONCLUSIONS The present study confirmed that pneumonia after renal transplant is not a rare complication but a significant cause of morbidity. Long-term and close follow-up for pneumonia is necessary after renal transplant.
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Affiliation(s)
- Sibel Kara
- From the Department of Pulmonary Diseases, Baskent University Adana Dr. Turgut Noyan Teaching and Medical Research Center, Adana, Turkey
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Gershman E, Ridman E, Fridel L, Shtraichman O, Pertzov B, Rosengarten D, Rahman NA, Shitenberg D, Kramer MR. Efficacy and safety of trans-bronchial cryo in comparison with forceps biopsy in lung allograft recipients: Analysis of 402 procedures. Clin Transplant 2018; 32:e13221. [PMID: 29436115 DOI: 10.1111/ctr.13221] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Trans-bronchial forceps biopsy (TBFB) is the gold standard to establish the presence of allograft rejection or infection after lung transplantation. We aimed to analyze the diagnostic yield and safety of trans-bronchial cryobiopsy (TBCB) in lung allografts. METHODS Retrospective analysis of 402 TBB procedures in 362 lung recipients was performed between 2011 and 2016. Half of the cases (201) were performed by TBCB and the other half by TBFB. One hundred random slides of TBB specimens from lung allografts were reviewed for artifacts, bleeding, and histological evidence. RESULTS Both TBB groups were comparable in age, gender distribution, and time following transplantation. Acute rejection was diagnosed in 21.9% of the TBCB group vs 14.9% in the TBFB group (P = .09) and only 2 cases (1%) of nondiagnostic tissue in TBCB group and 4 cases (2%) in TBFB group (P = .685). Complications of pneumothorax and bleeding occurred in 9 (4.5%) vs 8 (4%) and 5 (2.5%) vs 4 (2%) in TBCB vs TBFB groups, respectively. The TBCB specimens were larger than TBFB (average 16.6 vs 6.6 mm2 ; P < .001). Crush and bleeding artifacts were seen in 11 (22%) and 23 (46%) of TBFB, respectively, yet none in TBCB group (P < .001). CONCLUSION Trans-bronchial cryobiopsy is safe and effective for diagnosis of lung allograft rejection.
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Affiliation(s)
- Evgeni Gershman
- Rabin Medical Center, Pulmonary Institute, Belinson Campus, Petah Tikva, Israel.,Sackler School of Medicine, Medical Faculty, Tel Aviv University, Tel Aviv, Israel
| | - Elena Ridman
- Rabin Medical Center, Pulmonary Institute, Belinson Campus, Petah Tikva, Israel
| | - Ludmila Fridel
- Rabin Medical Center, Pathology Institute, Belinson Campus, Petah Tikva, Israel
| | - Osnat Shtraichman
- Rabin Medical Center, Pulmonary Institute, Belinson Campus, Petah Tikva, Israel.,Sackler School of Medicine, Medical Faculty, Tel Aviv University, Tel Aviv, Israel
| | - Barak Pertzov
- Rabin Medical Center, Pulmonary Institute, Belinson Campus, Petah Tikva, Israel.,Sackler School of Medicine, Medical Faculty, Tel Aviv University, Tel Aviv, Israel
| | - Dror Rosengarten
- Rabin Medical Center, Pulmonary Institute, Belinson Campus, Petah Tikva, Israel.,Sackler School of Medicine, Medical Faculty, Tel Aviv University, Tel Aviv, Israel
| | - Nader Abdel Rahman
- Rabin Medical Center, Pulmonary Institute, Belinson Campus, Petah Tikva, Israel.,Sackler School of Medicine, Medical Faculty, Tel Aviv University, Tel Aviv, Israel
| | - Dorit Shitenberg
- Rabin Medical Center, Pulmonary Institute, Belinson Campus, Petah Tikva, Israel.,Sackler School of Medicine, Medical Faculty, Tel Aviv University, Tel Aviv, Israel
| | - Mordechai R Kramer
- Rabin Medical Center, Pulmonary Institute, Belinson Campus, Petah Tikva, Israel.,Sackler School of Medicine, Medical Faculty, Tel Aviv University, Tel Aviv, Israel
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Harris B, Geyer AI. Diagnostic Evaluation of Pulmonary Abnormalities in Patients with Hematologic Malignancies and Hematopoietic Cell Transplantation. Clin Chest Med 2017; 38:317-331. [PMID: 28477642 PMCID: PMC7172342 DOI: 10.1016/j.ccm.2016.12.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pulmonary complications (PC) of hematologic malignancies and their treatments are common causes of morbidity and mortality. Early diagnosis is challenging due to host risk factors, clinical instability, and provider preference. Delayed diagnosis impairs targeted treatment and may contribute to poor outcomes. An integrated understanding of clinical risk and radiographic patterns informs a timely approach to diagnosis and treatment. There is little prospective evidence guiding optimal modality and timing of minimally invasive lung sampling; however, a low threshold for diagnostic bronchoscopy during the first 24 to 72 hours after presentation should be a guiding principle in high-risk patients.
