Systemic inflammatory response after bronchoalveolar lavage in critically ill patients.

Bronchoscopic bronchoalveolar lavage (BAL) may be followed by a systemic inflammatory response. Previous reports have suggested pneumonia as a predisposing condition and systemic cytokines as possible mediators. To test this hypothesis, systemic levels of interleukin (IL)-1beta, IL-6 and tumour necrosis factor-alpha (TNF-alpha) were studied before and at 12 h and 24 h after bronchoscopically guided BAL in 30 mechanically ventilated patients (median age 67 (range 54-76) yrs, simplified acute physiology score II (SAPS II) 33 (12-56)), 20 of whom had pneumonia and 10 of whom were control patients without pneumonia. Arterial oxygen partial pressure to inspired oxygen fraction ratio (Pa,O2/FI,O2), body temperature, mean arterial pressure, and cardiac frequency were recorded. The majority of patients (28/30, 93%) received antibiotic treatment prior to the procedure. Pa,O2/FI,O2 ratio was lower at 12 h compared to baseline in patients with pneumonia (baseline median 192 (range 65-256); 12 h 160 (66-190) mmHg, p<0.001) and ventilated controls (baseline 293 (205-473); 12 h 226 (153-330) mm Hg p=0.011), but returned to baseline levels at 24 h (pneumonia: 194 (92-312), p=0.991; controls: 309 (173-487) mmHg, p=0.785). No changes in other clinical variables were observed. Systemic TNF-alpha levels before BAL (pneumonia: 35 (10-88); controls: 17 (0-33) pg x mL(-1)) did not increase at 12 h (pneumonia: 35 (0-64); p=0.735; controls: 16 (0-21) pg x mL(-1), p=0.123 comparison to baseline) or 24 h (pneumonia: 31 (0-36), p=0.464; controls: 19 (0-43) pg x mL(-1), p=0.358). No changes of IL-1beta (baseline: pneumonia 0 (0-13); controls 1 (0-32) pg x mL(-1)) or IL-6 (baseline: pneumonia, 226 (9-4300); controls, 53 (0-346) pg x mL(-1)) were detected. No deterioration of clinical variables and no increase in systemic cytokine release has been observed after bronchoalveolar lavage, in critically ill patients. The potential cytokine increase is probably too small, in relation to the pre-existing inflammatory response, to yield clinical significance in this population otherwise antibiotic therapy may have been protective.     

A prospective study of fever and bacteremia after flexible fiberoptic bronchoscopy in children

STUDY OBJECTIVES: To assess the incidence of fever and bacteremia after fiberoptic bronchoscopy in immunocompetent children. DESIGN: Prospective study. PATIENTS: Immunocompetent children undergoing fiberoptic bronchoscopy between January 1997 and June 1998. Measurements and results: Ninety-one children were included in the study. Forty-four children (48%) developed fever within 24 h following bronchoscopy. Bacteremia was not detected in any of the cases at the time of the fever. Children who developed fever were younger than those who remained afebrile (mean age, 2.4 +/- 3.6 years vs 4.2 +/- 3.7 years; p = 0.025). In the fever group, 66% of the bronchoscopies were considered abnormal, compared to 45% in the nonfever group (p = 0.04). Of the fever group, 40.5% of BAL fluid cultures had significant bacterial growth, significantly higher compared to the nonfever group (13.2%; p = 0.006). Of the 80 patients in whom BAL was performed, fever occurred in 52.5% compared to only 18.2% in those who did not have BAL (p = 0.03). BAL fluid content of cell count, lipid-laden macrophages, and interleukin-8 were not significantly different in both groups. In a logistic regression analysis, the significant predictors for developing fever were positive bacterial culture (relative risk, 5.1; 95% confidence interval, 1.6 to 16.4; p = 0.007) and abnormal bronchoscopic findings (relative risk, 3.1, 95% confidence interval, 1.2 to 8.3; p = 0.02). When age < 2 years was included in the model, this factor became highly significant (relative risk, 5.01; 95% confidence interval, 1.83 to 13.75; p < 0.002). CONCLUSIONS: Fever following fiberoptic bronchoscopy is a common event in immunocompetent children and is not associated with bacteremia. Risks to develop this complication are age < 2 years, positive bacterial cultures in BAL fluid, and abnormal bronchoscopic findings.     

