Pulmonary complications in hematopoietic SCT: a prospective study

Abstract

Pulmonary complications are common and often lethal in hematopoietic SCT recipients. The objective of this prospective interventional study was to evaluate the etiology, diagnostic procedures, risk factors and outcome of pulmonary complications in a cohort of hematopoietic SCT recipients followed up for 1 year. For patients suffering from a pulmonary complication, a diagnostic algorithm that included non-invasive and bronchoscopic procedures was performed. We identified 73 pulmonary complications in 169 patients: 50 (68%) were pneumonias; 21 (29%) were non-infectious complications and 2 (3%) were undiagnosed. Viruses (particularly Rhinovirus) and bacteria (particularly P. aeruginosa) (28 and 26%, respectively) were the most common causes of pneumonia. A specific diagnosis was obtained in 83% of the cases. A non-invasive test gave a specific diagnosis in 59% of the episodes. The diagnostic yield of bronchoscopy was 67 and 78% in pulmonary infections. Early bronchoscopy (⩽5 days) had higher diagnostic yield than late bronchoscopy (78 vs 23%; P = 0.02) for pulmonary infections. Overall mortality was 22 and 32% of all fatalities were due to pulmonary complications. Pulmonary complications are common and constitute an independent risk factor for mortality, stressing the importance of an appropriate clinical management. The increasing number of indications and the selection of more debilitated patients as potential candidates for HSCT seem to be changing the epidemiology of PC. 5,6 Studies have shown that in immunocompromised patients an early identification of the etiology of PC improves survival. 7,8 Fiberoptic bronchoscopy (FOB) has an important role in the diagnosis of PC; 9-12 however, detractors of this technique consider that the information provided may be also obtained by different non-invasive explorations. [13][14][15] The majority of the studies evaluating the etiology, diagnosis and prognosis of PC in patients with hematologic diseases are retrospective, 4,6,16 and include both non-transplantation and transplantation recipients. 2,7 We hypothesized that the prospective follow-up of a cohort of HSCT recipients may improve the clinical management of PC. First, the knowledge of the epidemiology of the PC with the different prevalence of infectious and non-infectious etiologies can be accurately determined. Second, predetermined criteria for performing a FOB should clarify the role of this technique by better defining the diagnostic yield, clinical implications and potential complications. Finally, the identification of prognostic factors is much more precise when data are recorded prospectively in a homogeneous group of immunocompromised patients.The aim of this study was to evaluate the incidence, diagnostic and clinical implications of non-invasive and FOB explorations, risk factors and outcome of PC. To this aim, a cohort of consecutive patients requiring HSCT was followed-up for 1 year and the PC were closely analyzed.

Early predictors of mortality in children with pulmonary complications after haematopoietic stem cell transplantation

“…As management of PCs is critically dependent on the possible or presumptive diagnosis, clinicians expect that the identification of specific aetiologies would allow for therapy to be removed, changed, or added, which would lead to survival. Consistent with previous studies, we found that the modification of treatment based on examination results (performed in 29 episodes; 60.0%) did not influence the outcome. In contrast, Yoo et al reported an affirmative effect of therapeutic modification following procedures for diffuse PI causing respiratory failure in cancer patients.…”

“…Therefore, to precisely distinguish the aetiology of PCs, invasive work‐ups with BAL or LB are inevitable. In previous studies, BAL was performed in up to 88% of adult recipients and 43% of paediatric HSCT recipients with 30%‐73% diagnostic yields . LB also yielded a specific diagnosis in 41%‐94% of lung infiltrates, especially for non‐infectious PCs.…”

“…With the increasing indication of HSCT over the past decade and improvements in short‐term survival, concerns have grown about the adverse effects of HSCT. PCs with infectious or non‐infectious causes have been recently reported to occur in 20%‐30% of adult and paediatric HSCT recipients and are usually related with poor outcomes . Various diagnostic tests can be utilized to identify the aetiologies of PIs for targeted therapy, depending on the condition of recipients with PCs .…”

“…Various diagnostic tests can be utilized to identify the aetiologies of PIs for targeted therapy, depending on the condition of recipients with PCs . However, controversy exists regarding whether a clear diagnosis leads to better outcomes . PCs can eventually cause respiratory failure with mechanical ventilation, and single or multiple organ dysfunctions have been identified as predisposing factors relating to prognosis …”

Tobacco smoking is associated with infectious pulmonary complications after allogeneic hematopoietic stem cell transplantation

“…1 Smoking is known to be associated with increased risk of various diseases, and can be a risk factor for respiratory tract infection in immunocompetent patients. 2 In patients with AML, smoking has been reported to increase the rate of pulmonary infections during induction chemotherapy.…”