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Affiliation(s)
- Bianca Harris
- Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Alexander I Geyer
- Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
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Youness HA, Keddissi J, Berim I, Awab A. Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy. J Thorac Dis 2017; 9:S1022-S1033. [PMID: 29214062 DOI: 10.21037/jtd.2017.05.45] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although, bronchoscopy is a relatively safe procedure, small amount of bleeding in the airway can have serious consequences. Careful consideration of the risks of diagnostic and therapeutic bronchoscopic intervention can help minimize potential complications. With increasing number of patients using antiplatelet and anticoagulation therapies, strategies for minimizing thromboembolic and operative bleeding events need to be included in the risk and benefit analyses. Growing evidence suggests that aspirin is safe and does not increase bleeding during bronchoscopy. In addition, despite small studies reporting that it may be safe to perform bronchoscopic procedures that have low risk for bleeding such as endobronchial ultrasound with transbronchial needle aspiration on clopidogrel, it is still recommended to hold it for 7 days prior to performing elective bronchoscopy. It is recommended to hold vitamin K antagonist, as well as new oral anticoagulation agents prior to bronchoscopy. The timing for pre-procedural discontinuation of anticoagulation therapy and the decision to bridge depend on the agent used, the renal function and the thromboembolic risk. In this review article, we will discuss available data regarding management of anticoagulation and antiplatelet therapy as it applies to bronchoscopic procedures.
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Affiliation(s)
- Houssein A Youness
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, OK, USA
| | - Jean Keddissi
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, OK, USA
| | - Ilya Berim
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, Creighton University, NE, USA
| | - Ahmed Awab
- Department of Medicine, Section of Pulmonary Diseases, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, OK, USA
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Makita K, Mikami Y, Matsuzaki H, Narumoto O, Takai D, Yatomi Y, Nagase T. Utility of bronchoscopy in the definitive diagnosis of patients with haematological malignancies presenting with radiological abnormalities. CLINICAL RESPIRATORY JOURNAL 2017; 12:1381-1388. [PMID: 28752537 DOI: 10.1111/crj.12666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/12/2017] [Accepted: 07/10/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with haematological malignancies usually have a plethora of respiratory complications. Bronchoscopy is one of the most important procedures used to diagnose respiratory complications. Despite enormous benefit, patients should be carefully selected for bronchoscopy as the process is invasive; however, there are only few reports evaluating the contributing factors of bronchoscopy that result in the definitive diagnosis of respiratory complications in these patients. OBJECTIVE This study aimed to elucidate and identify the contributing factors of bronchoscopy for definitive diagnosis in patients with haematological malignancies. METHODS We retrospectively analysed 275 patients with haematological malignancies who later showed respiratory complications, requiring consultation with pulmonologists. We found that 62 patients underwent bronchoscopy. Our data analysis focused on this particular subset of patients to identify the factors crucial for definitive diagnosis via bronchoscopy. RESULTS Bronchoscopy provided definitive diagnosis for 25 patients (diagnostic yield = 40.3%). We determined that nodular shadow was associated with high diagnostic yields by multivariate logistic regression [odds ratio (OR): 6.6 (2.1-23)]. Furthermore, in several bronchoscopic procedures, biopsy also contributed to definitive diagnosis of patients with nodular shadow [OR: 17 (1.5-180)]. Life-threatening complications were not observed due to bronchoscopy in our study. CONCLUSIONS Our study demonstrated that patients with haematological malignancies who showed lung nodular shadows are more likely to be definitively diagnosed by bronchoscopy, whereas transbronchial biopsy may also be beneficial for these patients.
