“BAL is no longer the gold standard when managing these patients,” lead investigator Dr. Elie Azoulay told Reuters Health via email. “Instead, a clinical assessment allows (us to) estimate of probabilities of each single diagnosis, and to perform the adequate noninvasive test.”
Dr. Azoulay, at Saint-Louis Teaching Hospital, Paris, and colleagues at multiple centers in France, conducted a study of 219 cancer patients with ARF of unknown cause admitted to the ICU. Noninvasive tests were performed in all patients, and fiberoptic bronchoscopy with BAL was also undertaken in 113 of the patients.
The team reports in the American Journal of Respiratory and Critical Care Medicine, published online June 25, that the noninvasive strategy was not inferior to the invasive strategy: a diagnosis could not be determined in 23 patients in each group (20.4% vs. 21.7%).
BAL “added diagnostic information to that obtained by noninvasive tests in only 18% of patients and had little therapeutic impact,” Dr. Azoulay commented. “Noninvasive tests identified the cause of acute respiratory failure more frequently and more quickly than did bronchoalveolar lavage.”
Are there circumstances when BAL is necessary? “Yes,” he replied. “In patients with drug-related pulmonary toxicity, because before depriving the patient of a major drug (i.e., for potential survival benefits), strong arguments are needed. Maybe also in patients under mechanical ventilation, but we must bear in mind that diagnostic performance is very low.”
In closing, Dr. Azoulay emphasized one more point. “This paper also adds important information on actual prognoses in hemato-onco patients admitted to the ICU with severe conditions. We are now far from 100% survival. Even more, when patients who are not bedridden and have a lifespan-extending therapy available, unrestricted admission to the ICU is in order and may be accompanied by substantial survival.”
Diagnostic Strategy for Hematology and Oncology Patients with Acute Respiratory Failure: Randomized Controlled Trial
Am J Respir Crit Care Med 2010.