Utility and Safety of Bronchoalveolar Lavage for Diagnosis and Management of Respiratory Illnesses in Immunocompromised Children.

Abstract

Background: Acute respiratory illnesses (ARIs) in immunocompromised children have diverse causes, which can obscure accurate diagnosis and lead to unnecessary antimicrobial use. The risk-benefit ratio of bronchoalveolar lavage (BAL) in these patients is debated. This study aimed to evaluate the safety, yield, and utility of BAL in managing ARIs in immunocompromised children.

Methods: This retrospective review examined BALs performed on immunocompromised children with ARI at St. Jude Children's Research Hospital between 2016 and 2021. Microbiological and molecular test results were reviewed from BAL, respiratory tract, and blood within 7 days of the BAL. The final ARI diagnosis was determined by the primary team, changes in antimicrobial management and adverse events were assessed.

Results: BAL identified a potential pathogen in 84/137 (61.3%) of ARI episodes. BAL results contributed to changes in antimicrobial management in 120 (87.6%) cases and contributed to the ARI diagnosis in 106 (77.3%) cases. In 81 (59.1%) cases, ARI diagnosis was established solely from BAL results (infectious [33.3%], noninfectious [63%], multifactorial [3.7%]). BAL results usually agreed with the ARI diagnosis, but 31/137 (22.6%) were not concordant. Post-BAL, only 5 (3.6%) had increased supplemental oxygen > 24 hours, and 3 (3.4%) required new, persistent intubation. Consolidative or nodular pulmonary lesions and post-hematopoietic cell transplant had the highest BAL yields, with no significant differences based on the diffuseness of lesions.

Conclusions: BAL is a safe, high-yield diagnostic procedure in immunocompromised children, with results leading to changes in clinical management of ARI. Prospective studies are needed to generate BAL guidelines for ARI in this population.