The Lung Transplant Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia.
Semin Respir Crit Care Med. 2010 Apr;31(2):208-21. doi: 10.1055/s-0030-1249117. Epub 2010 Mar 30.
Despite advances in gene and immunological monitoring techniques that hold great promise for the future, fiberoptic bronchoscopy remains the gold standard to establish the presence or absence of acute pulmonary allograft rejection or infection after lung transplantation (LT). There is general agreement that clinically mandated transbronchial lung biopsies enhance diagnostic precision and have a satisfactory risk:benefit ratio in experienced hands. Surveillance transbronchial biopsies have a lower yield but may provide longitudinal insight into immunological events in the allograft, which can assist long-term management. Indeed, much of our knowledge about the significance of allograft histopathological events over time has been garnered from centers that perform routine surveillance procedures, and it is exactly the balance between individual and community benefit which underscores discussion about the value of invasive monitoring. Obliterative bronchiolitis (OB) is the most common cause of late chronic allograft dysfunction leading to death after LT. Significant OB is invariably associated with reduced graft function, denoted physiologically by the bronchiolitis obliterans syndrome (BOS). Importantly, not all BOS is due to OB; hence the move to develop an all embracing phraseology for late graft dysfunction, specifically "chronic lung allograft dysfunction" (CLAD). The major risk factor for BOS was once thought to be acute cellular rejection (ACR), but new data support an important role for lymphocytic bronchiolitis (LB) independent of so-called vascular acute rejection, albeit when diagnosed and treated. This review examines the role of fiberoptic bronchoscopy after LT as a surveillance tool versus a clinically mandated diagnostic procedure.
尽管基因和免疫监测技术的进步为未来带来了巨大的希望，但纤维支气管镜检查仍然是诊断肺移植（LT）后急性肺移植物排斥或感染的金标准。人们普遍认为，在有经验的医生手中，临床要求的经支气管肺活检可以提高诊断准确性，并且具有令人满意的风险效益比。监测性经支气管肺活检的检出率较低，但可能提供移植物免疫事件的纵向见解，有助于长期管理。事实上，我们对移植物组织病理学事件随时间变化的意义的大部分了解都是从进行常规监测程序的中心获得的，正是这种个体和社区利益之间的平衡，突显了关于侵袭性监测价值的讨论。闭塞性细支气管炎（OB）是 LT 后导致晚期慢性移植物功能障碍和死亡的最常见原因。明显的 OB 总是与移植物功能降低相关，这在生理学上表现为闭塞性细支气管炎综合征（BOS）。重要的是，并非所有 BOS 都是由 OB 引起的；因此，人们提出了一种全面的术语来描述晚期移植物功能障碍，即“慢性肺移植物功能障碍”（CLAD）。BOS 的主要危险因素曾经被认为是急性细胞排斥（ACR），但新数据支持淋巴细胞性细支气管炎（LB）在所谓的血管性急性排斥之外的重要作用，尽管在诊断和治疗时如此。这篇综述探讨了 LT 后纤维支气管镜检查作为监测工具与临床要求的诊断程序的作用。
