Immunocompromised host · Investigating respiratory failure in the immunocompromised
Diagnostic strategy for hematology and oncology patients with acute respiratory failure
| Design | Multicentre randomised controlled trial |
|---|---|
| Treatment | Non-invasive diagnostic testing alone |
| Control | Non-invasive testing plus fibreoptic bronchoscopy with bronchoalveolar lavage |
| Population | 219 critically ill haematology and oncology patients with acute respiratory failure |
| Follow-up | ICU stay |
| Primary endpoint | Need for mechanical ventilation |
| Result | Mechanical ventilation was needed in 35.4% of the bronchoscopy group versus 38.7% of the non-invasive group (p=0.62). No cause was identified in 21.7% versus 20.4% (difference -1.3%, 95% CI -10.4 to 7.7), meeting the non-inferiority criterion — though a fifth of patients in both arms remained undiagnosed. |
| Secondary endpoints | Diagnostic yield, time to diagnosis, mortality |
FO-BAL performed in the intensive care unit did not significantly increase intubation requirements in critically ill cancer patients with ARF. Noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL for identifying the cause of ARF.
The trial authors, in the published abstract
Answers both halves of a long-standing anxiety: bronchoscopy in this fragile group is safer than feared, and less necessary than assumed. Modern non-invasive microbiological testing has only strengthened the case since.
Azoulay E, Mokart D, Lambert J, et al. Diagnostic strategy for hematology and oncology patients with acute respiratory failure: randomized controlled trial. Am J Respir Crit Care Med 2010 Oct 15;182(8):1038-46.