Diagnostic strategy for hematology and oncology patients with acute respiratory failure: randomized controlled trial.
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).
Azoulay
Elie
E
Medical Intensive Care Unit, Saint-Louis Teaching Hospital, 75010 Paris, France. elie.azoulay@sls.aphp.fr
Mokart
Djamel
D
Lambert
Jérôme
J
Lemiale
Virginie
V
Rabbat
Antoine
A
Kouatchet
Achille
A
Vincent
François
F
Gruson
Didier
D
Bruneel
Fabrice
F
Epinette-Branche
Géraldine
G
Lafabrie
Ariane
A
Hamidfar-Roy
Rebecca
R
Cracco
Christophe
C
Renard
Benoît
B
Tonnelier
Jean-Marie
JM
Blot
François
F
Chevret
Sylvie
S
Schlemmer
Benoît
B
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