Berita Kesehatan
Diagnosis and outcome of acute respiratory failure in immunocompromised patients after bronchoscopy
Jumat, 26 Jul 2019 13:55:00

Philippe R. BauerSylvie ChevretHemang YadavSangeeta MehtaPeter PickkersRamin B. BukanJordi RelloAndry van de LouwKada KloucheAnne-Pascale MeertIgnacio Martin-LoechesBrian MarshLorenzo Socias CrespiGabriel Moreno-GonzalezNina BuchteleKarin AmreinMartin BalikMassimo AntonelliMartine NyungaAndreas Barratt-DueDennis C.J.J. BergmansAngélique M.E. Spoelstra-de ManAnne KuitunenFlorent WalletAmelie SeguinVictoria MetaxaVirginie LemialeGaston BurghiAlexandre DemouleThomas KarvunidisAntonella CotoiaPål KlepstadAnn M. MøllerDjamel MokartElie Azoulay for the Efraim investigators and the Nine-I study group

European Respiratory Journal 2019 54: 1802442; DOI: 10.1183/13993003.02442-2018

Abstract

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% versus28%; 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.

In a pre-planned analysis of immunocompromised critically ill patients with acute respiratory failure, bronchoscopy was associated with better diagnosis and management but worse outcome. The decision to perform bronchoscopy should be individualised. http://bit.ly/2Dusahh

Footnotes

  • This article has supplementary material available from erj.ersjournals.com

  • Conflict of interest: P.R. Bauer has nothing to disclose.

  • Conflict of interest: S. Chevret has nothing to disclose.

  • Conflict of interest: H. Yadav has nothing to disclose.

  • Conflict of interest: S. Mehta has nothing to disclose.

  • Conflict of interest: P. Pickkers has nothing to disclose.

  • Conflict of interest: R.B. Bukan has nothing to disclose.

  • Conflict of interest: J. Rello has nothing to disclose.

  • Conflict of interest: A. van de Louw has nothing to disclose.

  • Conflict of interest: K. Klouche has nothing to disclose.

  • Conflict of interest: A-P. Meert has nothing to disclose.

  • Conflict of interest: I. Martin-Loeches has nothing to disclose.

  • Conflict of interest: B. Marsh has nothing to disclose.

  • Conflict of interest: L. Socias Crespi has nothing to disclose.

  • Conflict of interest: G. Moreno-Gonzalez has nothing to disclose.

  • Conflict of interest: N. Buchtele has nothing to disclose.

  • Conflict of interest: 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.

  • Conflict of interest: M. Balik has nothing to disclose.

  • Conflict of interest: M. Antonelli has nothing to disclose.

  • Conflict of interest: M. Nyunga has nothing to disclose.

  • Conflict of interest: A. Barratt-Due has nothing to disclose.

  • Conflict of interest: D.C.J.J. Bergmans has nothing to disclose.

  • Conflict of interest: A.M.E. Spoelstra-de Man has nothing to disclose.

  • Conflict of interest: A. Kuitunen has nothing to disclose.

  • Conflict of interest: F. Wallet has nothing to disclose.

  • Conflict of interest: A. Seguin has nothing to disclose.

  • Conflict of interest: V. Metaxa has nothing to disclose.

  • Conflict of interest: V. Lemiale has nothing to disclose.

  • Conflict of interest: G. Burghi has nothing to disclose.

  • Conflict of interest: 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.

  • Conflict of interest: T. Karvunidis has nothing to disclose.

  • Conflict of interest: A. Cotoia has nothing to disclose.

  • Conflict of interest: P. Klepstad has nothing to disclose.

  • Conflict of interest: A.M. Møller has nothing to disclose.

  • Conflict of interest: D. Mokart has nothing to disclose.

  • Conflict of interest: 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.

  • 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.

  • Received December 22, 2018.
  • Accepted April 21, 2019.