Diagnosis and Outcome of Acute Respiratory Failure in Immunocompromised after Bronchoscopy
- Philippe R. Bauer1,
- Sylvie Chevret2,
- Hemang Yadav1,
- Sangeeta Mehta3,
- Peter Pickkers4,
- Ramin B. Bukan5,
- Jordi Rello6,
- Andry van de Louw7,
- Kada Klouche8,
- Anne-Pascale Meert9,
- Ignacio Martin-Loeches10,11,
- Brian Marsh12,
- Lorenzo Socias Crespi13,
- Gabriel Moreno-Gonzalez14,
- Nina Buchtele15,
- Karin Amrein16,
- Martin Balik17,
- Massimo Antonelli18,
- Martine Nyunga19,
- Andreas Barratt-Due20,
- Dennis C.J.J. Bergmans21,
- Angélique M.E. Spoelstra-de Man22,
- Anne Kuitunen23,
- Florent Wallet24,
- Amelie Seguin25,
- Victoria Metaxa26,
- Virginie Lemiale27,
- Gaston Burghi28,
- Alexandre Demoule29,
- Thomas Karvunidis30,
- Antonella Cotoia31,
- Pål Klepstad32,
- Ann M. Møller33,
- Djamel Mokart34 and
- Elie Azoulay27
- Efraim investigators and the Nine-I study group
- 1Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- 2ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153, INSERM, Paris Diderot Sorbonne University and Service de Biostatistique et Information Médicale AP-HP, Hôpital Saint-Louis, Paris, France
- 3Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
- 4The Department of Intensive Care Medicine (710), Radboud University Medical Center, Nijmegen, The Netherlands
- 5Department of Anesthesiology I, Herlev University Hospital, Herlev, Denmark
- 6CIBERES, Instituto Salud Carlos III & Vall d'Hebron Institut of Research Barcelona, Spain
- 7Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA
- 8Department of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
- 9Service de médecine interne, Unité de soins intensifs et urgences oncologiques, Université de libre de Bruxelles (ULB), Institut Jules Bordet, Brussels, Belgium
- 10Department of Intensive Care Medicine, Universidad de Barcelona IDIBAPS, Barcelona, Spain
- 11Department of Clinical Medicine, Trinity College, Wellcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland
- 12Department of Critical Care, Mater misericordiae, Dublin, Ireland
- 13Department of Critical Care, Hospital Son Llatzer, Palma de Mallorca, Illes Balears, Spain
- 14Department of Intensive Care, Hospital Universitari de Bellvitge, Barcelona, Spain
- 15Department of Medicine I, Vienna, Austria
- 16Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz and Thyroid Endocrinology Osteoporosis Institute Dobnig, Graz, Austria
- 17Department of Anesthesiology and Intensive Care Medicine, 1st Medical Faculty Charles University, General University Hospital, Prague, Czech Republic
- 18Department. of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
- 19CHG Victor Provo, Roubaix, France
- 20Department of Emergencies and Critical Care, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- 21Department of Intensive Care, Maastricht University Medical Centre, Maastricht, the Netherlands
- 22Department of Critical Care, Amsterdam, the Netherlands
- 23Department of Intensive Care, Tampere University Hospital Tampere, Finland
- 24Department of Critical Care, University Hospital Lyon Sud, Pierre Benite, France
- 25Réanimation Medicale, CHU de Caen, Caen, France
- 26Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
- 27Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France
- 28Terapia Intensiva, Hospital Maciel, Montevideo, Uruguay
- 29CHU Pitié-Salpétrière, Paris, France
- 30Medical ICU, 1st Dept. of Internal Medicine, Teaching Hospital, Faculty of Medicine and Biomedical Center in Pilsen, Charles University, Pilsen, Czech Republic
- 31Department of Anesthesia, Intensive Care, and Pain Therapy, University of Foggia, Policlinico “OO. Riuniti”, Foggia, Italy
- 32Department of Intensive Care Medicine, St Olavs University Hospital, Trondheim, Norway
- 33Herlev University Hospital, UCPH, Herlev, Denmark
- 34Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
- Dr Philippe R Bauer, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA. E-mail: Bauer.Philippe{at}mayo.edu
Abstract
Question: What are the use, diagnostic capability and outcomes of bronchoscopy added to non-invasive testing in immunocompromised patients? In this setting, an inability to identify the cause of acute hypoxemic respiratory failure is associated with worse outcome. Every effort should be made to obtain a diagnosis, either with non-invasive 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 ICU. We compared patients with non-invasive testing only to those who had also bronchoscopy by bivariate analysis and after propensity score matching.
