To bronch or not to bronch? A recurring challenge in neutropenic patients with pulmonary infiltrates

Though it is generally accepted that both noninvasive and bronchoscopic procedures substantially increase the diagnostic yield ofpulmonaryinfiltrates, few studies address the therapeutic implications of invasive bronchoscopic procedures and their impact on survival.

We prospectively followed all patients with neutropenic fever and pulmonary infiltrates who were either referred to the inpatient Pulmonary Consult Service of Yale New Haven Hospital or admitted to the Medical Intensive Care Unit between July 2006 andJuly 2008. One hundred forty-four patients with febrile neutropenia and associated pulmonary infiltrates were identified of whom 128 underwent flexible bronchoscopy.

A diagnosis was obtained in 91 (71%) of the 128 patients. The diagnostic yield was highest when sputum cultures, bronchoalveolar lavage andtransbronchialbiopsywere combined (70%; 95% CI, 57% to 80%). Survivalwas higher in patients who had an early diagnosis of the underlying cause of the pulmonary infiltrates. The results obtained with the different bronchoscopic techniques led to a change in antibiotic treatment in 70 cases (55%). In 35/128 patients (27%), bronchoscopic techniques led to a definite diagnosis otherwise not detected with nonbronchoscopic techniques. However, in 23% of the cases, where bronchoscopic techniques led to a definite diagnosis, the clinical information was not translated into appropriate changes of the antimicrobial management.

When noninvasive procedures are not likely to be diagnostic, bronchoscopic procedures should be performed soon after the occurrence of pulmonary infiltrates as early diagnosis improves survival.