FIBEROPTIC BRONCHOSCOPY and BRONCHOALVEOLAR LAVAGE FOR THE EVALUATION OF PULMONARY DISEASE in IMMUNOCOMPROMISED CHILDREN

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FIBEROPTIC BRONCHOSCOPY and BRONCHOALVEOLAR
LAVAGE FOR THE EVALUATION OF PULMONARY DISEASE in
IMMUNOCOMPROMISED CHILDREN
E Yalçin, U Özçelik, D D Ersöz, N Çobanoglu, S
Pekcan, M Köse, T Öcal, Ö Sanal, N Kiper
Hacettepe University Faculty of
Medicine Pediatric Chest Diseases
Unit, Anestesiolgy and Reanimation
Department, Pediatric Immunology
Unit. 06100-Sihhiye, Ankara.
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Patients with childhood cancer or primary
immunodeficiencies (PID) are at high risk for
developing pulmonary infections and
non-infectious complications. An appropriate
diagnosis may be achieved in these situations by
fiberoptic bronchoscopy (FB) and bronchoalveolar
lavage (BAL).
3

• The overall daignostic rate achieved by FB and
  BAL investigations in immunocompromised patients
  was 84.
• A definite organism was recovered in 53.
• The rate of complications was 30.

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• 95 immunocomprimised patients receiving a regimen
  of broad spectrum ab and antifungal egents
• - Respirator pathogenes were detected only in
  BAL of 29 of the 95 patients (30)
• - Pathogens detected only in the BAL fluid were
  not susceptible to a standart broad spectrum
  antibiotic and antifungal regimen in 12 of the 29
  patients (41).
• FB and BAL give important informations in
  immunocompromised patients even if they were
  given ab and antifungal therapy.

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AIM
To evaluate the yield of FOB and BAL in these
children with pulmonary disease
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PATIENTS AND METHODS
To evaluate the yield of FOB and BAL in these
children with pulmonary disease, The medical
records of 16 immunocompromised children aged 3.5
months to 14 yrs (mean 4.7 yrs) between 2000 and
2007 were retrospectively reviewed.
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PATIENTS AND METHODS
Fiberoptic bronchoscopy with BAL was performed
with 5.2, 4 or 3.6-mm pediatric flexible
bronchoscope (Olympus BF-P200 Evis
bronchovideocsope/ Olympus BF-3C30 Olympus, New
Hyde Park, NY). Propofol was given for sedation
(Diprivan, Zeneca-Abdi Ibrahim, 1-1.5 mg/kg,
i.v.). Heart rate and transcutaneous oxygen
saturations were monitored throughout the
procedure (Sein Patient Monitor-SE 485).
Topical anesthesia of the upper and lower airways
was performed by 2 lidocaine. BAL was
performed either in an area most prominently
affected on the HRCT or in the right middle lobe
by gently wedging the tip of the bronchoscope in
a segmental bronchus. Three 1-mL/kg aliquouts
of sterile saline warmed at 370C were instilled
through the instrumentation channel.
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PATIENTS AND METHODS

• Each aliquot was immediately aspirated into a
  steril specimen container using a wall suction
  pressure of 100 to 120 mm Hg.
• The first aliquot of the recovered BAL fluid
  was discarded all other samples were pooled for
  analysis.

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PATIENTS AND METHODS

• The BAL fluid samples were analysed for total
  and differential cell counts.
• Aerobic and anaerobic cultures as well as
  cultures for tuberculosis and fungi were
  performed.
• Lipid laden and hemosiderin laden macrophages
  were also investigated.
• If purulan secretions was observed and/or
  culture positivity was detected in BAL fluid,
  presence of infection wass accepted.

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PATIENTS
Diagnosis No of Patients SCID 8 (2/8
BMT) CVID 2 ALL 2 HL 1 CGD 1 CD8 ? 1
Vasculitis 1
Early bronchoscopy could not performed in these
patients, because they had severe respiratory
distress and/or thrombocytopenia. So, almost all
the patients were receiving empiric therapy
while bronchoscopic studies were performed.
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PATIENTS
HRCT Findings No of Patients Diffusef/local
noduler infiltrations 5 Consolidation and/or
atelectasis 5 Diffused interstitial
infiltrations 4 Diffused ground glass opacities
2
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SONUÇLAR
HRCT Findings FB BAL results Diffusef/local
noduler infiltrations Pu (1/5) 1 PCP, 2 fungal
pneumonia, 1hemorrhage (n5) Hemorrhage
(C.albicans and A.fumigatus) (1/5) Consolidat
ion and/or atelectasis Pu (2/5) 2 bacterial
pneumonia (n5) (H.inf ve P.aerugin) Diffuse
d interstitial infiltrations Pu (3/4) 1 CMV, 1
PCP, 1 A.fumigatus (n4) Diffused ground
glass opacities Normal - (n2)
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Tani Takayasu vasculitis X-ray and HRCT
Diffused intestitiel infiltrations BAL PCP
Fluorescein-labeled antibody method
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RESULTS .I.

• The overall diagnostic rate achieved in children
  was 68 with FB-BAL. .
• Microorganisms were detected in all patients
  observed purulant secretions.
• The results of the FB-BAL changed therapeutic
  decision in 7 patients (43) exactly
• - Pulmonary hemorrhage (n1)
• - PCP (n2)
• - Fungal infections (n3)
• - CMV infection (n1)

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RESULTS .II.

• No significant adverse events were observed
  after the procedure.
• Sensitivity of HRCT findings in estimate of
  etiology
• was weak other than bacterial pneumonia.
• Mean 2.5 years follow-up, mortality rate was
  found as 18.

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DISCUSSION

• Early bronchoscopy could not performed in these
  patients, because they had severe respiratory
  distress and/or thrombocytopenia. So, almost all
  the patients were receiving empiric therapy
  while bronchoscopic studies were performed.
• Therefore, the yield of this procedure was low in
  our retrospective study.
• FB and BAL should be considered as an initial
  diagnostic tool in pediatric immunocompromised
  patients with pulmonary complications, if the
  patients condition suitable.
• When this safe procedure could be done early, it
  will prevent unnecessary use of drugs which have
  often side effects and high cost.