(From the July 2014 Issue of PediatricsOnline)
Performing a bronchoscopy in patients with cystic fibrosis (CF) who are undergoing surgery is an effective way to identify fungal and bacterial pathogens that more conventional screens often miss, according to a new study by clinician-scientists at Nationwide Children’s Hospital.
“We found a high rate of bacterial and fungal pathogens that cause chronic airway infection that we hadn’t previously discovered by the routine clinical monitoring of cultures, and those findings often changed our management of those patients,” says Stephen Kirkby, MD, a pulmonologist at Nationwide Children’s and lead author of the study.
The study, published in a recent issue of the journal Pediatric Pulmonology, involved 77 patients with CF aged 2 to 29 years who were under anesthesia for sinus surgery at Nationwide Children’s between January 2009 and October 2010. Using flexible fiberoptic bronchoscopy, clinicians collected samples from the lower respiratory track. They analyzed the cultures and compared them to samples collected from patients earlier in the year either by oropharyngeal swab, OP for short, or by sputum culture.
The samples taken by bronchoscopy identified a new bacterial pathogen in 19 percent of patients and a new fungal pathogen in 42 percent of patients. The discovery led to changes in therapy for 15 patients.
Although the frequency of pathogen screens for CF patients varies from center to center, most will receive either an OP swab or sputum collection at least four times a year. OP swabs are usually used on very young patients or those who are unable to produce sputum. Because they only sample cultures from the mouth and throat, OP swabs offer the least complete picture of fungal and bacterial infection. While sputum cultures originate in the lungs, Dr. Kirkby notes that they can often miss bacteria and fungi hiding in the lower respiratory pathways of the lungs.
“The gold standard for determining whether or not there’s a lung infection is with a bronchoscopy,” Dr. Kirkby says. However, since bronchoscopies are invasive, clinicians are often reluctant to do them unless a patient has an infection that can’t be diagnosed with OP swab or sputum culture.
In this new study, Dr. Kirkby and his colleagues examined patients who received a bronchoscopy when they were already under anesthesia for sinus surgery. Most patients with CF will develop sinus disease at some point during their lifetime and some will require surgery.
“If a patient is undergoing anesthesia anyway, our practice is moving toward taking advantage of that and doing a bronchoscopy to make sure we get the most accurate diagnosis of bacterial or fungal pathogens as we can,” says Dr. Kirkby, who also is the clinical director of the Heart and Heart-Lung Transplant programs at Nationwide Children’s and an assistant professor of internal medicine and pediatrics at The Ohio State University College of Medicine. “The findings from this study support this practice.”
To further the research, Dr. Kirkby and his colleagues are planning to look at similar results in CF patients undergoing surgery for gastrointestinal complications, which are common in patients with the disease.
Kirkby S, Hayes D Jr, Ginn-Pease M, Gatz J, Wisely CE, Lind M, Elmaraghy C, Ryan-Wenger N, Sheikh SI. Identification of new bacterial and fungal pathogens on surveillance bronchoscopy prior to sinus surgery in patients with cystic fibrosis. Pediatric Pulmonology. 2014 Apr 15. [Epub ahead of print]