DISCUSSION
Conclusions:
OLB's have an important clinical utility in immunocompromised children with pulmonary infiltrates with definitive diagnosis reached in 36%-94% and clinical improvement in 10%-46%. What is not answered by the literature, however, is the best timing and patient selection for these procedures and prospective controlled trials are needed for this. Specifically we need to know when should immunocompromised patients who develop pulmonary infiltrates be considered for OLB: When they develop pulmonary infiltrates? When they become symptomatic? When they do not respond to therapy? Earlier biopsies may establish a diagnosis while the child can tolerate the procedure better and potentially when the process is more susceptible to treatment. However this would involve many more patients undergoing treatment and possible complications including many who not progress. Therefore prospective controlled trials are needed to establish the timing of the biopsy and patient selection
Overall immunocompromised patients with respiratory failure are at highest risk for morbidity and mortality associated with OLB. There is further increased risk if the patient is mechanically ventilated or post BMT.
Of note as well is that BAL showed poor sensitivity and specificity in many of the case series on patients in which both were performed. However there may have been a selection bias for patients who had a negative BAL (those with positive results had the BAL often performed much earlier in course).
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