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Bronchoscopy in the HIV-Infected Patient in the Era of Antiretroviral Therapy: Role of Bronchoalveolar Lavage and Transbronchial Lung Biopsy

Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY

PURPOSE: Antiretroviral therapy has reduced the incidence of pulmonary complications of HIV. The use of high-volume, multilobe bronchoalveolar lavage (BAL) has improved the yield for Pneumocystis jiroveci pneumonia (PCP). This study evaluates the role of bronchoscopy in 2000-2002 in comparison to our same-institution data from 1992 (Salzman et al, JBronchology1996;3:88-95).

METHODS: All HIV-infected inpatients who underwent bronchoscopy from 7/00-9/02 were enrolled. Data collected included results of sputum examination, BAL and trans-bronchial biopsy (TBB). Charts were reviewed to determine final diagnoses.

RESULTS: In the 2000-2002 period 147 bronchoscopic procedures were performed in HIV-infected patients, including 27 in mechanically-ventilated patients. Bronchoscopy was diagnostic in 84/147(57%) cases; BAL in 69/147(47%) and TBB in 58/99(59%). TBB was the exclusive source of diagnostic material in 11/99(11%). In 1992, bronchoscopy was more frequently diagnostic, with 162/181(90%) positive (p<0.001). In 2000-2002 PCP was diagnosed in 60(41%) procedures; BAL was positive in 58/60(97%) and TBB was positive in in 45/48(94%). Only 2/48(5%) had PCP established only by TBB. In 1992, TBB was the exclusive positive specimen for PCP in 8/95(8%)(p=NS). For diagnoses other than PCP, in 2000-2002 TBB provided exclusive diagnosis in 9/24(38%). In 1992, TBB provided exclusive diagnosis in 34/55(62%) of non-PCP cases (p<0.05). In 2000-2002, there were 5(3.4%) complications (pneumothorax(2), massive hemoptysis requiring intubation(1), post-procedure intubation(2)). TBB was performed in 6 mechanically-ventilated patients without complication. Pneumothorax post-bronchoscopy occurred only in PCP cases, 2/53 (3.7%).

CONCLUSION: In comparison with 1992, bronchoscopy in HIV-infected patients was perfomed less frequently in 2000-2002 and was less likely to be diagnostic. This is likely due to the lower incidence of opportunistic pulmonary complications due to antiretroviral therapy. The use of large-volume bilobar BAL as standard technique in HIV-infected patients may account for the significanly lower additional yield of TBB in 2000-2002.

CLINICAL IMPLICATIONS: Although the complication rate of bronchoscopy was relatively low (3.4%) in HIV-infected patients, some will choose to use BAL alone. TBB should also be done when non-PCP diagnoses are likely or when BAL is negative on an initial procedure.

DISCLOSURE: A.J. Posner, None.