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Affiliation(s)
- Kosuke Makita
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yu Mikami
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Clinical Laboratory Medicine, Graduate school of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirotaka Matsuzaki
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Narumoto
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daiya Takai
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Clinical Laboratory Medicine, Graduate school of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Yutaka Yatomi
- Department of Clinical Laboratory Medicine, Graduate school of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, Graduate school of Medicine, The University of Tokyo, Tokyo, Japan
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Abstract
PURPOSE Some patients with diffuse interstitial lung disease (ILD) undergo bronchoscopy with transbronchial biopsy (TBB) as part of their diagnostic evaluation. It is unclear what the incidence and risk factors for pneumothorax (PTX) following TBB are in this patient population. METHODS Ninety-seven subjects with pulmonary fibrosis who underwent a research bronchoscopy with TBB as part of the multicenter correlating outcomes with biochemical markers to estimate time-progression in idiopathic pulmonary fibrosis (COMET) trial were retrospectively reviewed. We compared subjects who developed a PTX during research bronchoscopy with TBB versus those who did not. RESULTS Seven patients (7.2%) experienced a PTX during research bronchoscopy with TBB. Subjects who experienced PTX during TBB had significantly lower DLCO percent predicted (29 ± 8 vs. 45 ± 15, P = 0.006) and had lower resting room air saturation of peripheral oxygen (SPO2) on 6-min walk testing (91 ± 10 vs. 95 ± 3, P = 0.02). No differences between groups were found with respect to age, gender, race, BMI, HRCT characteristics, or the number of transbronchial biopsies performed. CONCLUSION The incidence of PTX following research bronchoscopy with TBB in patients with pulmonary fibrosis was found to be 7.2% in this study. Patients who developed a pneumothorax had greater impairments in gas exchange at baseline evidenced by a lower DLCO % predicted and a lower resting room air SPO2 compared with subjects without PTX as a complication.
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Smibert OC, Slavin MA. Cart before the horse: use of Aspergillus PCR to increase the diagnostic yield from BAL in hematological patients at risk of invasive aspergillosis. Leuk Lymphoma 2017; 58:2773-2776. [PMID: 28573907 DOI: 10.1080/10428194.2017.1330479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Olivia Catherine Smibert
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , East Melbourne , Victoria , Australia
| | - Monica A Slavin
- a Department of Infectious Diseases , Peter MacCallum Cancer Centre , East Melbourne , Victoria , Australia.,b Victorian Infectious Diseases Service at the Peter Doherty Institute for Infection and Immunity , Melbourne , Victoria , Australia.,c University of Melbourne , Melbourne , Australia
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Abstract
Bacterial pneumonias exact unacceptable morbidity on patients with cancer. Although the risk is often most pronounced among patients with treatment-induced cytopenias, the numerous contributors to life-threatening pneumonias in cancer populations range from derangements of lung architecture and swallow function to complex immune defects associated with cytotoxic therapies and graft-versus-host disease. These structural and immunologic abnormalities often make the diagnosis of pneumonia challenging in patients with cancer and impact the composition and duration of therapy. This article addresses host factors that contribute to pneumonia susceptibility, summarizes diagnostic recommendations, and reviews current guidelines for management of bacterial pneumonia in patients with cancer.
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Affiliation(s)
- Justin L Wong
- Division of Internal Medicine, Department of Pulmonary, Critical Care and Sleep Medicine, The University of Texas Health Sciences Center, 6431 Fannin Street, MSB 1.434, Houston, TX 77030, USA
| | - Scott E Evans
- Division of Internal Medicine, Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1100, Houston, TX 77030, USA.
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"Noninterventional Pulmonology": Birth of a New Subspecialty With Emergence of Interventional Pulmonology. J Bronchology Interv Pulmonol 2017; 24:1-3. [PMID: 27984380 DOI: 10.1097/lbr.0000000000000340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Prise en charge du patient neutropénique en réanimation (nouveau-nés exclus). Recommandations d’un panel d’experts de la Société de réanimation de langue française (SRLF) avec le Groupe francophone de réanimation et urgences pédiatriques (GFRUP), la Société française d’anesthésie et de réanimation (Sfar), la Société française d’hématologie (SFH), la Société française d’hygiène hospitalière (SF2H) et la Société de pathologies infectieuses de langue française (SPILF). MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1278-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Lachant DJ, Croft DP, McGrane Minton H, Prasad P, Kottmann RM. Nasopharyngeal viral PCR in immunosuppressed patients and its association with virus detection in bronchoalveolar lavage by PCR. Respirology 2017; 22:1205-1211. [PMID: 28382762 PMCID: PMC7169060 DOI: 10.1111/resp.13049] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/20/2017] [Accepted: 02/20/2017] [Indexed: 12/05/2022]
