Severe respiratory failure requiring ICU admission in bone marrow transplant recipients

Two groups of bone marrow transplant (BMT) recipients with febrile noncardiogenic respiratory failure requiring intensive care unit (ICU) admission, in the early phase of bone marrow transplantation were compared: those who had proven infectious pneumonia and those in whom bronchoalveolar lavage (BAL) failed to establish a diagnosis. Thirty-eight consecutive neutropenic BMT recipients admitted to an ICU with febrile noncardiogenic respiratory failure were enrolled. All of them underwent a BAL with viral, fungal, bacterial, and histopathological examinations. Lung biopsies were performed in nonsurviving patients in order to compare with BAL results. Haematological, biological, respiratory failure and other organ failure parameters, infectious results, outcome, and lung biopsy results were evaluated. BAL allowed an infectious diagnosis to be established in 16 BMT recipients. No aetiology was proven in 22 patients. Without a significant difference in respiratory failure parameters on ICU admission, noninvasive continuous positive airway pressure ventilation, which was given to 11 patients in each group, was significantly more successful in patients with proven infectious pneumonia (6 of 11 versus 0 of 11 patients) and enabled endotracheal intubation to be avoided in significantly more patients with infectious disease (10 of 16 versus 22 of 22 patients). The evolution of patients without diagnosis was significantly different with more frequent renal failure, hepatic failure, and death (20 of 22 versus 9 of 16 patients). Post mortem biopsies confirmed the absence of micro-organisms, but endothelial damage and fibrosis was found in 14 of the 22 patients. In conclusion, in the early phase of bone marrow transplantation the recipients without proven aetiology of pneumonia have a worse outcome than grafted patients with proven infectious pneumonia.