Transbronchial
Biopsies
in Children
After
Heart-Lung
Transplantation
John
P. Scott,
FRACP;
Tim W. Higenbottam,
BSc, MD, FRCP;
Rosalind
L. Smyth,
MA, MCRP;
Bruce
Whitehead,
MB, BS;
Peter
Helms,
MD, FRCP;
Guy Fradet,
FRCS(C);
Marc
De Leval,
MD, FRCS;
and John
Wallwork,
FRCS
From the Heart-Lung Transplant Groups, Papworth Hospital, Cambridge, and The Hospitals for Sick Children, Great Ormond Street, London, England
ABSTRACT. Sixty transbronchial biopsies have been
per-formed in eight children after heart-lung transplantation.
The selection of fiber-optic bronchoscope or a small (4
mm; 30 cm) rigid bronchoscope was made according to
the size of endotracheal tube required at surgery. If the endotracheal tube was size 7.5 or greater, a fiber-optic
bronchoscope was used, whereas if the endotracheal tube
size was below 7, a rigid bronchoscope was used. For the diagnosis of lung rejection, the histology of biopsies
re-vealed a sensitivity of 91% and specificity of 69% (similar
to the result in adults). The histology also distinguished lung infection from rejection. Complications included
three pneumothoraces and two clinically significant
epi-sodes of hemorrhage, one of which led to a cardiorespi-ratory arrest, which may have been caused by hypoxia. As a result, arterial oxygen saturation is now monitored during the procedure using a pulse oximeter. Pediatrics
1990;86:698-702; bronchoscopy, transbronchial biopsy, heart-lung transplantation.
pulmonary disease in adults,2’3 including cystic fi-brosis,4 and it has now been successfully used in children.5’6 Transbronchial biopsies obtained
through a fiber-optic bronchoscope (FOB) have
been required in adult HLT patients to distinguish acute lung rejection from opportunistic infection,7’8
reducing the incidence of chronic rejection#{176} which
had
been
common
in early
series.’0
Transbnonchial
biopsy in children poses special problems in obtain-ing adequate tissue for histology and culture, inhemostasis, and in the maintenance of safe levels
of oxygenation while achieving adequate sedation during bronchoscopy. We report our experience
with TBB in children after HLT and describe the
clinical and physiologic features of acute lung nejec-tion and infection in these children.
PATIENTS AND METHODS
ABBREVIATIONS. TBB, transbronchial biopsy; HLT, heart and lung transplantation; FOB, fiber-optic bronchoscope (bronchos-copy); FEV,, forced expiratory volume in 1 second; ET, endotra-cheal; RB, rigid bronchoscope (bronchoscopy).
Although transbronchial biopsy (TBB) is well
established in adults for the diagnosis of diffuse
lung disease,’ its use has not been extended to
children. Heart and lung transplantation (HLT)
was initially introduced to treat end-stage
candio-Received for publication Aug 18, 1989; accepted Nov 28, 1989. Reprint requests to (J.P.S.) Heart-Lung Transplant Research Unit, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, UK.
PEDIATRICS (ISSN 0031 4005). Copyright © 1990 by the American Academy of Pediatrics.
Eight children underwent HLT between 1987 and
1989 (Table 1). Their mean age was 11.3 years
(range 3 to 15 years). Their original diagnoses in-cluded Eisenmenger syndrome (n = 2), pulmonary primary hypertension (n = 2),
and
cystic
fibrosis
(n = 4). Donor and recipient selectionand
surgical
techniques have been previously reported.’#{176}
Rejec-tion was controlled with oral cyclosponine and
aza-thiopnine, supplemented in four patients who
ex-penienced recurrent rejection with oral
predniso-lone (0.25 mg/kg).
After surgery all patients were carefully
moni-tored using respiratory symptoms-particularly
breathlessness, physical signs, crackles and wheezes
on auscultation,” pulmonary shadows on chest
na-diognaphs,’2 or a fall in forced expinatory volume in
1 second (FEy,) and vital capacity of greater than
10%7”3-as indications for TBB. In the 3-year-old
meas-TABLE 1. Patient Age, Sex, R ecipient Dis ease, Frequen cy of Rejection, and Types of Recipient Infection*
Patient Original Age, Sex Time Since Total No. Total and Type of Infection Episodes Present Disease y Surgery,
mo
of Rejection Episodes
FEy,, % Predicted
1 PPH 11 M 18 (died) 11 CMV pneumonia
...
2 PPH 15 F 18 3 Nil 94
3 CF 11 F 14 5 CMV pneumonia, Pseudomonas pneumonia 61
4 CF 14 F 11 7 Pseudomonas pneumonia 77
5 ES 14 F 10 5 Herpes simplex pneumonia 80
6 ES 3 M 6 4 Nil
...
