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Published on: June 23, 2023
Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates
Prasoon Jain1, Sunder Sandur, Yvonne Meli
1Department of Medicine, Louis A. Johnson Veterans Affairs Medical Center, Clarksburg, WV, USA.
Insights
Flexible bronchoscopy (FB) is effective for diagnosing lung infiltrates in immunocompromised patients, yielding a 56.2% diagnostic rate. Transbronchial biopsy (TBB) is recommended when feasible for improved diagnostic accuracy.
Area of Science:
- Pulmonology
- Infectious Diseases
- Critical Care Medicine
Background:
- Pulmonary infiltrates in immunocompromised patients present diagnostic challenges.
- Early and accurate diagnosis is crucial for effective management and improved patient outcomes.
Purpose of the Study:
- To evaluate the diagnostic utility of flexible bronchoscopy (FB) in non-HIV immunocompromised patients with pulmonary infiltrates.
- To compare the diagnostic yields of various FB sampling techniques.
Main Methods:
- A prospective, observational study was conducted in a tertiary care hospital.
- 104 immunocompromised patients with lung infiltrates underwent flexible bronchoscopy.
- Diagnostic yield was calculated based on final diagnoses established through FB, surgical lung biopsy, microbiology, serology, and clinical response.
Main Results:
- Flexible bronchoscopy achieved an overall diagnostic yield of 56.2%, identifying at least one diagnosis in 51% of patients.
- FB was more effective in diagnosing infectious agents (81% yield) compared to non-infectious causes (56% yield).
- Bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) had similar yields (38%), while protected specimen brush (PSB) sampling was lower (13%). Combined BAL and TBB yielded 70%.
Conclusions:
- Flexible bronchoscopy demonstrates a significant diagnostic yield in immunocompromised patients with pulmonary infiltrates.
- Performing transbronchial biopsy (TBB) during FB is recommended to maximize diagnostic accuracy in this patient population.
Study Objective:
To study the diagnostic role of flexible bronchoscopy (FB) in immunocompromised patients with pulmonary infiltrates.
Design:
Prospective, observational study.
Setting:
Tertiary care hospital.
Patients:
A total of 104 consecutive non-HIV-infected immunocompromised patients with lung infiltrates in whom FB was performed.
Methods:
The primary outcome measure was the diagnostic yield of FB, which was derived as the number of the diagnoses made using FB results divided by all final diagnoses. Final diagnoses were established using data from FB, surgical lung biopsy (SLB), and microbiology and serology testing, and by the clinical response to empiric therapy. We also studied the diagnostic yields of individual sampling procedures such as BAL, transbronchial biopsy (TBB), and protected-specimen brush (PSB) sampling.
Results:
Overall, 128 diagnoses were made in 104 patients. The overall diagnostic yield of FB was 56.2% (95% confidence interval [CI], 47 to 64%). FB provided at least one diagnosis in 53 of 104 patients (51%; 95% CI, 40 to 62%). FB was more likely to establish the diagnosis when the lung infiltrate was due to an infectious agent (81%; 95% CI, 67 to 90%) than to a noninfectious process (56%; 95% CI, 43 to 67%; p = 0.011). The diagnostic yields of BAL (38%; 95% CI, 30 to 47%) and TBB (38%; 95% CI, 27 to 51%) were similar (p = 0.94). The diagnostic yield of PSB sampling was lower (13%; 95% CI 6 to 24%; p = 0.001) than that of BAL. The combined diagnostic yield of BAL and TBB (70%; 95% CI, 57 to 80%) was higher than that of BAL alone (p < 0.001). Finally, the diagnostic yield of FB with PSB sampling, BAL, and TBB was similar to that of FB with BAL and TBB. The complication rate from FB was 21% (95% CI, 15 to 31%). Minor bleeding (13%) and pneumothorax (4%) were the most common complications.
Conclusions:
FB has a high diagnostic yield in immunocompromised patients with pulmonary infiltrates. Based on our results, we recommend performing TBB in these patients, whenever possible.
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