Elevated serum levels of tumor necrosis factor-alpha after bronchoscopy and bronchoalveolar lavage

Fiberoptic bronchoscopy and bronchoalveolar lavage are often followed by the development of fever and other influenza-like symptoms. We report the onset of these symptoms in a healthy volunteer following bronchoscopy and bronchoalveolar lavage; the symptoms were temporally associated with the dramatic elevation of serum levels of tumor necrosis factor. Our observations suggest that tumor necrosis factor may be involved in mediating fever and other influenza-like symptoms occurring after bronchoscopy.     

Safety of research bronchoscopy, biopsy and bronchoalveolar lavage in asthma.

Bronchoscopy with endobronchial biopsy (EBB) and/or bronchoalveolar lavage (BAL) has become an important research tool in asthma. A recent report has suggested audit and reporting of the safety of these procedures. A total of 159 asthmatic patients (84 males, 75 females), aged 18-52 (median 27) yrs, forced expiratory volume in one second 53-120 (median 88) % predicted, underwent 273 bronchoscopies in six clinical research studies. On 228 occasions, EBB and BAL were performed and, on 45 occasions, EBB was performed alone. On 48 occasions, bronchoscopy was performed 24 h post-allergen challenge. Adverse events occurred on 34 out of 273 occasions, none of which were following allergen challenge. Post-EBB and BAL, four patients developed pleuritic chest pain, shortness of breath and fever. A further two patients experienced pleuritic chest pain alone post-EBB/BAL. Bronchospasm or worsening of asthma symptoms occurred on 14 occasions, 13 post-EBB/BAL and on one occasion post-EBB alone. Fever/flu-like symptoms were reported on nine occasions following EBB and BAL. One subject had haemoptysis post-EBB/BAL, but required no intervention. In conclusion, bronchoscopy, endobronchial biopsy and bronchoalveolar lavage can be performed safely in asthmatic patients. Most of the complications were seen where bronchoalveolar lavage and endobronchial biopsy were both performed, suggesting that bronchoalveolar lavage accounts for most of the adverse events.     

The diagnostic value of bronchoalveolar lavage in immunocompetent children with chronic diffuse pulmonary infiltrates

We have investigated the diagnostic value of (BAL) in 29 immunocompetent children (ages 1 month to 18 years) with chronic diffuse pulmonary infiltrates on chest radiograph who presented for evaluation over a 3-year period. The median age at the time of the BAL was 20 months with a range of 1–210 months. Positive results (1) diagnostic of a primary disorder; (2) consistent with a diagnosis; or (3) diagnostic of a secondary disorder, were obtained in 20/29 patients (13 with a single positive BAL finding and 7 with more than one finding). BAL was diagnostic of a primary disorder in only 5 patients (17%) with aspiration detected in 3 and infection in 2. The differential diagnosis was narrowed in 15 patients by the presence of lymphocytosis, neutrophilia, or eosinophilia. A secondary disorder was uncovered in 8 patients. Negative results were obtained in 9 additional patients. We conclude that BAL provided useful information in children with chronic diffuse infiltrates, but its ability to determine the primary cause was limited. Pediatr Pulmonol. 1997; 23:8–13. © 1997 Wiley-Liss, Inc     

Prospective study of fever and pneumonia after flexible fiberoptic bronchoscopy in older people

OBJECTIVES: To assess the frequency of fever and pneumonia after fiberoptic bronchoscopy (FOB) in older people and to evaluate increased risk for these two adverse events with increasing age. DESIGN: Prospective study. SETTING: University hospital system. PARTICIPANTS: Three hundred fifty-eight patients, with 165 (46.1%) patients aged 70 and older, undergoing bronchoscopy. MEASUREMENTS: Indications, abnormal bronchoscopic findings, sampling procedures, final diagnosis, and fever and pneumonia after bronchoscopy. RESULTS: With regard to the indication for bronchoscopy and abnormal bronchoscopic findings, there was no statistical difference between elderly patients (> or =70) and younger patients (<70). Procedures such as forceps biopsy, brushing, and curetting were not performed more often in elderly patients, although final diagnosis of lung cancer was significantly more common in the elderly group (P=.002). The overall incidence of fever after FOB was 6.7%, and that of pneumonia after FOB was 5.6%. The patients aged 70 and older had an incidence of fever after FOB of 3.6% and an incidence of pneumonia of 4.2%, which were not higher than those in patients younger than 70. CONCLUSION: Increasing age is not associated with increasing fever and pneumonia after FOB, and chronological age should not be considered a limiting factor in the decision of whether to perform FOB when it is clinically indicated.     

