title: Diagnostic strategy for hematology and oncology patients with acute respiratory failure: randomized controlled trial.
abstract: BACKGROUND
  Respiratory events are common in hematology and oncology patients and manifest as hypoxemic acute respiratory failure (ARF) in up to half the cases. Identifying the cause of ARF is crucial. Fiberoptic bronchoscopy with bronchoalveolar lavage (FO-BAL) is an invasive test that may cause respiratory deterioration. Recent noninvasive diagnostic tests may have modified the risk/benefit ratio of FO-BAL.
  
  
  OBJECTIVE
  To determine whether FO-BAL in cancer patients with ARF increased the need for intubation and whether noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL.
  
  
  METHODS
  We performed a multicenter randomized controlled trial with sample size calculations for both end points. Patients with cancer and ARF of unknown cause who were not receiving ventilatory support at intensive care unit admission were randomized to early FO-BAL plus noninvasive tests (n = 113) or noninvasive tests only (n = 106). The primary end point was the number of patients needing intubation and mechanical ventilation. The major secondary end point was the number of patients with no identified cause of ARF.
  
  
  RESULTS
  The need for mechanical ventilation was not significantly greater in the FO-BAL group than in the noninvasive group (35.4 vs. 38.7%; P = 0.62). The proportion of patients with no diagnosis was not smaller in the noninvasive group (21.7 vs. 20.4%; difference, -1.3% [-10.4 to 7.7]).
  
  
  CONCLUSIONS
  FO-BAL performed in the intensive care unit did not significantly increase intubation requirements in critically ill cancer patients with ARF. Noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL for identifying the cause of ARF. Clinical trial registered with www.clinicaltrials.gov (NCT00248443).
authors.affiliation: Medical Intensive Care Unit, Saint-Louis Teaching Hospital, 75010 Paris, France. elie.azoulay@sls.aphp.fr
authors.forename: Elie
authors.initials: E
authors.lastname: Azoulay
authors.forename: Djamel
authors.initials: D
authors.lastname: Mokart
authors.forename: Jérôme
authors.initials: J
authors.lastname: Lambert
authors.forename: Virginie
authors.initials: V
authors.lastname: Lemiale
authors.forename: Antoine
authors.initials: A
authors.lastname: Rabbat
authors.forename: Achille
authors.initials: A
authors.lastname: Kouatchet
authors.forename: François
authors.initials: F
authors.lastname: Vincent
authors.forename: Didier
authors.initials: D
authors.lastname: Gruson
authors.forename: Fabrice
authors.initials: F
authors.lastname: Bruneel
authors.forename: Géraldine
authors.initials: G
authors.lastname: Epinette-Branche
authors.forename: Ariane
authors.initials: A
authors.lastname: Lafabrie
authors.forename: Rebecca
authors.initials: R
authors.lastname: Hamidfar-Roy
authors.forename: Christophe
authors.initials: C
authors.lastname: Cracco
authors.forename: Benoît
authors.initials: B
authors.lastname: Renard
authors.forename: Jean-Marie
authors.initials: JM
authors.lastname: Tonnelier
authors.forename: François
authors.initials: F
authors.lastname: Blot
authors.forename: Sylvie
authors.initials: S
authors.lastname: Chevret
authors.forename: Benoît
authors.initials: B
authors.lastname: Schlemmer
mesh_terms: D000208:Acute Disease; D000368:Aged; D018893:Bronchoalveolar Lavage; D001999:Bronchoscopy; D003948:Diagnostic Techniques, Respiratory System; D005260:Female; D005336:Fiber Optic Technology; D006801:Humans; D000860:Hypoxia / Q000150:complications*; D007362:Intensive Care Units; D057194:Intention to Treat Analysis; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications*; D012131:Respiratory Insufficiency / Q000175:diagnosis* / Q000209:etiology