Abstract
Background and objective Pulmonary infiltrates are common in immunosuppressed patients. Bronchoscopy with bronchoalveolar lavage (BAL) is often used to evaluate their aetiology. However, it may not always be easily performed. Thus, alternative diagnostic strategies may be needed. There is limited data on the correlation of nasopharyngeal (NP) respiratory viral panel (RVP)‐PCR testing compared with BAL. We aimed to identify the predictive value of NP RVP‐PCR samples compared with samples obtained from BAL in immunosuppressed patients with pulmonary infiltrates. Methods We conducted an observational retrospective study of immunosuppressed adults who underwent bronchoscopy in the Pulmonary Department at the University of Rochester Medical Center between January 2011 and June 2016. We compared the positive and negative predictive values, sensitivity, specificity and false negative rate of NP RVP‐PCR and BAL RVP‐PCR, as well as identified clinical predictors of positive viral BAL RVP‐PCR. Results Eighty‐nine immunosuppressed patients had both NP and bronchoalveolar RVP‐PCR testing. Twenty‐one patients had NP(+)BAL(+) RVP‐PCR testing. Seven patients had false negative (NP(−)BAL(+)) RVP‐PCR testing. Three patients had NP(+)BAL(−) RVP‐PCR testing. The positive and negative predictive values of NP RVP‐PCR testing were 88% and 89%, respectively. Allogeneic bone marrow transplantation and testing performed in the winter and spring months were significantly associated with positive BAL RVP‐PCR (OR = 3.3 (1.19–9.12); OR = 4.62 (1.64–12.99), respectively). Conclusion NP RVP‐PCR testing has high concordance with testing performed on BAL samples. Repeat testing through BAL is beneficial when there is high concern for viral infection after initial NP RVP‐PCR testing is negative. There are limited data on nasopharyngeal (NP) testing compared with bronchoscopy in immunosuppressed patients. NP PCR testing has a false negative rate of 8%, positive predictive value of 88% and negative predictive value of 89%. http://onlinelibrary.wiley.com/doi/10.1111/resp.13061/abstract
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Affiliation(s)
- Daniel J Lachant
- Department of Pulmonary and Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, New York, USA
| | - Daniel P Croft
- Department of Pulmonary and Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, New York, USA
| | | | - Paritosh Prasad
- Department of Transplant Infectious Disease, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, New York, USA.,Department of Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, New York, USA
| | - Robert M Kottmann
- Department of Pulmonary and Critical Care Medicine, University of Rochester Medical Center/Strong Memorial Hospital, Rochester, New York, USA
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Nonbronchoscopic Methods [Nonbronchoscopic Bronchoalveolar Lavage (BAL), Mini-BAL, Blinded Bronchial Sampling, Blinded Protected Specimen Brush] to Investigate for Pulmonary Infections, Inflammation, and Cellular and Molecular Markers: A Narrative Review. ACTA ACUST UNITED AC 2017. [DOI: 10.1097/cpm.0000000000000185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tomotani DYV, Bafi AT, Pacheco ES, de Sandes-Freitas TV, Viana LA, de Oliveira Pontes EP, Tamura N, Tedesco-Silva H, Machado FR, Freitas FGR. The diagnostic yield and complications of open lung biopsies in kidney transplant patients with pulmonary disease. J Thorac Dis 2017; 9:166-175. [PMID: 28203420 DOI: 10.21037/jtd.2017.01.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to assess the efficacy of open lung biopsy (OLB) in determining the specific diagnosis and the related complications in patients with undiagnosed diffuse pulmonary infiltrates. METHODS This single center, retrospective study included adult kidney transplant patients who underwent OLB. The patients had diffuse pulmonary infiltrates without definitive diagnoses and failed to respond to empiric antibiotic treatment. We analyzed the number of specific diagnoses, changes in treatment and the occurrence of complications in these patients. A logistic regression was used to determine which variables were predictors of hospital mortality. RESULTS From April 2010 to April 2014, 87 patients consecutively underwent OLB. A specific diagnosis was reached in 74 (85.1%) patients. In 46 patients (53%), their therapeutic management was changed after the OLB results. Twenty-five (28.7%) patients had complications related to the OLB. The hospital mortality rate was 25.2%. Age, SAPS3 score and complications related to the procedure were independent predictors of all-cause mortality. CONCLUSIONS OLB is a high-risk procedure with a high diagnostic yield in kidney transplant patients with diffuse pulmonary infiltrates who did not have a definitive diagnosis and who failed to respond to empiric antibiotic treatment. Complications related to OLB were common and were independently associated with intra-hospital mortality.
