Transcript Febrile neutropenia nd bilateral infiltrates

Febrile neutropenia and bilateral infiltrates
► Learning
Objectives
 Describe expected results
from BAL, TBLB, and
TBNA in this case.
 Describe risks of TBLB.
 Describe 3 ways to
manage TBLB-related
bleeding.
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Case description
(practical approach 1)
► AA
is a 64 year old
physician with history
of lymphoma, febrile
neutropenia and
bilateral infiltrates.
Bronchoalveolar
lavage is offered, but
the referring physician
insists on tissue
biopsy to exclude
neoplasm.
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The Practical Approach
Initial Evaluation
Procedural Strategies
• Examination and,
functional status
• Significant comorbidities
• Support system
• Patient preferences and
expectations
• Indications, contraindications, and
results
• Team experience
• Risk-benefits analysis and
therapeutic alternatives
• Informed Consent
Techniques and Results
Long term Management
• Anesthesia and peri-operative
• Outcome assessment
care
• Follow-up tests and procedures
• Techniques and
• Referrals
instrumentation
• Quality improvement
• Anatomic dangers and other
risks
• Results and procedure-related
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Initial Evaluations
►
Lymphoma history
 Type of lymphoma, Hodgkin’s, NHL, chronic low grade LL
 Lung involvement: mediastinal LAN, lung nodules
 Treatment received, response to treatment, and staging
►
Treatment
 Chemotherapy regimen, duration of neutropenia
► Drug
► Type
toxicity: cardiac and lung
of infection influence by neutropenia duration
 Radiation given, length, duration, XRT field
 Complications of previous treatment
►
Comorbidities
 Smoker, ? Previous Pulmonary function tests
 Prednisone: dosage/duration
 Bleeding risks: plavix/aspirin, stopped for 3 days
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Initial Evaluation
►
Presentation
 Fever, AMS, hypoxia, possible toxic/septic appearance
 Unknown: tachypnea, duration of symptoms, previous
antibiotics/antifungal, prophylactic medications given
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Physical Exam
 Decreased breath sounds bilateral expiratory wheezes
 LE edema and erythematous rash in back
► Pulmonary
edema, infection, drug rxn
 Unknown: perineal/skin, IV access exam, exclude other sources of
infection.
►
Laboratory
 Chemistry, check uremia, renal function, coag,
 Consider BNP (cardiac), galactomannan Ag (aspergillus), CMV PCR
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Initial Evaluation
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Radiographic
 CXR diffuse bilateral infiltrates
 CT scan: diffused, ground glass opacities RUL, LLL, subcarinal
adenopathy
 Unknown: previous films, duration of findings
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Patient’s Preference
 Unknown, needs to discuss with family as altered mental status
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Family
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Wife and children with good medical background
Level of support/involvement unknown
Who has durable power for health care
Needs to discuss diagnostic concerns, procedures, risk/benefits
with family
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Procedural Strategies
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Likely differential for diffuse infiltrates in immunocompromised host
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infection: bacterial, PCP, CMV, fungal, mycobacterial
Pulmonary edema cardiac and non-cardiac
Leukoagglutinin rxn, diffused alveolar hemorrhage, alveolar proteinosis
Radiation
Drugs
recurrence of lymphoma in subcarinal lymph node
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Narrow differential
avoid prolonged duration of toxic medications, drug resistance
Avoid missed diagnosis that would affect treatment and outcome
Confirm treatment plans
Provide prognosis to family
Approach to treatment: empiric broad spectrum antibiotics and
antifungal and follow versus invasive workup
Indications/expected benefits of an invasive work up
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Procedural Strategies
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Bronchoscopy
 Bronchoscopy with BAL
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Good for infection: bacterial, viral, fungal, AFB culture
BAL established dx in 65% bacterial (CI: 43-84%), 75% of viral (CI 4395%), and 40% of fungal infection (17-69%)*
 Consider protected specimen brush
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Provided exclusive diagnosis in 13% of bacterial infection in which BAL was
negative
 Consider transbronchial biopsies
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Improve diagnostic yield for non- infectious etiology
In one case series, TBB provided exclusive diagnosis in 2/47 (4%) infectious
etiology (CMV and candida PNA)
May help differentiate invasive fungal/CMV; however, most doctor assume
invasive in BAL positive
Non infectious etiology: Bronchiolitis obliterans, drug induced pneumonitis,
ARDS, alveolar hemorrhage
TBB provided exclusive diagnosis in 15/81 (19%) of non-infectious etiology
Added risks of bleeding and pneumothorax
Avoid repeat procedure if BAL is non-diagnostic
*Jain et al. Role of flexible bronchoscopy in immunocompromised patients with Lung Infiltrates. Chest Vol 125 (2). 2004.
