Letters to the Editor
To the Editor:
Microbiological surveillance is vital in cystic fibrosis (CF) patients; the gold standard for which is the culture of expectorated sputum. Unfortunately, a significant number of children with CF are unable or unwilling to provide adequate sputum samples. In such instances flexible bronchoscopy with bronchoalveolar lavage (FB-BAL) is being increasingly utilized.1 This procedure has been shown to be safe in children.2 Despite its increasing use, a study comparing outcomes from standard therapy versus FB-BAL-directed therapy in children with CF did not show any difference in the prevalence of Pseudomonas aeruginosa (PA) infection or computed tomography scores up to the age of 5 years.3 At our CF center we do not undertake FB-BAL electively in children. We do, however, have a relatively low threshold for undertaking FB-BAL in children with CF and the number of such procedures has increased over recent years. We routinely obtain FB-BAL samples from all the 6 lobes of the lung including the lingula. We wanted to review the use of FB-BAL in children with CF, particularly focusing on the indications, the results, and any subsequent management changes. We therefore conducted a retrospective study to review all FB-BAL performed in children with CF between May 2009 and September 2012.
During the study period we performed 64 bronchoscopies on 36 patients (19 males). The median (interquartile range) age at the time of FB-BAL was 6.0 (4.0 to 11.0) years. The main indication for bronchoscopy was the need for a definitive microbiological diagnosis. Positive BAL cultures were obtained in 54 (84%) FB-BALs. A total of 96 organisms were isolated and the median (interquartile range) number of different organisms per FB-BAL was 2 (1 to 2). Thirty organisms (from 20 FB-BALs) were grown for the first time; including PA in 2 patients and Aspergillus fumigatus in 9 (Table 1). Twenty-two bronchoscopies grew organisms not isolated from routine microbiology cultures in the preceding year. In keeping with previous studies, the bacterial distribution was not uniform throughout the 6 sampled lobes.4 The bronchoscopy findings led to a treatment being changed or modified on 36/64 (therapeutic impact: 56%) occasions. Most commonly this was a change in antibiotic regimen, the targeting of physiotherapy or the addition of a mucolytic agent.
Although BAL-directed therapy does not reduce the prevalence of PA or computed tomography scores in children with CF3 this review of recent practice confirms that FB-BAL is an important tool in the investigation of children with CF. FB-BAL identified a number of organisms missed by routine microbiological methods (usually oropharyngeal “cough” swabs). Undiagnosed infection by these organisms could potentially cause significant morbidity. The results of the FB-BAL also led directly to a change of treatment in over half of the procedures. In summary, FB-BAL is a useful investigation in children with CF, especially when seeking a definitive microbiological diagnosis.
Francis J. Gilchrist, MBChB
University Hospital of North Staffordshire, Staffordshire, UK
1. Brennan S, Gangell C, Wainwright C, et al..Disease surveillance using bronchoalveolar lavage.Paediatr Respir Rev.2008;9:151–159.
2. De Blic J, Marchac V, Scheinmann P.Complications of flexible bronchoscopy in children: prospective study of 1,328 procedures.Eur Respir J.2002;20:1271–1276.
3. Wainwright CE, Vidmar S, Armstrong DS, et al..Effect of bronchoalveolar lavage-directed therapy on Pseudomonas aeruginosa
infection and structural lung injury in children with cystic fibrosis: a randomized trial.JAMA.2011;306:163–171.
4. Gilchrist FJ, Salamat S, Clayton S, et al..Bronchoalveolar lavage in children with cystic fibrosis: how many lobes should be sampled?Arch Dis Child.2011;96:215–217.