What is the diagnostic yield of bronchoscopy (Bronchoalveolar Lavage) in oncological adult patients with febrile neutropenia?

From the Guidelines

The diagnostic yield of bronchoscopy with bronchoalveolar lavage (BAL) in adult oncology patients with febrile neutropenia is approximately 25-50%, as reported in studies 1.

Diagnostic Yield and Clinical Context

The yield of BAL can vary depending on the clinical context and timing of the procedure. It is most valuable when performed early in the course of pulmonary infiltrates, ideally before antimicrobial therapy is initiated or changed 1. The procedure is particularly useful for diagnosing opportunistic infections including Pneumocystis jirovecii pneumonia, invasive fungal infections (especially aspergillosis), viral pneumonias (cytomegalovirus, respiratory viruses), and bacterial pathogens that may not be identified through less invasive methods.

Timing and Patient Selection

The yield is typically higher in patients with focal rather than diffuse infiltrates on imaging, and in those with severe or persistent neutropenia 1. However, the diagnostic yield decreases significantly when BAL is performed after broad-spectrum antimicrobials have been administered for several days.

• The procedure carries some risks including bleeding, pneumothorax, and respiratory deterioration, which must be weighed against potential benefits, especially in severely neutropenic patients with thrombocytopenia 1.
• For optimal results, BAL samples should be processed for comprehensive microbiological studies including bacterial, fungal, and viral cultures, as well as molecular diagnostic tests and cytological examination 1.

Recommendations for Bronchoscopy and BAL

Bronchoscopy and BAL should be carried out using a standardized protocol, and should be available within 24 hours after clinical indication has been established 1.

• Transbronchial biopsies are not recommended in febrile neutropenic (and thrombocytopenic) patients 1.
• If a tissue sample for histological, microbiological, and molecular workup is required, CT-guided side-cut percutaneous biopsy, video-assisted thoracoscopy, or open-lung biopsy should be used 1.
• Microbiological workup of BAL samples should follow a standardized protocol, and urgent need to start or modify antimicrobial therapy should not be postponed by bronchoscopy and BAL 1.

From the Research

Diagnostic Yield of Bronchoscopy in Oncological Adult Patients with Febrile Neutropenia

The diagnostic yield of bronchoscopy, specifically bronchoalveolar lavage (BAL), in oncological adult patients with febrile neutropenia has been studied in various research papers.

• The diagnostic yield of BAL in these patients ranges from 23% to 54% 2, 3, 4, 5.
• A study published in Cureus in 2020 found that BAL cultures were diagnostic in 44% of patients with febrile neutropenia and lung infiltrates 2.
• Another study published in Mayo Clinic proceedings in 2005 reported a diagnostic yield of 49% for BAL in patients with febrile neutropenia and pulmonary infiltrates 3.
• A study published in Haematologica in 2000 found that the diagnostic yield of protected BAL guided by high-resolution computed tomography was 54% in febrile oncohematologic patients with a normal chest X-ray 4.
• The most common diagnoses identified in these patients include fungal pneumonias, bacterial pneumonias, and diffuse alveolar hemorrhage 2, 3, 5, 6.

Safety and Complications of Bronchoscopy

• Bronchoscopy is generally considered a safe procedure in patients with febrile neutropenia, with minimal complications reported in the studies 2, 3, 5, 6.
• The most common complications reported include transient hypoxia, minor hemoptysis, and worsening of oxygenation parameters in mechanically ventilated patients 2, 3, 6.
• The overall mortality rate in these patients is high, ranging from 19.2% to 71%, but is not directly related to the bronchoscopy procedure 2, 5, 6.

Therapeutic Implications of Bronchoscopy

• The results of bronchoscopy can lead to changes in management, including de-escalation of antibiotics, initiation of new antibiotics, and modification of antifungal therapy 2, 3, 5.
• A study published in Internal medicine journal in 2012 found that the bronchoscopic results altered the clinical management of 38.4% of patients with febrile neutropenia and pulmonary infiltrate 5.
• Another study published in Critical care medicine in 2000 reported that 26 patients who underwent diagnostic BALs changed therapy, but this did not lead to an increased probability of survival 6.