DISCUSSION:

Stefanuttiⁱⁱ and colleagues published a retrospective review of 36 OLB's in 32 patients with either primary or secondary immunodeficiency. A specific diagnosis was stablished in 22 of 36 cases (61%) with infection diagnosed 12 times (8 fungal, 4 PCP) and a non infectious diagnosis 10 times (6 tumor, 4 bronchiolitis obliterans). A treatment change occurred in 77% of cases and a clinical improvement was reported in 33%.

Patients with an infectious diagnosis tended to have the highest likelihood of improvement. The overall mortality was 33% and all the patients who died had developed acute respiratory distress. The mortality was increased in children ventilated prior to their OLB, especially if they had a BMT. 8 of 12 (75%) ventilated children died including 4 of 5 (80%) post BMT. Furthermore there was a significant decrease in mortality in patients with 1º immunodeficiency compared to 2º immunodeficiency; 2 of 17 (12%) vs 10 of 19 with (53%) respectively. Of note was that 4 of the 12 infectious etiologies on OLB were not identified on BAL including all 3 PCP diagnosis and 1 of the 6 aspergillus diagnosis. However the mean time of symptom onset to procedure was 6 days for the BAL and 33 days for the OLB.

A few things that can be learned from this series are that children with 2º immunodeficiencies who require OLB's have a much higher mortality rate than children with 1º immunodeficiencies. Children who are mechanical ventilated prior to OLB have a higher mortality and negative BAL results may still have an infectious etiology.