TY - JOUR
T1 - Diagnosis and outcome of acute respiratory failure in immunocompromised patients after bronchoscopy
AU - Bauer, Philippe R.
AU - Chevret, Sylvie
AU - Yadav, Hemang
AU - Mehta, Sangeeta
AU - Pickkers, Peter
AU - Bukan, Ramin B.
AU - Rello, Jordi
AU - van de Louw, Andry
AU - Klouche, Kada
AU - Meert, Anne-Pascale
AU - Martin-Loeches, Ignacio
AU - Marsh, Brian
AU - Crespi, Lorenzo Socias
AU - Moreno-Gonzalez, Gabriel
AU - Buchtele, Nina
AU - Amrein, Karin
AU - Balik, Martin
AU - Antonelli, Massimo
AU - Nyunga, Martine
AU - Barratt-Due, Andreas
AU - Bergmans, Dennis C. J. J.
AU - Spoelstra-de Man, Angelique M. E.
AU - Kuitunen, Anne
AU - Wallet, Florent
AU - Seguin, Amelie
AU - Metaxa, Victoria
AU - Lemiale, Virginie
AU - Burghi, Gaston
AU - Demoule, Alexandre
AU - Karvunidis, Thomas
AU - Cotoia, Antonella
AU - Klepstad, Pal
AU - Moller, Ann M.
AU - Mokart, Djamel
AU - Azoulay, Elie
AU - Rabbat, Antoine
AU - Darmon, Michael
AU - Klouche, Kada
AU - Platon, Laura
AU - Mayaux, Julien
AU - Chermak, Akli
AU - Lemaitre, Caroline
AU - Artaud-Macari, Elise
AU - Nelsen, Jonas
AU - Kaufmann, Thomas
AU - Viana, William
AU - Lishoa, Thiago
AU - Correa, Thiago Domingos
AU - Encina, Belen
AU - Socias, Antonio
AU - Efraim investigators and the Nine-I study group
N1 - Funding Information:
Conflict of interest: P.R. Bauer has nothing to disclose. S. Chevret has nothing to disclose. H. Yadav has nothing to disclose. S. Mehta has nothing to disclose. P. Pickkers has nothing to disclose. R.B. Bukan has nothing to disclose. J. Rello has nothing to disclose. A. van de Louw has nothing to disclose. K. Klouche has nothing to disclose. A-P. Meert has nothing to disclose. I. Martin-Loeches has nothing to disclose. B. Marsh has nothing to disclose. L. Socias Crespi has nothing to disclose. G. Moreno-Gonzalez has nothing to disclose. N. Buchtele has nothing to disclose. K. Amrein reports grants and personal fees for lecturing from Fresenius Kabi, personal fees for lecturing and advisory board work from Vifor Pharma and Shire, outside the submitted work. M. Balik has nothing to disclose. M. Antonelli has nothing to disclose. M. Nyunga has nothing to disclose. A. Barratt-Due has nothing to disclose. D.C.J.J. Bergmans has nothing to disclose. A.M.E. Spoelstra-de Man has nothing to disclose. A. Kuitunen has nothing to disclose. F. Wallet has nothing to disclose. A. Seguin has nothing to disclose. V. Metaxa has nothing to disclose. V. Lemiale has nothing to disclose. G. Burghi has nothing to disclose. A. Demoule reports grants, personal fees and nonfinancial support from Philips, personal fees for lecturing and advisory board work from Baxter, personal fees for lecturing from Hamilton, grants and nonfinancial support from Fisher & Paykel, grants from French Ministry of Health, outside the submitted work. T. Karvunidis has nothing to disclose. A. Cotoia has nothing to disclose. P. Klepstad has nothing to disclose. A.M. Møller has nothing to disclose. D. Mokart has nothing to disclose. E. Azoulay reports personal fees for lecturing and travel support for conference attendance from Gilead, personal fees for lecturing from Baxter, personal fees for lecturing and nonfinancial support from Alexion, grants from Ablynx and MSD, and devices for trials from Fisher & Paykel, outside the submitted work.
