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% 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 (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.

CIBERES Instituto Salud Carlos 3 and Vall d'Hebron Institut of Research Barcelona Barcelona Spain

Dept of Anesthesia Intensive Care and Pain Therapy University of Foggia Policlinico OO Riuniti Foggia Italy

Dept of Anesthesiology 1 Herlev University Hospital Herlev Denmark

Dept of Anesthesiology and Intensive Care Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Dept of Anesthesiology Herlev University Hospital UCPH Herlev Denmark

Dept of Anesthesiology Intensive Care and Emergency Medicine Fondazione Policlinico Universitario A Gemelli IRCCS Università Cattolica del Sacro Cuore Rome Italy

Dept of Clinical Medicine Trinity College Wellcome Trust HRB Clinical Research Facility St James Hospital Dublin Ireland

Dept of Clinical Pharmacology Medical University of Vienna Vienna Austria

Dept of Critical Care Hospital Son Llatzer Palma de Mallorca Spain

Dept of Critical Care King's College Hospital NHS Foundation Trust London UK

Dept of Critical Care Mater Misericordiae Dublin Ireland

Dept of Critical Care University Hospital Lyon Sud Pierre Benite France

Dept of Emergencies and Critical Care Oslo University Hospital Rikshospitalet Oslo Norway

Dept of Intensive Care Amsterdam UMC VU Medical Center Amsterdam The Netherlands

Dept of Intensive Care Hospital Universitari de Bellvitge Barcelona Spain

Dept of Intensive Care Maastricht University Medical Centre Maastricht The Netherlands

Dept of Intensive Care Medicine Lapeyronie University Hospital Montpellier France

Dept of Intensive Care Medicine Radboud University Medical Center Nijmegen The Netherlands

Dept of Intensive Care Medicine St Olav's University Hospital Trondheim Norway

Dept of Intensive Care Medicine Universidad de Barcelona IDIBAPS Barcelona Spain

Dept of Intensive Care Tampere University Hospital Tampere Finland

Dept of Internal Medicine Division of Endocrinology and Diabetology Medical University of Graz and Thyroid Endocrinology Osteoporosis Institute Dobnig Graz Austria

Dept of Medicine and Interdepartmental Division of Critical Care Medicine Sinai Health System University of Toronto Toronto ON Canada

Division of Pulmonary and Critical Care Medicine Mayo Clinic Rochester MN USA

Division of Pulmonary and Critical Care Penn State University College of Medicine Hershey PA USA

ECSTRA 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

Medical ICU 1st Dept of Internal Medicine Teaching Hospital Faculty of Medicine and Biomedical Center in Pilsen Charles University Pilsen Czech Republic

Medical Intensive Care Unit AP HP 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

Medical Intensive Care Unit CHG Victor Provo Roubaix France

Réanimation Médicale CHU de Caen Caen France

Réanimation Polyvalente et Département d'Anesthésie et de Réanimation Institut Paoli Calmettes Marseille France

Service de Médecine Interne Unité de Soins Intensifs et Urgences Oncologiques Université de Libre de Bruxelles Institut Jules Bordet Brussels Belgium

Service de Pneumologie et Réanimation CHU Pitié Salpétrière Paris France

Terapia Intensiva Hospital Maciel Montevideo Uruguay

Eur Respir J. 2019 Dec 12;54(6):1901950. doi: 10.1183/13993003.01950-2019. PubMed

Eur Respir J. 2019 Dec 12;54(6):1902177. doi: 10.1183/13993003.02177-2019. PubMed

Citace poskytuje Crossref.org

Acute respiratory failure in immunocompromised patients: outcome and clinical features according to neutropenia status