7 CF 14 M 5 2 Pseudomonas pneumonia 73
8 CF 13 M 3 3 Pseudomonas pneumonia 94
* FEV,, forced expiratory volume in 1 second; PPH, primary pulmonary hypertension; CF, cystic fibrosis; ES,
Eisenmenger syndrome; CMV, cytomegalovirus.
urements, including spirometry, total lung capacity,
and
gas
transfer
for
carbon
monoxide,
were
made
in the others. Routine biopsies of the lungs wereperformed in five patients when well at 3 and 12
months.
The
choice
of bronchoscopic
technique
was
made
according to the endotracheal (ET) tube size used
during transplant surgery. If a size 8 or larger was
used, a FOB was performed as in adult HLT
patients7 but using a 4.6-mm instrument. Sedation
was with intravenous diazepam or midazolam.
When
a size
7 to 8 ET tube had been used, patientswere anesthetized with propofol and nitrous oxide
and
an
ET
tube
size
7 to
8 was
passed.
The
FOB
was passed through this ET tube while the patients
received assisted ventilation. In two children who
had
required
ET
tubes
of
a size
below
7, rigidbronchoscopy (RB) (4.0 mm diameter and 30 cm
length)
was
performed
using
propofol
and
nitrous
oxide,
assisted
ventilation
being
provided
through
the scope. Throughout the procedure, arterial
oxy-gen saturation was monitored using a pulse
oxi-meter (Oximeten, Copenhagen, Denmark).
Through both the FOB and RB, “alligator”
for-ceps were positioned under fluoroscopic control in
the lung periphery. Through the FOB three biopsies
were taken from each lobe in one lung, including
the lingula on the left side, whereas just middle/
lingula
and
lower lobes were sampled with the RB.Tnansbnonchial biopsies were fixed in 10%
neu-tral
buffered
formalin
and
were
processed
in
a
Shandon hypercenter overnight or in 2 hoursac-cording
to
urgency.
Initial
biopsies
were
cut
at
several levels 5 m apart. Later biopsies were
seri-ally sectioned and stained with Harris’ hematoxylin
eosin. Special stains, including pyronin methyl
green and Perl’s/Miller’s elastic Van Gieson, were
performed in all cases. Periodic acid-Schiff and
Gnocott’s silver method were used to demonstrate
fungi and Pneumocystis carinii.
A histologic
diagnosis
of rejection
was
made
when
there were dense perivascular lymphocytic
infil-trates, often associated with mixed cell
inflamma-tory changes in the bronchial mucosa.79 A
histo-logic diagnosis of cytomegalovirus pneumonitis was
made by the presence of typical inclusion bodies
within epithelial or endothelial cells.’4 This was
also confirmed by the growth of the virus from lung
biopsy. The histologic appearances of herpes
sim-plex virus pneumonia were those of a viral alveolitis
associated with typical “ground-glass” intranuclear 15
Acute rejection was treated with intravenous
methylprednisolone, 20 to 25 mg/kg daily for 3 days,
andthen 1 mg/kg ofonal prednisolone in decreasing
doses for 10 days. Cytomegalovirus pneumonitis was treated with ganciclovir”6 (Syntex Pharma-ceuticals, Maidenhead, Berks). Intravenous
acyclo-yin, 5 to 10 mg every 8 hours, was used to treat
herpes simplex virus pneumonia. This was
contin-ued for 14 days, when oral acyclovin was commenced
and continued as a prophylactic dose indefinitely.
For
the
purposes
of the
determination
of
sensi-tivity and specificity, a final diagnosis of rejectionwas made if there was an improvement of
symp-toms, signs, and spirometnic measurements or chest
radiographic appearances after a course of
aug-mented immunosuppression. Similarly for
infec-tion, a response to specific treatment was regarded
as confirmation (Table 2).
Analyses of sensitivity and specificity of both
TBB
and
radiographic
changes
were
calculated
for
both rejection and infection separately. (Sensitivity= true positives X 100%/all patients with disease;
specificity = true negatives X 100%/all patients without disease).
Analysis of the optimal number of biopsies was by the method of Gilman and Wang,17 namely the minimum number of biopsies required to achieve a
positive diagnosis.
RESULTS
A total
of 60 sets
of TBB
were
performed
in eight
patients, 49 through a FOB and 11 through a RBpneumo-thonaces after RB and two clinically significant
hemorrhages during FOB, one requiring assisted
ventilation and the other causing a
cardiorespira-tony arrest.
There were 40 episodes of rejection (Figs 1 and
2), where in the absence of infection patients
im-proved
after
initiation
of steroid
therapy.
