Bronchoscopic techniques for the diagnosis of pulmonary complications of HIV infection

Bronchoscopy has played the central role in defining the spectrum of pulmonary disorders that occur in patients with HIV infection. Transbronchial biopsy (TBB) and bronchoalveolar lavage (BAL) both have high yields in the diagnosis of Pneumocystis carinii pneumonia (PCP) and other infections. Paradoxically, despite our knowledge and experience using bronchoscopy, controversy still exists regarding whether to attempt to make a bronchoscopic diagnosis in most patients with suspected PCP who have negative sputum studies or whether to administer initial empiric therapy and reserve invasive diagnostic techniques for patients who have a response. I prefer establishing a diagnosis as soon as possible because bronchoscopy is safe and because the patient may not have PCP and may become too ill to have bronchoscopy after a few days of ineffective therapy. A second controversy relates to the necessity of including routine TBB in addition to BAL during bronchoscopy. Although biopsies increase the risk of pneumothorax and hemorrhage, they add to the diagnostic yield in PCP and other infections. They are also necessary to provide tissue specimens for diagnosing noninfectious pulmonary disorders such as Kaposi's sarcoma and lymphocytic and nonspecific pneumonitis.