Clinical utility of flexible bronchoscopy and bronchoalveolar lavage in young children with recurrent wheezing

The management of young children with severe recurrent wheeze is difficult because symptoms are often refractory to conventional asthma therapy and other diagnoses must be excluded. The present authors aimed to evaluate the outcome of detailed, invasive investigations in such patients.Children aged between 3 months and 5 yrs with severe recurrent wheezing, who had been referred to a tertiary centre, underwent a protocol of investigations including a chest computed tomography scan, blood tests, nasal ciliary brushings, fibreoptic bronchoscopy, bronchoalveolar lavage (BAL), endobronchial biopsy and passage of an oesophageal pH probe.A total of 47 children (25 males) with a median age of 26 (range 5-58) months underwent investigation. Of these, 39% were atopic, two-thirds had evidence of gastro-oesophageal reflux and 37 out of 47 had an abnormal bronchoscopy. Findings included structural abnormalities (13 out of 37), excessive mucus (20 out of 37) and macroscopic inflammation (10 out of 37). BAL revealed bacterial growth in 12 out of 44 (27%) patients. Good quality endobronchial biopsies were obtained from 36 out of 46 (78%) patients; of these, 44% had tissue eosinophila and 28% had a thickened reticular basement membrane.Additional investigations (including bronchoscopy) in young children with severe wheeze may help to identify positive diagnoses and provide information to support a clinical diagnosis of asthma. This hypothesis-generating work should form the basis of future interventional studies.

Section: Investigations In Preschool Wheezers S Saglani Et Alsupporting

confidence: 94%

Section: Investigations In Preschool Wheezers S Saglani Et Alsupporting

confidence: 91%

Investigation of young children with severe recurrent wheeze: any clinical benefit?

Saglani

Nicholson²,

Scallan³

et al. 2006

“…In those studies that included healthy controls [22], lipid-laden macrophages were seldom found and therefore the lipid index was low (mean SD 1.31.5). A lipid index of 85±100 in bronchoalveolar lavage fluid has been suggested to be a sensitive indicator of parenchymal disease associated with clinically evident macroaspiration [11,21].…”

Section: Discussionmentioning

confidence: 96%

Lipid-laden macrophages in induced sputum are a marker of oropharyngeal reflux and possible gastric aspiration

Parameswaran¹,

Anvari²,

Efthimiadis³

et al. 2000

The diagnostic properties of a "lipid index" of macrophages in induced sputum as a noninvasive marker of aspiration of acidic gastric contents were evaluated.In a cross-sectional study, 33 subjects (17 with symptoms suggestive of gastrooesophageal reflux) with normal chest radiographs and no symptoms of aspiration or sinus disease, underwent dual-channel 24-h ambulatory oesophageal pH recording and sputum induction. Oropharyngeal reflux, defined as at least one episode of a fall in pH to <4 at the upper oesophageal electrode, was considered indicative of aspiration of acidic gastric contents ("gold standard"). An index for the presence of intracellular lipid in sputum macrophages, detected by oil red O stain, was obtained. The sensitivity, specificity and predictive values of this "lipid index" were calculated.The "lipid index" could be calculated in 29 of 33 samples with high interobserver repeatability (intraclass correlation coefficient 0.96). Twenty subjects showed oropharyngeal reflux and nine did not. The median "lipid index" in subjects with oropharyngeal reflux (24.5) was significantly greater than that in those without reflux (1.0) (p<0.001). A "lipid index" of 7.0 had a sensitivity of 90%, a specificity of 89%, a positive predictive value of 95% and a negative predictive value of 80%.A "lipid index" of 7.0 in the macrophages of induced sputum is a good marker of oropharyngeal reflux.

“…In a retrospective study, SCHELLHASE et al [4] reported central airway anomalies in 57% of 30 children, 0-18 months of age, with recurrent episodes of wheezing that were clinically refractory or poorly responsive to inhaled albuterol. Central airway abnormalities were found in 17 (57%) subjects and tended to be more common in the 0-6-month age group.…”

Section: Discussionmentioning

confidence: 99%

“…The European Respiratory Society recommends selectively referring young children who do not respond to such medical interventions for flexible bronchoscopy with bronchoalveolar lavage (BAL) to evaluate other aetiologies of chronic/ recurrent wheeze and cough [2,3]. In a retrospective study, SCHELLHASE et al [4] reported airway anomalies in 57% of 30 children, 0-18 months of age, with recurrent episodes of wheezing that were clinically refractory or poorly responsive to inhaled albuterol. SAITO et al [5] reported a high percentage of positive BAL fluid (BALF) cultures in children with recurrent cough and/or wheeze who had failed to respond to empirical treatment for asthma and gastro-oesophageal reflux.…”

mentioning

confidence: 99%

Malacia, inflammation and bronchoalveolar lavage culture in children with persistent respiratory symptoms

Baets¹,

Schutter²,

Aarts³

et al. 2011

In children with persistent respiratory symptoms despite regular anti-asthma inhalation treatment, diagnostic investigations to exclude underlying disease are warranted.124 children were prospectively enrolled, and 24-h oesophageal pH measurement and fibreoptic bronchoscopy with bronchoalveolar lavage (BAL) were performed. BAL fluid (BALF) was processed for neutrophil counting and bacterial culture. Inflammation of the respiratory mucosa was assessed.A structural abnormality of the central airways was found in 47% of subjects (40% females). In 19% of subjects, neither anatomical anomalies nor inflamed respiratory mucosa were observed, whereas in 64%, definite macroscopic mucosal inflammation was observed. Inflammation of the respiratory mucosa was associated with a significantly higher percentage of neutrophils in the BALF: median (interquartile range) 48 (14-82)% compared with 7 (0-16)% (p,0.025). A positive BALF culture was found in 62% of the infants with mucosal inflammation compared with 25% in the group without inflammation (p,0.016). 56% of the BALF samples were positive for bacterial culture.In children with persistent respiratory symptoms, nearly half have anatomical anomalies of the central airways. In 62% of the children with mucosal inflammation, a positive BAL culture and a significantly higher percentage of BALF neutrophils were detected.