Bronchoscopy in the Immunosuppressed Patient

Bronchoscopy in the immunosuppressed patient is routinely undertaken, as mortality of immunosuppressed hosts with pulmonary infiltrates is high. Generally, complications from bronchoscopy are rare, with pneumothorax and respiratory failure being the most serious. Immunosuppressed hosts do not have a higher complication rate than the general patient. In patients with HIV, bronchoscopy should be undertaken even if sputum samples are negative when suspicion is high for Pneumocystis jirovecii or tuberculosis. Patients with a hematologic malignancy have a high incidence of pulmonary infiltrates, and delaying bronchoscopy can significantly reduce the diagnostic yield of a causative agent. Diagnostic testing should include galactomannan levels if the concern is high, even if serum testing is negative. Transbronchial biopsy does not increase the yield of an organism. In patients with stem cell and solid organ transplant, fungal and viral studies including galactomannan should be sent, and diffuse alveolar hemorrhage should be ruled out. Diagnostic bronchoscopy for pulmonary infiltrates in the immunosuppressed host is both a relatively safe and useful tool for increasing identification of an offending pathogen in the setting of a pulmonary infiltrate. Given the high morbidity and mortality associated with many of these disease processes, quick identification and pathology-directed treatment is necessary. Myth: Bronchoscopy in immunosuppressed patients for evaluation of pulmonary infiltrates is a high risk but high yield procedure.