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Affiliation(s)
- Daniere Yurie Vieira Tomotani
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil;; Hospital do Rim, Nephrology Division, São Paulo, SP, Brazil
| | - Antônio Tonete Bafi
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil;; Hospital do Rim, Nephrology Division, São Paulo, SP, Brazil
| | - Eduardo Souza Pacheco
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Nikkei Tamura
- Hospital do Rim, Nephrology Division, São Paulo, SP, Brazil
| | | | - Flavia Ribeiro Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Flávio Geraldo Rezende Freitas
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, SP, Brazil;; Hospital do Rim, Nephrology Division, São Paulo, SP, Brazil
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Leiten EO, Martinsen EMH, Bakke PS, Eagan TML, Grønseth R. Complications and discomfort of bronchoscopy: a systematic review. Eur Clin Respir J 2016; 3:33324. [PMID: 27839531 PMCID: PMC5107637 DOI: 10.3402/ecrj.v3.33324] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/20/2016] [Indexed: 01/19/2023] Open
Abstract
Objective To identify bronchoscopy-related complications and discomfort, meaningful complication rates, and predictors. Method We conducted a systematic literature search in PubMed on 8 February 2016, using a search strategy including the PICO model, on complications and discomfort related to bronchoscopy and related sampling techniques. Results The search yielded 1,707 hits, of which 45 publications were eligible for full review. Rates of mortality and severe complications were low. Other complications, for instance, hypoxaemia, bleeding, pneumothorax, and fever, were usually not related to patient characteristics or aspects of the procedure, and complication rates showed considerable ranges. Measures of patient discomfort differed considerably, and results were difficult to compare between different study populations. Conclusion More research on safety aspects of bronchoscopy is needed to conclude on complication rates and patient- and procedure-related predictors of complications and discomfort.
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Affiliation(s)
| | | | - Per Sigvald Bakke
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tomas Mikal Lind Eagan
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Rune Grønseth
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
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50
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Zhang X, Kuang Y, Zhang Y, He K, Lechtzin N, Zeng M, Yung RC, Xie C. Shifted focus of bronchoalveolar lavage in patients with suspected thoracic malignancy: an analysis of 224 patients. J Thorac Dis 2016; 8:3245-3254. [PMID: 28066604 DOI: 10.21037/jtd.2016.11.06] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bronchoscopies are extensively adopted for diagnosing and staging thoracic malignancies, but studies are missing as how to keep the process streamlined and more efficient. To evaluate current role of bronchoalveolar lavage (BAL) for cancer and possible infection diagnosis when practicing comprehensive bronchoscopy for patients suspected with thoracic malignancy, and provide foundation for possible practice modification. METHODS We retrospectively analyzed a prospectively kept database of immunocompetent patients undergoing bronchoscopy for suspected non-hematologic malignancies. Clinical, radiographic data, bronchoscopic sampling techniques and diagnostic results were recorded. Initially undiagnostic patients were followed up for 2 years for a definitive diagnosis. RESULTS Of 224 patients included, 179 (79.9%) were confirmed with active thoracic malignancies. BAL diagnostic yield of cancer based on different radiographic characters of target lesion are as follow: isolated lymphadenopathies 0%, central lesions 45.5%, peripheral masses (diameter ≥3 cm) 21.4%, peripheral large nodules (2≤ diameter <3 cm) 15.8%, and peripheral small nodules (diameter <2 cm) 7.1%, while composite bronchoscopy achieved diagnostic yield of 93.3%, 95.5%, 91.7%, 76.9%, and 66.7% in corresponding lesion types. No cancer was diagnosed solely by BAL-cytology. Proportions of patients with positive BAL culture did not differ significantly between patients with and without pre-test suspicion for infections (P=0.199). In multivariable analysis, infections were associated with age ≥75 (OR 3.0; 95% CI: 1.29-7.06), chronic obstructive pulmonary disease (COPD) (OR 2.7; 95% CI: 1.14-6.26) and diabetes mellitus (DM) (OR 4.5; 95% CI: 1.90-10.44). CONCLUSIONS Omitting BAL cytology in settings of comprehensive bronchoscopy may not compromise cancer diagnosis. For patients primarily suspected with thoracic malignancy, performing BAL culture only based on clinical suspicion could miss important infectious etiology.
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Affiliation(s)
- Xin Zhang
- Department of Respiratory Medicine, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China;; Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA;; Institute of Respiratory Diseases, Sun Yat-sen University, Guangzhou 510275, China
| | - Yukun Kuang
- Department of Respiratory Medicine, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China;; Institute of Respiratory Diseases, Sun Yat-sen University, Guangzhou 510275, China
| | - Yuan Zhang
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA;; Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Kai He
- Department of Medical Oncology, the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Noah Lechtzin
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mingying Zeng
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rex C Yung
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA;; Greater Baltimore Medical Center, Towson, Maryland, USA
| | - Canmao Xie
- Department of Respiratory Medicine, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China;; Institute of Respiratory Diseases, Sun Yat-sen University, Guangzhou 510275, China
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