Bronchoscopic evaluation of pulmonary infiltrates following bone marrow transplantation

Study objective: To determine the impact of fiberoptic bronchoscopy (FOE), including quantitative bacterial cultures obtained by BAL and protected specimen brushing on therapeutic decisions and outcome in bone marrow transplant (BMT) patients. Design: Retrospective review of all BMT patients undergoing FOE during a 4-year period. Setting: A tertiary care university hospital. Results: Three hundred five patients underwent BMT; 71 (23%) had FOE to assess pulmonary infiltrates. Allogeneic BMT recipients underwent FOE 3.37 times more often than autologous recipients (p<0.001). Pathogens were identified in 31 (46%) patients undergoing FOE; bacteria were most commonly isolated although 86% of patients had received broad-spectrum empiric antibiotics. Therapy was changed in 20 (65%) patients when a microorganism was identified and in 9 (22%) with nondiagnostic results (p=0.0026), but isolation of a presumed pathogen had no apparent effect on survival. There were 19 (27%) FOE complications, including bleeding in 8 (11%) patients and death in 2 (3%). Major complications were associated with prolonged prothrombin time (p=0.006) and were more common (36% vs 14%; p<0.05) in patients who had protected specimen brushing vs BAL alone. Mortality at 40 months in BMT patients not requiring FOE was 33% compared with 61% mortality in those undergoing FOE (p<0.001); mortality was 96% in patients with respiratory failure requiring mechanical ventilation. Conclusion: FOE is diagnostically useful in the evaluation of some BMT patients with pulmonary complications and often influences therapy, although no impact on survival was clearly demonstrated. FOE should be performed only after benefits of the procedure are weighed carefully against its increased risk in this select population.