Pulmonary surveillance using bronchoscopy and bronchoalveolar lavage during high-dose antineoplastic therapy

Pulmonary failure is a major contributor to morbidity and mortality during marrow aplasia following high-dose antineoplastic therapy. For this reason, we initiated a pulmonary surveillance program for patients undergoing high-dose chemotherapy for leukemia or bone marrow transplantation. As part of this program, bronchoscopy with BAL was performed prior to therapy and at the onset of granulocytopenia. Thirty-three of the first 57 patients managed in this program developed some evidence of pulmonary complications. Twelve patients died in aplasia; all had pulmonary failure. Forty patients had clinically significant abnormalities on the bronchoscopy before treatment including 12 of 19 patients who had normal findings on chest x-ray films, physical examination, and pulmonary function testing, and no fever. Twenty-seven patients had clinically significant abnormal bronchoscopy or BAL at the onset of granulocytopenia. Thirteen patients required additional bronchoscopy. No patient required an open lung biopsy. Pulmonary surveillance using bronchoscopy with BAL is useful in the detection of pulmonary disease prior to the initiation of and following high-dose antineoplastic therapy.     

Chronic cough in children: bronchoalveolar lavage findings.

Isolated chronic cough in childhood is a common complaint. Although the symptom cough is included in the definition of clildhood asthma, there is debate as to whether the majoritv of these children have asthma. The authors studied children with isolated chronic cough looking for evidence of airway inflammation typical of asthma, with increased numbers of airway eosinophils as assessed from bronchoalveolar lavage (BAL). The investigations were carried out on 23 children (median age: 6.7 yrs; range: 1.7-12.75 yrs), attending the Royal Belfast Hospital for Sick Children for elective surgery, who also had a chronic unexplained cough. Written informed consent was obtained from the parent(s) and a nonbronchoscopic BAL was performed. BAL samples were analysed for total and differential white cell counts and also for the inflammatory mediators, eosinophil cationic protein (ECP) and histamine. Results were compared with a group of normal nonatopic children and also a group of atopic asthmatic children, who had been recruited for other studies on airway inflammation. There was a small but statistically significant increase in BAL percentage eosinophils in the children with chronic cough compared with nonasthmatic controls (0.28% versus 0.10%, p=0.03). However, the children with cough had lower percentage eosinophils than the atopic asthmatic controls (0.28% versus 0.66%, p=0.01). Three out of 23 children with chronic cough had BAL eosinophils greater than the normal upper 95% reference interval in BAL. There was a small but statistically significant increase in percentage neutrophils in the children with cough compared with the nonasthmatic controls (5.85% versus 3.21%, p=0.03). Four out of the 23 children had BAL neutrophils greater than the normal upper 95% reference interval in BAL. The authors conclude that only a minority of children with chronic unexplained cough have asthmatic-type airway inflammation. It is speculated that the increased percentage neutrophils in bronchoalveolar lavage from children with cough could relate to underlying persistent airways infection.     

Yield from flexible bronchoscopy in children

Flexible fiberoptic (FO) bronchoscopy can now be undertaken readily in children using topical anesthesia and light sedation and has largely supplanted rigid open tube (OT) bronchoscopy for diagnostic purposes. The present study examined the contribution of the FO bronchoscope to clinical management in children presenting with specific types of problems. We examined the first 200 consecutive flexible bronchoscopies performed in 1995 in children under 18 years of age (median age, 2.27 years). Indications for bronchoscopy were noisy breathing (26.5%), recurrent pneumonia (21.0%), suspected pneumonia in an immunocompromised patient (10.5%), atelectasis or bronchial toilet (12.5%), possible foreign body aspiration (13.0%), and miscellaneous other reasons (16.5%). Inspection of the airway was abnormal in 67.0% of all investigations and made a clinically meaningful contribution to management in 67.5%, especially in those with noisy breathing (98.1%), possible foreign body aspiration (100%), and atelectasis (76.0%). Bronchoalveolar lavage (BAL) cytology was abnormal in 80.4% of the 107 lavages, but contributed little to management except in those with recurrent pneumonia (73.8%). Bacteria were isolated in 26.6% of the 109 specimens cultured, but this finding rarely affected management. Fungi were isolated in 47.4% of the 19 lavages in the immunocomprised group. Together, inspection, BAL and microbiology contributed to management in a mean of 90.5% (range, 76.2–100%) of patients in the various groups. We concluded that a high yield of clinically meaningful information can be expected from FO bronchoscopy in children when coupled with BAL and microbiological studies of lavage fluid. Pediatr. Pulmonol. 1997; 23:261–269 © 1997 Wiley-Liss, Inc.     

