Non-bronchoscopic bronchoalveolar lavage (mini-BAL) in critically ill pediatric patients with severe respiratory failure (pARDS) after Hematopoietic stem-cell transplantation (HSCT) – A single-center experience

Introduction The technique of non-bronchoscopic bronchoalveolar lavage (mini-BAL) in pediatrics has been utilized in several studies and involves instillation and re-aspiration of saline (1 mL/kg up to 20 mL) using an in-line suction catheter at the level of the carina [1] [2] [3] [4] [5] [6].

A study in children showed a higher specifity of mini-BAL in pediatric patients compared to endotracheal aspiration (ETA) [2] and is considered to be a generally well-tolerated procedure, although particularly in patients with oxygenation indices (OI) of greater than 20, careful monitoring seems to be requiered.[5]

In adults, BAL is considered important for detection of respiratory tract pathogens in patients with hematological malignancies, particularly invasive pulmonary aspergillosis (IPA) and Pneumocystis jirovecii pneumonia (PJP).[7] Among immunosuppressed children, mini-BAL was successfully utilized in children with HIV-associated chronic lung disease.[6]

A strong correlation between the isolation rates of bacteria and fungi in traditional BAL and mini-BAL samples obtained from immunocompromised adult patients with pneumonia and respiratory failure was documented.[8]

To our knowledge, there are no publications in the literature concerning mini-BAL after Hematopoietic stem-cell transplantation (HSCT).

Aim The aim of this study is to describe the feasibility and clinical relevance of mini-BAL in critically ill pediatric patients with respiratory failure (pARDS) after HSCT in our institution.

Methods A retrospective analysis including 12 intubated pediatric patients undergoing 17 mini-BALs in the setting of pARDS after HCST in our tertiary university hospital in the years 2017 – 2023 was performed.

Results Chart reviews with calculations of OI as well as the vasoactive-inotropic score (VIS) showed no patient-centered complications such as prolonged desaturation, cardiac arrest or significantly increased need for cardiovascular support.

The intervention was performed on average 55 days (5 – 270 days) after HSCT. Mean patient characteristics were an age of 5,9 years (0,3 – 18,3 years) and weight of 22,1 kg (4,9 – 66 kg). The patients had severe pARDS (OI ≥ 16).[9] The mean OI before the mini-BAL was 22,2 (SD +/−12,5), the mean OI after the procedure was 19,9 (SD +/−13,4). The VIS before mini-BAL was 7,7 (SD +/−15) and after the procedure 9 (SD +/−15,3). In 6/17 mini-BAL studies (35,2 %) infectious agents were detected (e.g. C. krusei, Asp. fumigatus, PCJ, CMV).

Conclusion We were able to demonstrate for the first time the feasibility and safety of non-bronchoscopic bronchoalveolar lavage (mini-BAL) in pediatric patients with severe respiratory failure (pARDS) after Hematopoietic stem-cell transplantation (HSCT), even if the oxygenation index is greater than 20. Regarding the relatively high rate of positive findings, the use of mini-BAL sampling in such patients could therefore be a less-invasive, less-costly and simpler alternative to traditional BAL.

 

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Interessenkonflikt

The authors declare no possible conflicts of interest due to economic or personal ties.

• Literatur

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• 6 Singh R., Thula S.A., Jeena P.M.. Lung infiltrates in antiretroviral-naive HIV-infected children with chronic lung disease: value of non-bronchoscopic bronchoalveolar lavage in the detection of Candida albicans. J. Trop. Pediatr 2013; 59: 59-63
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• 8 Tasbakan M.S.. et al. Comparison of bronchoalveolar lavage and mini-bronchoalveolar lavage in the diagnosis of pneumonia in immunocompromised patients. Respir. Int. Rev. Thorac. Dis. 2011; 81: 229-235
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Publikationsverlauf

Artikel online veröffentlicht:
06. Juni 2023