To investigate bronchoscopic findings, adjustments in management and survival benefits of bronchoscopy in patients with neutropenic fever.
With approval of the Institutional Review Board we quarried the medical record database and identified 416 broncho-alveolar lavages (BAL) in 2002. All patients with fever, moderate or severe neutropenia (absolute neutrophil count (ANC) <1000/microliter) and chest-radiographic abnormalities at the time of BAL were included.
38 BALs evaluated pulmonary infiltrates in patients with febrile neutropenia. Underlying diagnoses included hematological malignancies (74.3%) and lymphomas (11.4%). Neutropenia was caused by chemotherapy (19 patients), hematopoetic stem cell transplantation (11 patients) and manifestations of the underlying disease (7 patients). Neutropenia was moderate (ANC 1000-500/microliter) in 13 cases (34.2%) and severe (ANC <500/microliter) in 25 cases. Ten patients also underwent Transbronchial biopsy (TBB). Procedure related complications were rare and limited to one intubation, two ICU admissions and the need for repeat-bronchoscopy in two patients because of inadequate samples. Bronchoscopic findings changed the management in 19 cases (50%). Glucocorticoids were added in 10 cases (9 patients with diffuse alveolar hemorrhage (DAH)), antibiotics were withdrawn in 6 patients and added in 4. In 19 patients (50%) bronchoscopy established a specific diagnosis. TBB contributed only one specific diagnosis not established by BAL and sputum analysis. Sputum sampling was infrequently utilized (9 patients) but provided diagnostic information in 6 cases of aspergillosis, supplementing BAL in 2 cases. Radiographic patterns did not predict the impact of bronchoscopy on diagnosis and management. Diagnosis and management changes had no impact on hospital-mortality.
Bronchoscopy is a safe diagnostic procedure. It is a valuable tool to establish a diagnosis in patients with febrile neutropenia and chest-radiographic abnormalities. Bronchoscopic findings frequently result in alterations of management particularly if the diagnosis is DAH. TBB contributes very little to BAL and sputum analysis. Noninvasive techniques such as sputum analysis are underutilized.
Even though survival benefits are not estabished bronchoscopy should be utilized to obtain a diagnosis and guide management of neutropenic patients.
T. Peikert, None.