Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, 06510, USA.
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
Lung. 2018 Dec;196(6):729-736. doi: 10.1007/s00408-018-0169-8. Epub 2018 Oct 10.
Flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) have major roles in the evaluation of parenchymal lung diseases in immunocompromised patients. Given the limited evidence, lack of standardized practice, and variable perception of procedural safety, uncertainty still exists on what constitutes the best approach in critically ill patients with immunocompromised state who present with pulmonary infiltrates in the era of prophylactic antimicrobials and the presence of new diagnostic tests.
To evaluate the diagnostic yield, safety and impact of FB and BAL on management decisions in immunocompromised critically ill patients admitted to the intensive care unit (ICU).
A prospective, observational study of 106 non-HIV immunocompromised patients admitted to the intensive care unit with pulmonary infiltrates who underwent FB with BAL.
FB and BAL established the diagnosis in 38 (33%) of cases, and had a positive impact on management in 44 (38.3%) of cases. Escalation of ventilator support was not required in 94 (81.7%) of cases, while 18 (15.7%) required invasive and 3 (2.6%) required non-invasive positive pressure ventilation after the procedure. Three patients (2.6%) died within 24 h of bronchoscopy, and 46 patients (40%) died in ICU. Significant hypoxemia developed in 5% of cases.
FB can be safely performed in immunocompromised critically ill patients in the ICU. The yield can be improved when FB is done prior to initiation of empiric antimicrobials, within 24 h of admission to the ICU, and in patients with focal disease.
在免疫功能低下的患者中，纤维支气管镜（FB）和支气管肺泡灌洗（BAL）在肺实质疾病的评估中具有重要作用。鉴于有限的证据、缺乏标准化的实践以及对程序安全性的不同看法，对于免疫功能低下、处于免疫抑制状态的危重症患者，在预防性使用抗生素和新诊断测试的时代，出现肺部浸润时，什么是最佳方法仍然存在不确定性。
评估 FB 和 BAL 在 ICU 收治的免疫功能低下的危重症患者中的诊断效果、安全性和对管理决策的影响。
一项前瞻性、观察性研究，纳入 106 例因肺部浸润而入住 ICU 的非 HIV 免疫功能低下患者，对其进行 FB 联合 BAL。
FB 和 BAL 确定了 38 例（33%）患者的诊断，对 44 例（38.3%）患者的管理产生了积极影响。94 例（81.7%）患者无需升级呼吸机支持，18 例（15.7%）患者在操作后需要有创通气，3 例（2.6%）患者需要无创正压通气。3 例患者（2.6%）在支气管镜检查后 24 小时内死亡，46 例患者（40%）在 ICU 死亡。5%的患者出现显著低氧血症。
在 ICU 收治的免疫功能低下的危重症患者中，FB 可以安全进行。当 FB 在经验性抗生素使用之前、入住 ICU 后 24 小时内、以及在局灶性疾病患者中进行时，其诊断效果可以提高。