Fever and pneumonia after flexible fiberoptic bronchoscopy.

The frequencies of fever, parenchymal infiltration, and bacteremia were studied prospectively after 100 flexible fiberoptic bronchoscopies performed transnasally under topical anesthesia. Fever occurred after 16 per cent, and parenchymal infiltration, after 6 per cent of the procedures. Most complications were mild and transient; however, one patient developed rapidly progressive pneumonia and died. No organisms were isolated from cultures of blood drawn at the time of the procedure or during complications. The organisms most commonly isolated from the sputum of the patients who developed pneumonia were the aerobic and anaerobic bacteria normally found in the mouth. Isolation of a significant pathogen before the procedure did not predispose to development of a complication. Advanced age (greater than 60 years) and the endoscopic findings of abnormalities were significant predisposing factors. Bronchial brushing, but not bronchial biopsy or bronchial washing, was associated with significantly higher complication rates in patients with bronchial carcinomas than in those without a neoplasm. The mechanism of the fever and parenchymal infiltration is thought to be related to obstructive atelectasis and infection produced by organisms present in the airways at the time of the procedures.     

纤维支气管镜检查术后发热的临床表现及特点

目的评价纤维支气管镜术（纤支镜）后发热的发生率和临床特点。方法前瞻性地观察和分析了从2005年2月至2007年8月呼吸科住院患者纤支镜术后发热的临床表现。结果153例住院行纤支镜检查患者,28例（18%）患者出现了术后发热,其中23例（15%）患者未经处理,体温在24h内降至正常,另4例发热持续3~5d,给予对症处理。平均术后开始发热时间（3.3±1.6h）,平均发热持续时间（9.6±5.7h）。术后发热和不发热患者纤支镜术后外周血中性粒细胞计数均显著高于术前（P均〈0.01）,但发热患者术后外周中性粒细胞升高比不发热患者更明显（P均〈0.01）。结论纤支镜术后短期发热是一比较常见的术后并发症,无需特殊处理治疗。     

纤维支气管镜术后发热的临床特点

目的评价纤维支气管镜(简称纤支镜)术后发热的发生率和临床特点。方法前瞻性地观察和分析了从2004年5月至2005年4月呼吸科住院患者纤支镜术后发热的临床表现。结果172例住院行纤支镜检查患者,37例(22%)患者出现了术后发热,其中32例(19%)患者未经处理,体温在24 h内降至正常,另5例发热持续3~5 d,给予对症处理。平均术后开始发热时间(3.5±1.7)h,平均发热持续时间(10.8±6.7)h。术后发热和不发热患者纤支镜术后外周血白细胞和中性粒细胞计数均显著高于术前(P均<0.01),但发热患者术后外周血白细胞和中性粒细胞升高比不发热患者更明显(P均<0.01)。结论纤支镜术后短期发热是一比较常见的术后并发症,无需特殊处理。     

Diagnostic bronchoalveolar lavage in children with AIDS

Between October, 1985 and May 1987, 29 children (mean age 22 +/- 22 months, range 2-54 months) with AIDS or ARC developed acute respiratory illness. The initial diagnostic procedure was flexible fiberoptic bronchoscopy, with bronchoalveolar lavage (BAL). BAL was positive for Pneumocystis carinii in 14 and for respiratory syncytial virus, Staphylococcus aureus, and Escherichia coli in 3 additional patients. Subsequent lung tissue analysis and/or clinical course suggested no false negative lavages. Complications possibly related to the procedure occurred in two patients. We find BAL an effective diagnostic technique in these patients, offering a less invasive alternative to open lung biopsy.     

