Role of fiberoptic bronchoscopy in early diagnosis of non-resolving pneumonia

Introduction

Non resolving pneumonia is defined as a clinical syndrome in which focal infiltrates begin with some clinical association of acute pulmonary infection and despite a minimum of 10 days of antibiotic therapy patient either don’t improve or worsen (or) radiographic opacities fail to resolve within 12 weeks.1 It has always been a challenge to diagnose a case of non-resolving pneumonia due to its wide spectrum of differential diagnosis and was very stressful on the patients’ aspects as they need to go through wide range of investigations. 2 Such patients may be at risk of delay in diagnosis which adversely affects their outcomes. 1 Delay in diagnosis increases the mortality by 3-5% in community acquired pneumonia and nosocomial pneumonia. Fiber optic bronchoscope is very useful which aids in early and accurate diagnosis of non-resolving pneumonia there by helping in differentiating pyogenic causes and also rule out bronchogenic carcinoma. 3

Materials and Methods

Results

Among 90 cases of non-resolving pneumonia studied, 50 to 60 years age group were commonly affected accounting to 33%. Male predominance was observed with 73.3%. Smoking was common observation accounting to 51%. Pseudomonas was the commonest organism isolated in cases of non-resolving pneumonia followed by mycobacterial tuberculosis accounting for 23.3 and 22.2% of cases. Staphylococcus and klebsiella were noted in 10 and 13.3 % of cases respectively. Right lung involvement was noted in 63.3% of cases followed by left lung involvement in36.7% of cases. Bilateral lobar involvement was noted in 13(14.4%). Right upper lobe was the commonest site affected accounting for 46.7% of cases followed by left lobe involvement and bilateral involvement with 38.95 and 14.4 % respectively. Bacterial pneumonias were found to be commonest aetiology followed by tuberculosis, bronchogenic carcinoma and fungal infection accounting to 46.6%; 22.2%; 17.7%; 1.1% respectively. Diagnosis was indeterminate in 12.2% of cases.

Discussion

Non resolving pneumonia is not an infrequent problem faced by practicing pulmonologist.4 Radiological resolution lags behind the clinical signs in most of the pulmonary infections. When that is not the case, other etiologies should be sought, which include unusual organisms like mycobacteria, higher order bacteria and fungi.4 Noninfectious causes that could be causingthe delayed resolutionare neoplastic disease, immunologic disease, thromboemboli, and inhalation injuries.

Chalmers et al.5 reported that by 3^rd day if clinical improvement is not attained then the diagnosis should be reevaluated. Physical examination and important blood investigations like CRP should be done. When microbiological investigations and blood sampling investigations are not informative then bronchoscopy is a good diagnostic tool especially when multidrug resistant microbes and endobronchial lung cancers are present. Bronchoscopy and bronchoalveolar lavage should be done in such patients.

BAL performed without protected catheters may be contaminated, but there is no evidence that protected BAL is more reliable than conventional BAL. BAL can be done safely and rapidly for diagnosing lower respiratory infections. So the Aim of this study is to evaluate the important role of bronchoscopy and BAL in arriving at a diagnosis in patients with non-resolving pneumonia.

Non Resolving Pneumonia accounts for 15% of pneumonia cases and 8% of bronchoscopies. There are a wide variety of reasons for slow resolution of pneumonia including host factors, etiology, complications following pneumonia etc. non-infectious causes etc. aggravating 20% of non resolving pneumonia cases non-infectious. In this study the clinical, radiological profile of non-resolving pneumonia is studied along with bronchoscopic findings and etiological diagnosis also delineated.

In our study non resolving pneumonia is common in 50-60 years age group accounting to 33% followed by 40-50 years age group with 30%. But in the study done by mohammed et al shabrowy et al showing a mean age of 47.6± 12.2 years. Our study coincided with study done by arunobhai datta choudary et al accounting to 57.33%± 1.71 years of mean age. This is being further supported by study done by Ramesh P M et al showing non resolving pneumonia more common in 57-60 years age group.

Male predominance is noted in our study showing 72.3% and female accounting to 26.7%. Male preponderance is observed in studies done by Mohamed el shabrowy et al, Arunabha et al. Rane et al accounting to 66%, 65%, 80% respectively.

Cough is the predominant symptom followed by the expectoration, shortness of breath. Right upper lobe is the commonest site of non-resolving pneumonia 46.7% of cases showed right lung involvement followed by 38.9% left lung involvement. Bilateral lung involvement is noted in 14.4% of cases. In the study done by Mohamed el shobrawy et al right upper lobe is the predominant site accounting to 25.9%. The same was revealed in study done by Arunabha datta chaudhrani et al accounting to 25% and right lung involvement is seen in 65% of cases.

Among the bronchogenic findings; purulent secretions is mostly observed in 31 casees accounting to 34.4% of cases followed by mucosal inflammation in 24.4% of cases. In the study done by MD majeed pasha et al, mucosal inflammation and purulent secretions are the commonest findings and purulent secretions are the commonest findings observed in 56.25% of cases

Fungal pneumonia are same but one case of mucormycosis was noted in our study. In study dine by Rajesh et al. fungal pneumonia were observed in 3 cases accounting to 5%.Bronchogenic carcinoma was one of the causes of non-resolving pneumonia. 17.8% of caes were noted in our study. The same was observed by study done by Mohammed el al accounting for 13.3% and 26.7% in study done by Arunabha et al1 followed by 24.4% in study done by Ramesh et al. Malignant causes were seen in 10% of each in Rajesh et al.

In our study bacterial etiology is commonly observed in 46% of cases among the cacterial causes pseudomonas is the commonest micro organisms involved in NRP to 26.3% of cases. NRP followed by klebsiella and staphylococcus with 13.3% and 10% of total NRP cases respectively. In the study done by Mohammed el shabrawy et al bacterial pneumonia are the commonest aetiology accounting to 83.7% with BAL gramstain sample positive in 65.4% of cases. Pyogenic organism were isolated in 113 patients with 83.7% by BAL culture.

Similarly pyogenic infection was common aetiology with 53.3% in study done by arunabha et al. our study coincides with study done by Ramesh et al. bacterial pneumonia are more common accounting to 42.2%.

Tuberculoma is the second most common cause next to bacterial infection in our study accounting to 22.2%. The same is the scenario in study done by Ramesh et al with 26.77%, 28.8% respectively. But in study done by mohammed et al tuberculosis was observed only in 2.96%. In study done by Rajesh et al tb is seen in 66.67%.

Conclusion

Fiberoptic bronchoscopy is an excellent aid in diagnosis of non-resolving pneumonia thus enabling to differentiate bacterial pneumonias as well as fungal infection and pulmonary tuberculosis. It also helps to rule out bronchogenic carcinoma.

Limitations

The study sample being small is inadequate to calculate the exact yield of FOB in NRP. Fob in noninfectious causes can’t be evaluated further due to lack of further investigations example wegener’s granulomatosis. TB being endemic in India, FOB gives a higher yield in diagnosis of endobronchial tuberculosis.

Conflict of Interest

There are no conflicts of interest in this article.

Source of Funding

None.