Of these,
36 sets of biopsies showed the characteristic
abnor-malities of rejection, giving a sensitivity of 86%. Of
the 16 occasions when patients were well, 11
biop-sies
had
normal
appearances,
giving
a specificity
of
69%. Of the remaining biopsies, 2 showed evidence
of fibrosis and 2 showed nonspecific bronchial
in-flammation. Three episodes of pneumonia, one of
cytomegalovirus, and two of herpes simplex virus
were diagnosed by histology.
In
41 of the
50
TBBs
obtained
using
FOB,
all
TABLE 2. Clinical Criteria for Diagnosing Opportun-istic Infection of the Lungs and Rejection of the Lungs*
Infection
Criteria Abnormalities
Symptoms Cough and dyspnea Physical signs Fever, basal crackles on
auscultation
Physiology Fall in FEV, and FVC, fall in DLCO Radiology Diffuse bilateral
pulmo-nary shadows Response to specific
therapy (see text) Rejection
Criteria Abnormalities Symptoms Cough and dyspnea Physical signs Fever, basal crackles on
auscultation
Physiology Fall in FEV, > FVC
Radiology Diffuse bilateral pulmo-nary shadows
Response to high-dose steroids (see text)
* FEV,, forced expiratory volume in 1 second; FVC,
forced vital capacity; DLCO, diffusing capacity for carbon
monoxide.
three lobes (lingula on left) of one lung were
sam-pled.
In
9 only
the
lower
lobe
was
biopsied.
Two
lobes were biopsied on each of the 10 occasions RBwas used. In the 24 rejection episodes where all
lobes of one lung were sampled, the characteristic
histologic abnormalities of rejection were found in
the
upper
lobe
in 89%,
middle
lobe
(or
lingula)
in
92%, and lower lobe in 91%.A total
of
28
individual
biopsy
samples
in
6
episodes of rejection studied by RB were required
to confirm the diagnosis histologically. At least 2.7
biopsies are required to provide a 99% chance of
diagnosing rejection,’7 although this calculation is
based on only two patients. By similar calculation of 36 episodes of rejection confirmed by TBB
through FOB, some 313 individual biopsy samples
were
obtained
and
4.5
individual
biopsies
were
re-quired to confirm rejection (P < .01).The incidence of rejection in children was a mean
of 3.6 episodes per patient per 6 months. There was
a total of 3 episodes of infection. In all but 1 of the
rejection episodes, recovery followed steroid
then-apy.
Infiltrates were present on 55% of the chest
radiographs of those 40 rejection episodes
con-firmed by histology. Radiologic abnormalities were
more common during rejection episodes occurring
in the first 3 months, giving an 88% sensitivity.’5”7
In the
16 episodes
of rejection
occurring
after
the
first 3 postoperative months, only 19% of the chestnadiognaphs showed abnormalities.5”2 The
infec-tions were associated with infiltrates on chest
ra-diographs in all cases. There was a significant fall
in FEy, in only 52% of cases of histologically
confirmed rejection episodes. A fall in FEV1 when
present remains a valuable noninvasive guide to the
timing of TBB. Mean FEy, was 77% of predicted
at
6 months
and
76%
of predicted
at
12 months
(Fig 3).DISCUSSION
Transbronchial biopsy of the lung, through a
FOB
or
RB,
can
be
performed
in
children
after
TABLE 3. Total Biopsy Numbers for Each on Histologic Examination and Obtained by Bronchoscopy (RB)
Patient, Positi Fiber-Optic B
ye or Negative for Reje ronchoscopy (FOB) or
ction Rigid
Patient No. FOB Patient No. RB
Positive Negative
Positive Negative
1
35 492 12 10
3 54 11
4 46 10
5 49 10
7 22 13
6
8
24 8
22 2
0-6
2
6-12
Time in Months
Fig 1.
Incidence
of rejection
plotted
against
time
inmonths.
12-18
0
-0 100 200 300 400 600
Days since Transplant
Fig 3.
Forced
expiratory
volume
in
1 second (FEy,) as recipient predicted of the six “long-term” (>4 months) survivors, 1 1 years of age or older, plotted against time.Fig 2.
Photomicrograph
of characteristic
perivascular
lymphocytic
infiltrate
of acute
lung
rejection
using
he-matoxylin
and eosin
stain.
Magnification
is x200.
Episodes of Rejection FEVI % Predicted
1 20
HLT.
It allows
the
diagnosis
of acute
lung
rejection
and
lung
infection,
showing
a similar
sensitivity
and
specificity
to
TBB
when
used
in
adult
HLT
patients.7
Complications
appear
to
be
no
more
frequent7”8
but
can
be more
serious.