Funding Information:
Support statement: This work was supported by the Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologique (Grrr-OH). Funding information for this article has been deposited with the Crossref Funder Registry.
Publisher Copyright:
Copyright © ERS 2019.
PY - 2019/7/1
Y1 - 2019/7/1
N2 - Objective: We wished to explore the use, diagnostic capability and outcomes of bronchoscopy added to noninvasive testing in immunocompromised patients. In this setting, an inability to identify the cause of acute hypoxaemic respiratory failure is associated with worse outcome. Every effort should be made to obtain a diagnosis, either with noninvasive testing alone or combined with bronchoscopy. However, our understanding of the risks and benefits of bronchoscopy remains uncertain.Patients and methods: This was a pre-planned secondary analysis of Efraim, a prospective, multinational, observational study of 1611 immunocompromised patients with acute respiratory failure admitted to the intensive care unit (ICU). We compared patients with noninvasive testing only to those who had also received bronchoscopy by bivariate analysis and after propensity score matching.Results: Bronchoscopy was performed in 618 (39%) patients who were more likely to have haematological malignancy and a higher severity of illness score. Bronchoscopy alone achieved a diagnosis in 165 patients (27% adjusted diagnostic yield). Bronchoscopy resulted in a management change in 236 patients (38% therapeutic yield). Bronchoscopy was associated with worsening of respiratory status in 69 (11%) patients. Bronchoscopy was associated with higher ICU (40% versus 28%; p<0.0001) and hospital mortality (49% versus 41%; p=0.003). The overall rate of undiagnosed causes was 13%. After propensity score matching, bronchoscopy remained associated with increased risk of hospital mortality (OR 1.41, 95% CI 1.08-1.81).Conclusions: Bronchoscopy was associated with improved diagnosis and changes in management, but also increased hospital mortality. Balancing risk and benefit in individualised cases should be investigated further.
AB - Objective: We wished to explore the use, diagnostic capability and outcomes of bronchoscopy added to noninvasive testing in immunocompromised patients. In this setting, an inability to identify the cause of acute hypoxaemic respiratory failure is associated with worse outcome. Every effort should be made to obtain a diagnosis, either with noninvasive testing alone or combined with bronchoscopy. However, our understanding of the risks and benefits of bronchoscopy remains uncertain.Patients and methods: This was a pre-planned secondary analysis of Efraim, a prospective, multinational, observational study of 1611 immunocompromised patients with acute respiratory failure admitted to the intensive care unit (ICU). We compared patients with noninvasive testing only to those who had also received bronchoscopy by bivariate analysis and after propensity score matching.Results: Bronchoscopy was performed in 618 (39%) patients who were more likely to have haematological malignancy and a higher severity of illness score. Bronchoscopy alone achieved a diagnosis in 165 patients (27% adjusted diagnostic yield). Bronchoscopy resulted in a management change in 236 patients (38% therapeutic yield). Bronchoscopy was associated with worsening of respiratory status in 69 (11%) patients. Bronchoscopy was associated with higher ICU (40% versus 28%; p<0.0001) and hospital mortality (49% versus 41%; p=0.003). The overall rate of undiagnosed causes was 13%. After propensity score matching, bronchoscopy remained associated with increased risk of hospital mortality (OR 1.41, 95% CI 1.08-1.81).Conclusions: Bronchoscopy was associated with improved diagnosis and changes in management, but also increased hospital mortality. Balancing risk and benefit in individualised cases should be investigated further.
KW - BRONCHOALVEOLAR LAVAGE
KW - HEMATOLOGIC MALIGNANCIES
KW - FLEXIBLE BRONCHOSCOPY
KW - ONCOLOGY PATIENTS
KW - UTILITY
KW - SAFETY
KW - INFECTIONS
KW - GROUPE
KW - YIELD
U2 - 10.1183/13993003.02442-2018
DO - 10.1183/13993003.02442-2018
M3 - Article
C2 - 31109985
SN - 0903-1936
VL - 54
JO - European Respiratory Journal
JF - European Respiratory Journal
IS - 1
M1 - 1802442
ER -