What interventions can be done for Bronchiolitis Obliterans (BO) in the setting of Acute Respiratory Distress Syndrome (AST)?

From the Guidelines

For bronchiolitis obliterans (BO) in the setting of allogeneic stem cell transplantation (AST), initial management should focus on augmenting immunosuppression with high-dose systemic corticosteroids and optimizing calcineurin inhibitors to therapeutic levels, as these interventions have shown to improve morbidity, mortality, and quality of life in these patients. The management of BO in AST patients requires a multifaceted approach, considering the patient's overall health status and the potential for complications.

Key Interventions

• Augmenting immunosuppression with high-dose systemic corticosteroids (prednisone 1-2 mg/kg/day) followed by a slow taper over 3-6 months 1
• Optimizing calcineurin inhibitors like tacrolimus or cyclosporine to therapeutic levels 1
• Adding agents such as azithromycin (250-500 mg three times weekly) due to its anti-inflammatory properties 1
• Considering extracorporeal photopheresis for patients with steroid-refractory disease 1

Symptom Management

• Inhaled bronchodilators (albuterol, ipratropium) and inhaled corticosteroids (fluticasone, budesonide) may provide relief for symptoms 1
• Pulmonary rehabilitation to improve exercise capacity and quality of life 1

Prevention of Infections

• Antimicrobial prophylaxis is crucial to prevent infections in these immunocompromised patients 1

Advanced Cases

• For advanced cases unresponsive to therapy, lung transplantation may be considered 1 Early intervention is critical as BO represents fibrotic airway remodeling from chronic graft-versus-host disease affecting the lungs, with progressive and often irreversible airflow obstruction if not promptly addressed. The most recent and highest quality study 1 supports the use of these interventions to improve outcomes in BO patients with AST.

From the Research

Interventions for Bronchial Obstruction (BO) in the Setting of Acute Asthma (AST)

• The management of acute asthma exacerbations involves the use of short-acting beta2 agonists (SABAs) such as albuterol, which can be administered via metered dose inhaler (MDI) with a holding chamber, wet nebulizer, or dry powder inhaler 2, 3, 4.
• The dose-response relationship to albuterol by wet nebulization or MDI has been studied, and it has been found that about 1/6 the wet nebulizer dose of albuterol is needed to achieve a similar response to the MDI 2.
• The optimal treatment interval for administering albuterol MDI with a holding chamber has been found to be 60-min intervals for the majority of patients, but patients who initially demonstrate a low or poor bronchodilator response to albuterol should be given subsequent treatments at 30-min intervals 3.
• In addition to SABAs, other interventions that can be used in the management of acute asthma exacerbations include:
  • Short-acting muscarinic antagonists (SAMAs) 5, 6
  • Oral or parenteral corticosteroids 5, 6
  • Intravenous magnesium sulfate 5, 6
  • Helium/oxygen combination gas for inhalation 5
• The choice of intervention and treatment interval should be individualized based on the patient's response to treatment and severity of symptoms 3, 6.
• It is also important to note that patients with severe exacerbations may require transfer to an acute care facility and treatment with oxygen, frequent administration of a SABA, and corticosteroids 6.