Surveillance bronchoscopy in lung transplant recipients: risk versus benefit

Abstract

Background: Long-term survival of lung transplant (LT) recipients is limited by the development of the bronchiolitis obliterans syndrome (BOS). A number of risk factors for BOS have been identified, which can be detected using bronchoscopy with transbronchial biopsy (TBB). Many LT units perform routine surveillance bronchoscopy (SB) to detect problems such as: acute rejection (AR); infection, particularly with cytomegalovirus (CMV); and lymphocytic bronchiolitis. This study aimed to assess the safety and efficacy of surveillance bronchoscopy in lung transplant recipients (LTRs), including TBB and bronchoalveolar lavage (BAL).

Methods: All bronchoscopy procedures, including SB and clinically indicated (CB) procedures performed on LTRs in one calendar year, were audited prospectively. Complications and clinical utility were recorded to determine the clinical utility both early (3 months and 3 to 12 months) and late (>12 months) post-LT.

Results: In one calendar year, 353 procedures (232 SBs and 121 CBs) were performed on 124 LTRs, with 246 performed <1 year post-LT. The complication rates were similar to those reported previously, except for an increased rate of sedation-related complications, particularly up to 3 months post-LT. SBs showed high rates of acute rejection, particularly in the first year post-LT (p = 0.01). The rate of asymptomatic infection diagnosed on BAL remained high regardless of time post-transplant.

Conclusions: This study confirms that SB can frequently detect clinically significant infection and rejection with very low complication rates. The data support SB with TBB up to 12 months post-LT, and ongoing use of SB with BAL (only) to detect clinically silent infection beyond 1 year post-LT.