Utility of fiberoptic bronchoscopy in bone marrow transplant patients.

Fiberoptic bronchoscopy (FOB) has been reported to have a high diagnostic yield and to be safe in BMT patients with pulmonary infiltrates. At our institution, BMT patients with respiratory symptoms and/or pulmonary infiltrates had a thoracic CT and bronchoalveolar lavage (BAL). Transbronchial biopsy (TBBx) was considered if the platelet count could be raised to >30 x 10(9)/l. From March 1993 to August 1995, 52 patients had 68 FOBs (42 BAL + TBBx, 26 BAL only) for 60 episodes of clinical pneumonia. Patients' characteristics were: 38 males, mean age 42 years, and 39 allogeneic BMTs. Of the 68 FOBs, 47 were performed to evaluate diffuse infiltrates, 10 were done on mechanically ventilated patients, and 50 of the FOBs were preceded by a platelet transfusion. Thirty-one percent of FOBs (21 FOBs, 19 patients) were diagnostic. Twenty-four percent of FOBs (11 diagnostic FOBs, six nondiagnostic FOBs) changed therapy. Ten complications (15%) occurred in 10 FOBs (five acute respiratory failure, three pneumothoraces, one nose bleed, one death). Hospital and 6-month survival based on episodes of clinical pneumonia were 47 and 32%, respectively. Patients who had a diagnostic FOB or a FOB that changed treatment did not have better hospital or 6-month survival compared to patients who had FOBs that were nondiagnostic or did not change treatment. FOB in our BMT patient population, had a low diagnostic yield (31%), infrequently changed treatment (24%), a significant complication rate (15%) and was not associated with improved patient survival. The role of routine diagnostic FOB in BMT patients with pulmonary infiltrates and/or respiratory symptoms should be reevaluated.

Physician-derived asthma diagnoses made on the basis of questionnaire data are in good agreement with interview-based diagnoses and are not affected by objective tests.

BACKGROUND: Defining the phenotype is critical for investigating the genetic etiology of asthma. As part of the Collaborative Study on the Genetics of Asthma (CSGA), the primary objective of which is to identify asthma susceptibility loci, an algorithm was designed to determine diagnoses of definite asthma, probable asthma, less than probable asthma, or no asthma. A respiratory questionnaire was designed to assist in the process of characterizing the asthma phenotype. OBJECTIVE: This study was designed to determine the validity of the CSGA algorithm for the diagnosis of asthma, to determine agreement in assessing an asthma diagnosis between the information obtained by the CSGA questionnaire versus a patient interview by a panel of specialist physicians, and to determine the degree to which objective tests would alter the questionnaire-based certainty of asthma diagnosis. METHODS: An expert panel of asthma clinicians (n = 4) indicated to what degree they were certain that a subject (n = 48) had asthma as determined by using a 6-point Likert scale based on a 20-minute interview (phase I), a review of the CSGA questionnaire (phase II), a review of the questionnaire plus skin test and peripheral blood eosinophilia data (phase III), and a review of phase III information plus pulmonary data (spirometry and methacholine-reversibility testing; IV). Intraclass correlation coefficients (ICCs) were calculated between the physicians' interpretation of the likelihood of asthma based on the information they received during each of the phases and between the CSGA algorithm and each of the phases. RESULTS: Interjudge reliability with regard to the degree of certainty with which an asthma diagnosis could be made by interview was excellent (ICC, 98; 95% confidence intervals [95% CIs], 0.87-0.99). We also found that the agreement between the physicians' interview with the patients (phase I) and the CSGA algorithm was good and at least as good with the addition of the CSGA questionnaire data and objective data (ICC, 0. 65-0.75). Good agreement was also observed between the average certainty score from the interview and the CSGA questionnaire (ICC, 92; 95% CI, 0.76-0.93), and ICCs determining the agreement on asthma diagnosis between phase I and phases III and IV, in which objective data were introduced, did not change from the ICCs comparing phase I with phase II (ICC of 0.93 [95% CI, 0.79-0.96] and ICC of 0.91 [95% CI 0.73-0.95], respectively). CONCLUSION: We conclude that the CSGA algorithm is a valid tool for which the diagnosis of asthma can be made at an acceptable level of certainty and that the CSGA questionnaire, interpreted by an asthma specialist, is a useful tool for the diagnosis of asthma in clinical or epidemiologic studies.