Investigation of children with chronic nonspecific cough: any clinical benefit of bronchoscopy and bronchoalveolar lavage?

Chronic cough can be a complicated and frustrating diagnostic dilemma. The aim of this study was to identify the possible causes of chronic nonspecific cough in seemingly healthy children using fiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL). Eighteen children responded to criteria of selection for chronic cough. The average age was 5.8 years (range, 1.7-10.7 years) and BAL findings were compared with those of 16 nonatopic controls. Children with chronic cough had an increased percentage of BAL neutrophils in comparison with the control group (p = 0.098). Using a BAL neutrophil percent cutoff of 17%, 6 children had high BAL neutrophils (HBNs; median, 77%; range, 27-96%) and 12 children had normal BAL neutrophils (NBNs; median, 3%; range, 0-13%). In the HBN group, FOB showed endoscopic abnormalities in four patients, BAL culture was positive in three patients, and chest x-ray (CXRs) showed minimal densities in four. The IL-8 levels showed a significant increase with respect to the NBN group (p = 0.005). The combination of endoscopic anomalies, BAL culture, BAL IL-8 levels, and minor CXR changes can support the diagnosis of subclincal infection in seemingly healthy children with chronic nonspecific cough and HBN.     

Yield of bronchoalveolar lavage in ventilated and non-ventilated children after bone marrow transplantation

A study was undertaken to retrospectively evaluate the yield of bronchoalveolar lavage (BAL) in a single-institution series of children after bone marrow transplantation (BMT) and to compare the yield of BAL between the ventilated and nonventilated patients. We reviewed charts of 52 consecutive children after BMT who underwent BAL. Thirty patients (41 BALs) were nonventilated (group 1) and 33 patients (45 BALs) were ventilated for respiratory failure (group 2). Eleven patients were included in both groups. BAL was performed a median of 255 and 28.5 days after BMT in groups 1 and 2, respectively (P < 0.001). Group 1:17 pathogens were isolated from 13 BALs; a single pathogen from 10 BALs. Group 2:15 pathogens were isolated from 14 BALs (31.1% positive). Viruses were isolated from 13 BALs in group 2. A severe complication of BAL occurred in only one patient from group 1 (1.1%). Open lung biopsies were performed in one patient in group 1 and eight patients in group 2. The histological findings correlated with the BAL findings in 66.7%. In conclusion, there was no difference in the yield of BAL between the groups. Therapy was changed in one third of the patients dictated by the BAL findings. The risk of severe complications was relatively low. A good correlation between open lung biopsy (OLB) and BAL was found.     

Lipid-laden macrophage index and inflammation in bronchoalveolar lavage fluids in children.

The presence of lipids in alveolar macrophages has been used clinically as an indicator of aspiration, a process associated with increased lung inflammation in animal models. The hypothesis is that the quantity of lipids in alveolar macrophages, measured as lipid-laden index (LLI), would correlate with lung inflammation in paediatric patients. Children with chronic respiratory symptoms (21 cystic fibrosis (CF), 24 non-CF) underwent flexible bronchoscopy with bronchoalveolar lavage (BAL) and 24-h intraoesophageal pH monitoring for clinical indications. Total cell counts, number and per cent of neutrophils and macrophages, and LLI were determined in the bronchoalveolar lavage fluids (BALF) from all children. BALF were also obtained from eight healthy, young nonsmoking adults for comparison. LLI in non-CF children were 6.9 +/- 3.5 (mean +/- SEM) which were higher than LLI in healthy adults (1.0 +/- 0.4), (p=0.045). Children with CF had very high LLIs (19.2 +/- 4.5) compared with both healthy adults (p=0.014) and children without CF (p=0.045). LLI did not correlate with airway inflammation in any group. LLI in children with abnormal pH probes had a tendency to be higher than in children with normal pH probes, but the difference was not significant (p=0.098). It is concluded that the lipid-laden index was significantly elevated in children with chronic respiratory symptoms compared with healthy adults, and in children with cystic fibrosis compared with those who have other chronic respiratory conditions. However, the lipid-laden index did not correlate with the quantity of bronchoalveolar lavage fluid inflammation. The lipid-laden index in children may, in part, reflect processes other than aspiration, such as airways obstruction.