Clinical lung and heart/lung transplantation
Single-institution Study Evaluating the Utility of Surveillance Bronchoscopy After Lung Transplantation

https://doi.org/10.1016/j.healun.2008.10.010Get rights and content

Background

Many lung transplant physicians advocate surveillance bronchoscopy with transbronchial lung biopsy and bronchoalveolar lavage (TBB/BAL) to monitor lung recipients despite limited evidence this strategy improves outcomes. This report compares rates of infection (INF), acute rejection (AR), bronchiolitis obliterans syndrome (BOS) and survival in lung allograft recipients managed with surveillance TBB/BAL (SB) versus those with clinically indicated TBB/BAL (CIB).

Methods

We reviewed 47 consecutive recipients transplanted between March 2002 and August 2005. Of these recipients, 24 consented to a multi-center trial requiring SB and 23 were managed by our usual practice of CIB. Rates of freedom from INF, AR, BOS and survival were compared. BOS and AR were diagnosed according to published guidelines from the International Society for Heart and Lung Transplantation.

Results

A total of 240 TBB/BALs were performed. CIB and SB groups underwent 84 (3.7 ± 3.4/patient) and 156 (6.5 ± 2.0/patient) TBB/BALs, respectively. In the SB group, 54 (2.2 ± 1.6/patient) TBB/BALs were true surveillance procedures, whereas 102 (4.2 ± 2.3/patient) were clinically indicated. No AR episode requiring treatment was detected by true surveillance. Freedom from respiratory INF, AR, BOS and survival in the SB and CIB groups showed no significant differences. Five patients in the CIB group remained stable without requiring TBB/BAL. In the SB group, 4 previously asymptomatic patients developed pneumonia within 2 weeks of surveillance TBB/BAL.

Conclusions

With no obvious advantage identified, surveillance bronchoscopy may pose a risk to stable lung transplant recipients. A multi-center, controlled trial is required to validate the utility and safety of surveillance bronchoscopy in lung transplantation.

Section snippets

Methods

Between March 2002 and August 2005, 47 consecutive patients underwent lung transplantation. Analysis of AR, INF, BOS and survival data was completed through April 2007. The surveillance TBB/BAL group included 24 patients who consented to surveillance monitoring as part of a separate multi-center trial. This multi-center trial excluded cytomegalovirus (CMV)-negative recipients of CMV-positive donors. Therefore, during transplant evaluation only CMV-positive patients were considered for inclusion

Results

Other than induction immunosuppression and CMV serostatus, baseline and post-operative characteristics across groups were similar, as shown in Table 1, Table 2. In the SB cohort, 96 TBB/BALs were expected; however, 1 patient died on POD 12, and 3 others died before the first year post-operatively. Therefore, 89 TBB/BALs were scheduled with 38 clinical indications: 34% by exam (worsening dyspnea or cough, fever, tachycardia or new auscultatory findings), 32% by FEF25–75% criteria, 21% by FEV1

Discussion

This is the first prospective study evaluating the role of regularly scheduled TBB/BAL in asymptomatic lung transplant recipients. No statistical differences in AR, INF or BOS-free survival and patient survival were seen (Figure 1, Figure 2). Moreover, as no AR episodes requiring treatment were detected by true surveillance TBB/BAL, the incremental value of scheduled procedures in asymptomatic recipients with stable PFTs and chest radiographs is minimal. The SB cohort required 50% more TBB/BAL

References (39)

Cited by (52)

  • Donor-derived cell-free DNA as a composite marker of acute lung allograft dysfunction in clinical care

    2022, Journal of Heart and Lung Transplantation
    Citation Excerpt :

    Proponents further argue that the early detection and treatment of allograft injury may improve outcomes, namely a reduction in the development of CLAD – which has the greatest impact on long term survival in lung transplant recipients. In contrast, opponents argue that routine surveillance bronchoscopy is costly, time consuming, places the patient at risk of complications and has not been demonstrated to improve outcomes.38,39 In addition, the utility of performing surveillance bronchoscopy may decrease considerably after 3 months as the presence of asymptomatic rejection or infection decreases.40,41

  • Surveillance Bronchoscopy in Lung Transplantation Recipients: A Single Center Experience Analysis

    2020, Transplantation Proceedings
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    In 2002, Valentine et al compared 91 LTx recipients in the Ochsner Clinic with 5430 patients on the historical controls published by the ISHLT and found no difference in 1- to 3-year mortality and ACR when bronchoscopy was performed only when clinically indicated: asymptomatic 10% decline in FEV1 from established baseline; asymptomatic 20% decline in intermediary force expiratory flow (FEF25%-75%) from established baseline; unexplained dyspnea, nonproductive cough, or fever; or new auscultatory findings on lung exam [10]. A further report from Valentine et al in 2009 compared rates of ACR, infection, BOS, and survival in LTx recipients managed with SB vs those with clinically indicated bronchoscopy (CIB) [11]. Clinical indications included unexplained respiratory symptoms, signs, or fever; 10% decline in FEV1 or 20% decrease in forced expiratory flow (FEF25%-75%) below baseline; delay in anticipated improvement in lung function, especially if the forced vital capacity and FEV1 remained 60% predicted with FEF25%-75% remaining 50% of predicted; or radiographic changes.

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