They
may
be
reduced
by
monitoring
arterial
oxygen
saturation
and careful selection of bronchoscopic method.The
requirements
for
bronchoscopy
to
obtain
TBB
are
different
from
those
for
bronchoscopy
in
children
for
other
indications.’9’20
Flexible
FOB
al-lows
accurate
location
of the
forceps
under
fluoro-scopic
control,7
in particular
sampling
of the
upper
lobes.
Empirically
we
chose
to use
the
ET
size
at
surgery
as a means
of deciding
on the
use
of FOB
with
or without
an ET
tube
on RB.
The
size
of ET
tube
used
at operation,
although
usually
associated
with
age,20’2’
was
more
closely
linked
to height
ni
our
patients.
For
example,
a
13-year-old,
whose
growth
had
been
impaired
by cystic
fibrosis,
had
a
height
of the
50th
centile
for
a boy
aged
8.9 years,
and
he required
a 6-gauge
ET
tube
at surgery.
Clinical
distinction
between
acute
lung
rejection
and
infection
is not
possible,7’22
although
lung
func-tion,
symptoms,
physical
signs,
and
chest
nadiographs7’’3
are
useful
indications
for
under-taking
TBB.
In adults,
TBB
histology
can
not
only
diagnose
rejection,
it can
also
distinguish
rejection
from
infection.7
The
same
appears
true
in children.
The
diagnosis
of rejection,
we suspect,
can
be made
by
sampling
one
lobe
in
children,
unlike
adults
where
two
lobes
must
be sampled.23
Using
FOB
at
least
four
individual
biopsies
are
required.
Chest
radiographic
findings
are
comparable
with
those
in adults.’2
Nodular
shadows
with
septal
lines
associated with pleural effusion are common in
rejection,
but
these
changes
are
similar
to
those
seen
in infection.
As in adults,
the
radiograph
less
frequently
shows
abnormalities
in
rejection
epi-sodes 3 months on more after surgery. The FEy, is
of value,
as in adults,”3
but
requires
a consistent
technique
which
children
may
require
longer
to
master.
The
incidence
of complications
of this
procedure
iscomparable
with
that
in adults.7”8
However,
one
death
can
be directly
attributed
to hemorrhage
after
TBB.
This
patient’s
arterial
oxygen
saturation
was
not
monitored
and
we suspect
that
severe
hypoxia
occurred
during
the
procedure,
leading
to candiores
piratory
arrest.
As a result
of this
early
experience,
all patients,
irrespective
of the
use
of assisted
yen-tilation,
are
now
routinely
monitored
by pulse
ox-imetry
and
supplementary
oxygen
is given.
We have
found
pulse
oximetry
to be a sensitive
measurement
and
if a fall
occurs,
this
may
be
associated
with
bleeding
on with
the
position
of the
bronchoscope
on
a pneumothonax.
Practical
considerations
in-dude
fluonoscopic
screening
for
a pneumothorax,
aspiration
of bleeding
with
wedging
of the
broncho-scope
in the
affected
segment,
avoidance
of airway
obstruction,
and
early
assisted
ventilation.
repro-ducible
in children.
In these
HLT
patients
it is both
a specific
and
sensitive
means
of diagnosing
acute
rejection
of the
lung.
Transbronchial
biopsy
may
prove
valuable
in the
diagnosis
of diffuse
lung
dis-ease
in children,
for
example,
nonbactenial
pneu-monias,
lymphomas,
and
leukemic
infiltrates.
It
may
also
be
useful
in
opportunistic
infection
in
immunocompnomised
patients.
Acknowledgments
We thank
Dr Malone
(Department
of Histopathology,
The
Hospitals
for Sick Children),
Dr C. Clelland,
and Dr
S. Stewart (Department of Histopathology, Papworth
Hospital)
for
reviewing
the
pathology
of the
biopsies.
Also we thank
Mr Ben
Milstein
for his editorial
advice.
REFERENCES
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ERRATUM
In
the
article
“Cosleeping
in
a Community
Sample
of
2- and
3-Year-Old
Children”
by Madansky
and
Edelbrock
(Pediatrics1990;86:197-203),
Figures
1
1990;86;698
Pediatrics
Guy Fradet, Marc De Leval and John Wallwork
John P. Scott, Tim W. Higenbottam, Rosalind L. Smyth, Bruce Whitehead, Peter Helms,
Transbronchial Biopsies in Children After Heart-Lung Transplantation
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1990;86;698
Pediatrics
Guy Fradet, Marc De Leval and John Wallwork
John P. Scott, Tim W. Higenbottam, Rosalind L. Smyth, Bruce Whitehead, Peter Helms,
Transbronchial Biopsies in Children After Heart-Lung Transplantation
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