Earlier referral for bronchoscopy in immunocompromised patient

SESSION TITLE: Proceduralist Round Table SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/10/2023 12:00 pm - 12:45 pm PURPOSE: There are many indications for bronchoscopy with alveolar lavage (BAL), especially in the immunocompromised patient with a new pulmonary infiltrate (1). At our hospital, these immunocompromised patients have empiric antibiotics started before pulmonology is consulted. When these patients undergo a BAL, there is always a chance the sample is sterilized and nondiagnostic. The purpose of this retrospective review was to answer if doing a BAL in immunocompromised patients in the inpatient setting with a new pulmonary infiltrate changed clinical management. METHODS: We collected data over one year from patients who had a bronchscopy while inpatient. We selected for patients that were immunocompromised, inpatient, and had a new pulmonary infiltrate. We defined immunocompromised per IDSA guidelines (2). 54 patients were selected. Each patient chart was analyzed for the type of immunocompromised status, when pulmonology was consulted, how many days of antibiotics the patient received before bronchoscopy, types of serum tests, sputum culture, an adequate BAL per ATS guidelines, results of tests from BAL, if a transbronchial biopsy (TBBx) was done, and if the data changed management. Descriptive statistics were performed for analysis. RESULTS: 54 patients met criteria for this review. There were 28 (52%) patients who had a BAL that provided data to change initial management. The average time from antibiotics to bronchoscopy for these patients was 6 days. 26 (48%) patients did not have a diagnostic BAL and their average time from antibiotics to bronchoscopy was 7 days. The consult to bronchoscopy time was 2 days. Only 25 patients had adequate BAL return per ATS. 4 patients had TBBx with BAL. 41 patients did not get sputum cultures prior to BAL. The BAL cultures from 45 patients did not grow any organisms. The most common diagnostic results from the BALs were infection, malignancy, and pulmonary toxicity. Finally, there were 9 patients (16%) that had a BAL result that was opposite of initial diagnosis, however, management of those patients did not change. CONCLUSIONS: This retrospective review shows that BAL appears to be an effective tool to guide treatment in patients who are immunocompromised with new pulmonary infiltrates. The data shows that molecular tests from the BAL were superior over sputum and BAL cultures. Additionally, those who underwent a TBBx with BAL, seemed to have increased diagnostic yield in comparison to just BAL. However, our data shows that those who did not get appropriate BAL return, usually did not yield diagnostic data. CLINICAL IMPLICATIONS: This research shows the importance of early BALin immunocompromised patients with new pulmonary infiltrates. Early bronchoscopy is helpful to avoid unnecessary antibiotics and likely leads to lower length of stay. It also shows us that adding on TBBx to the BAL can lead to increased diagnostic yield (3). Additionally, BAL should be considered as one of the first tests in these patient’s due to the increasing accuracy of molecular tests (4). Finally, it shows us that these group of patients should have earlier referral to pulmonology to increase diagnostic yield. DISCLOSURES: No relevant relationships by Billie Bixby No disclosure on file for Madhav Chopra No relevant relationships by James Knepler No relevant relationships by Bhargav Patel