Perspective on Procedures
The clinical challenge to sculpture empiric therapy and prolong survival for immunocompromised patients remains a dilemma. The three basic choices, observation alone, to start or broaden empiric therapy, or pursue invasive diagnostic procedures, are clear but difficult options. It is not surprising that Robin and Burke chose “Lung Biopsy in Immunosuppressed Patients” as an initial topic for risk-benefit analysis in Chest. With a major change in therapy or prolonged survival as an endpoint, open lung biopsy (OLB) risk does exceed benefit for most of these patients. For this reason, many institutions have limited the use of OLB and focused on improving alternate means to clarify pulmonary pathology.
Rosenow and colleagues have presented characteristic behavior patterns for various pathogens in many variable subsets of immunocompromised host. Although all meet a broad definition of immunocompromise, there are substantial differences in approach and analysis of risk for patients with solid tumor malignancies, leukemia, collagen vascular disease, acquired immunodeficiency syndrome (AIDS), and the expanding field of organ transplantation. Many factors must be analyzed by the team of physicians involved in caring for these patients. The onset and relation to treatment for the infiltrate, the focal or diffuse pattern, and rate of deterioration or improvement remain critical elements in choosing the pulmonary procedure. The pulmonologist is expected to decide which procedure, single or in combination, offers the best alternative for dealing with uncertainty in these high risk patients. http://medicines-for-diabetes.com/
Saito and co-workers, in this issue (see page 745), discuss bronchoalveolar lavage (BAL) in patients with acute leukemia. The authors describe the science of BAL without overstating the contribution that the art of BAL contributes in this setting. This art involves the clinical judgment exercised and treatment changes originated in these patients by the procedure. If other team members are reluctant to accept any procedure as “negative for pathogens” and unwilling to sculpture therapy based on these results in clinical context, then that procedure can be judged only on positive predictive value.