Results: Bronchoscopy was performed in 618 (39%) patients who were more likely to have hematologic 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%) of 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 (odds ratio 1.41, 95% confidence interval 1.08–1.81).
Answer to the question: 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.
Footnotes
This manuscript has recently been accepted for publication in the European Respiratory Journal. It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article.
Conflict of interest: Dr. Bauer has nothing to disclose.
Conflict of interest: Dr. chevret has nothing to disclose.
Conflict of interest: Dr. Yadav has nothing to disclose.
Conflict of interest: Dr. Mehta has nothing to disclose.
Conflict of interest: Dr. Pickkers has nothing to disclose.
Conflict of interest: Dr. Bukan has nothing to disclose.
Conflict of interest: Dr. Rello has nothing to disclose.
Conflict of interest: Dr. VAN DE LOUW has nothing to disclose.
Conflict of interest: Dr. Klouche has nothing to disclose.
Conflict of interest: Dr. Meert has nothing to disclose.
Conflict of interest: Dr. martin-loeches has nothing to disclose.
Conflict of interest: Dr. Marsh has nothing to disclose.
Conflict of interest: Dr. SOCIAS has nothing to disclose.
Conflict of interest: Dr. Moreno-Gonzalez has nothing to disclose.
Conflict of interest: Dr. Buchtele has nothing to disclose.
Conflict of interest: Dr. Amrein reports grants, personal fees and non-financial support from Fresenius Kabi, personal fees from Vifor Pharma, personal fees from Shire, outside the submitted work.
Conflict of interest: Dr. Balik has nothing to disclose.
Conflict of interest: Dr. Antonelli has nothing to disclose.
Conflict of interest: Dr. NYUNGA has nothing to disclose.
Conflict of interest: Dr. Barratt-Due has nothing to disclose.
Conflict of interest: Dr. Bergmans has nothing to disclose.
Conflict of interest: Dr. Spoelstra - de Man has nothing to disclose.
Conflict of interest: Dr. Kuitunen has nothing to disclose.
Conflict of interest: Dr. WALLET has nothing to disclose.
Conflict of interest: Dr. SEGUIN has nothing to disclose.
Conflict of interest: Dr. Metaxa has nothing to disclose.
Conflict of interest: Dr. Lemiale has nothing to disclose.
Conflict of interest: Dr. Burghi has nothing to disclose.
Conflict of interest: Dr. Demoule reports grants, personal fees and non-financial support from Philips, personal fees from Baxter, personal fees from Hamilton, grants and non-financial support from Fisher & Paykel, grants from French Ministry of Health, outside the submitted work.
Conflict of interest: Dr. Karvunidis has nothing to disclose.
Conflict of interest: Dr. Cotoia has nothing to disclose.
Conflict of interest: Dr. Klepstad has nothing to disclose.
Conflict of interest: Dr. Møller has nothing to disclose.
Conflict of interest: Dr. Mokart has nothing to disclose.
Conflict of interest: Dr. Azoulay reports personal fees and other from GILEAD, personal fees from Baxter, personal fees and non-financial support from Alexion, grants from Ablynx, grants from MSD, other from Ficher & Payckle, outside the submitted work.
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