Safety, diagnostic yield, and therapeutic implications of flexible bronchoscopy in patients with febrile neutropenia and pulmonary infiltrates

OBJECTIVE: To evaluate the safety, diagnostic yield, and therapeutic implications of flexible bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy in patients with febrile neutropenia and pulmonary infiltrates. PATIENTS AND METHODS: We retrospectively reviewed the medical reports of all patients with neutropenic fever and pulmonary infiltrates evaluated by flexible bronchoscopy and BAL between January and December 2002 at the Mayo Clinic in Rochester, Minn. Appropriate demographic, clinical, microbiological, and histological data and procedure-related complications were summarized. Therapeutic decisions implemented based on information obtained by bronchoscopy, and 28-day mortality were determined. RESULTS: Thirty-five patients with febrile neutropenia and associated pulmonary infiltrates were identified. Flexible bronchoscopy, including 35 BALs and 9 transbronchial biopsies, was performed safely (3 complications). The diagnostic yield of BAL was 49%. Sputum analysis was underused (only 34%) but complementary to BAL. The combined diagnostic yield of BAL and sputum analysis was 63%. Transbronchial biopsy provided additional information to BAL and sputum analysis in only 1 patient and did not substantially increase the combined diagnostic yield. The most common diagnoses identified were fungal pneumonias (15/35 [43%]) and diffuse alveolar hemorrhage (5/35 [14%]). Bronchoscopic findings resulted in management changes in 51% of patients. The 28-day mortality rate was 26% and was highest in patients who required mechanical ventilatory assistance before bronchoscopy. CONCLUSION: The favorable safety record, good diagnostic yield, and frequent therapeutic implications support the routine use of BAL for the evaluation of pulmonary infiltrates in neutropenic patients. Bronchoalveolar lavage should be combined with the analysis of several sputum specimens. Transbronchial biopsy did only change the management of 1 patient.