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Procedural Strategies
Sampling Procedure
Diagnostic Yield (infectious &
non-infectious) [95% CI]
BAL, n = 99
38% [30-47%]
TBB, n =45
44% [27-51%]
PSB, n =42
13% [6-24%]
BAL + PSB, n = 40
45% [32-58%]
BAL + TBB, n =40
70% [57-80%]
BAL + TBB +PBS, n=25
86% [71-94%]
*Jain et al. Role of flexible bronchoscopy in immunocompromised patients with Lung
Infiltrates. Chest Vol 125 (2). 2004.
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Procedural Strategies
 Consider transcarinal needle aspirate
►Yield
for needle aspirate for lymphoma is lower, 3040%. Flow cytometry and immunochemistry can
improve yield to 86%.
►Mediastinal Tru-cut biopsy is best for architecture,
especially important for low grade lymphoma
 Not possible in most patients
 Core transcarinal histology needle may be adequate
 Consider local expertise for biopsies,
transcarinal needle for both the operator and
the lab/path department.
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Procedural Techniques and Results
► Patient
Factors:
 Consider intubation if unstable patient:
tachypnea, sepsis, hypotension
 If unstable: bedside BAL/brush and no biopsies
 Cautions with propofol if hypotensive
*Grebski et al. Chest. 1994. Vol 106, 414-420
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Procedural Techniques and Results
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Techniques and instrumentation
 Stable patient: conscious sedation w versed/fentanyl through the nares
 Unstable patient: Intubate, bedside procedure through ET tube with bite
block
 If brushing: used protected specimen brush for microbiology
 BAL segment with infiltrates
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Single sided versus bilateral
Bilateral LUL & RLL lavage can increase yield in PCP in non-HIV patient*
For pneumonia, lavage on single involve radiologic segment adequate
 Transbronchial biopsies:
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Should be done unilateral lung, avoid B pneumothorax
LL prefer as easier to manage bleeding in dependent region of lung
 Transcarinal needle: use large bore cutting needle for more tissue for
flow cytometry and immunochemistry.
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Anatomic danger/risks
 Bleeding, pneumothorax, prolonged hypoxemia, respiratory failure
*Grebski et al. Chest. 1994. Vol 106, 414-420
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Long-term Management Plan
► Outcome
assessments
 Does procedure change management?
 Additional diagnostic yield with brush,
transbronchial biopsy, TCNA
► Follow
up
 Serial CXR and CT with treatment
 Consider open lung biopsy if findings and
clinical deterioration persist despite treatment
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Q 1: Should TBLB be performed ?
► Added
diagnostic yield for infection is low.
► May help improve diagnostic yield for noninfectious etiology.
► Limited treatment options for non-infectious
etiologies.
► Consider time course of presentation, if
acute, likely infectious and TBLB not helpful.
► Consider bleeding risks and patient safety.
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Q 2: Should transcarinal needle
aspiration be performed?
► Lower
diagnostic yield for
lymphoma.
► Consider pathologist
expertise for diagnosis of
lymphoma from TBNA.
To view video, please
see Video Archive PA 1
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Jabbing
Piggyback
Cough
Hub against wall
Modified, from UpToDate
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Q 3: Medications and Bleeding Risk
► Plavix
increases risk of bleeding with
transbronchial biopsy.
► Risk increased when Plavix is taken with
aspirin.
► Aspirin alone does not increase bleeding risk
and does not need to be stopped prior to
procedure.
► Recommendation: stop Plavix 5-7 days prior
to plan transbronchial biopsy.
Ernst et al. Chest 2006; 129: 734-737.
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Q 4: What if referring physician insists
on a biopsy right away?
► Do
what you consider to be safest for the patient,
even if it means refusing to do the biopsy.
► In case of acute onset of pulmonary infiltrates and
fever with in the setting of neutropenia, most
likely etiology is infectious. TBLB adds very little
to the diagnostic yield for infection and increases
risk, especially in patient with respiratory
compromise, altered mental statues, and on
plavix.
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Q 5: What procedure do you
recommend?
► Bronchoscopy
with BAL in LUL and RLL
► If non-diagnostic and patient does not improve
with empiric therapy, repeat imaging and consider
repeat bronchoscopy with TBLB of gravity
dependent areas of right lower lobe.
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Prepared with the assistance of Dana Tran M.D.
www.bronchoscopy.org
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