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Acute hypoxemic respiratory failure in children following bone marrow transplantation: an outcome and pathologic
T Bojko1, D A Notterman, B M Greenwald
1Department of Pediatrics, New York Hospital and Cornell University Medical College, NY, USA.
Insights
Pediatric acute hypoxemic respiratory failure post bone marrow transplant has an 88% mortality rate. Infectious pneumonia was the most common cause in patients with available tissue, necessitating prompt antifungal and antiviral treatment.
Area of Science:
- Pediatric critical care medicine
- Hematology/Oncology
- Pulmonary medicine
Background:
- Bone marrow transplantation (BMT) is a life-saving procedure for various pediatric conditions.
- Acute hypoxemic respiratory failure (AHRF) is a severe complication following BMT, particularly in children.
- Understanding the specific pulmonary pathology and outcomes in pediatric BMT recipients with AHRF is crucial for improving patient care.
Purpose of the Study:
- To characterize the pulmonary pathology observed in children experiencing AHRF after BMT.
- To describe the clinical course and outcomes of pediatric patients with AHRF post-BMT.
- To identify the primary causes of AHRF in this vulnerable patient population.
Main Methods:
- Retrospective review of medical records and pathological specimens from children admitted to a pediatric intensive care unit (PICU) with AHRF after BMT.
- Patients were identified based on a defined criterion for AHRF during a 7-year study period.
- Pathologic materials were re-examined and categorized into specific diagnoses, including diffuse alveolar damage, pulmonary hemorrhage, interstitial pneumonitis, and infectious pneumonia.
Main Results:
- A total of 43 pediatric patients met the inclusion criteria for AHRF post-BMT.
- The in-hospital mortality rate in the PICU was high, with 88% of patients dying during their admission.
- Among patients with available tissue, infectious pneumonia (43%) was the most frequent diagnosis, followed by diffuse alveolar damage (33%).
Conclusions:
- The high acute mortality rate for pediatric AHRF after BMT mirrors that seen in adults.
- Diffuse alveolar damage, a common finding in adult respiratory distress syndrome, was less frequent in this pediatric cohort.
- Infectious pneumonia is a leading cause of AHRF in pediatric BMT survivors, underscoring the importance of early and aggressive diagnostic workup and treatment with antifungal and antiviral agents.
Objectives:
To describe the pulmonary pathology and clinical outcome in children with acute hypoxemic respiratory failure after bone marrow transplantation.
Design:
Review of medical records and pathologic material of patients diagnosed with acute hypoxemic respiratory failure after bone marrow transplantation.
Setting:
Pediatric intensive care unit (ICU) of a teaching hospital.
Patients And Methods:
Retrospective review of a consecutive cohort of children, with a history of bone marrow transplantation admitted to the pediatric ICU during a 7-yr study period, and who met a published definition of acute hypoxemic respiratory failure. For each admission, the pediatric ICU course and outcome were reviewed. Pathologic material that was obtained from the patients was reexamined and assigned to one of the following categories: acute or organizing diffuse alveolar damage, pulmonary hemorrhage, nonspecific interstitial pneumonitis, or infectious pneumonia.
Interventions:
None.
Measurements And Main Results:
Forty-three patients satisfied criteria for inclusion in the study group. Indications for bone marrow transplantation were: solid tumor (30%), leukemia (44%), congenital immunodeficiency (19%), and aplastic anemia (7%). Patients were admitted to the pediatric ICU a median of 1 month (range 0 to 126) after bone marrow transplantation. Thirty-eight (88%) patients died in the pediatric ICU. Tissue histologic material was available from 21 (49%) patients. Six (29%) of 21 patients had acute diffuse alveolar damage; one (5%) had organizing diffuse alveolar damage; three (14%) had nonspecific interstitial pneumonitis; and two (10%) had pulmonary hemorrhage. Infectious pneumonia occurred in nine (43%) cases (five fungal; four viral).
Conclusions:
The acute mortality rate (88%) for children with acute hypoxemic respiratory failure after bone marrow transplantation is similar to that reported for adults with this combination of conditions. Diffuse alveolar damage, the histologic hallmark of adult respiratory distress syndrome, was present in a minority (33%) of patients. Infectious pneumonia was the most frequent cause of acute hypoxemic respiratory failure in patients who had pathologic tissue available, emphasizing the need for aggressive diagnostic studies and early institution of antifungal and antiviral therapy.