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SUBOPTIMAL SENSITIVITY OF RADIOGRAPHIC AND ENDOSCOPIC TESTS FOR ASPIRATION IN LUNG TRANSPLANT RECIPIENTS

      TOPIC: Transplantation
      TYPE: Original Investigations
      PURPOSE: Aspiration is the diversion of food or liquid into the trachea, and the high incidence and potentially detrimental impact in lung transplant recipients has been documented. (Atkins J Heart Lung Transpl 2007; 26:1144-8) Currently, imaging and endoscopic techniques are used to diagnose aspiration, however the sensitivity of such techniques is not well studied. We evaluated the sensitivity of these techniques to diagnose aspiration as compared with lung tissue examination in a population of lung transplant recipients with and without aspiration.
      METHODS: A retrospective evaluation of 193 consecutive patients who underwent lung transplantation between January 1, 2015 and June 30, 2019 was performed. All patients underwent surveillance bronchoscopy with transbronchial biopsy as tolerated at 1, 3, 6, 9, and 12 months post-transplantation and as clinically indicated. Two pulmonary pathologists reviewed all specimens. The following features identified in either explanted lungs or transbronchial biopsies were considered consistent with pathologic aspiration: 1) granulomas with vegetable matter, 2) multinucleated giant cell with intracytoplasmic lipids, or 3) lipogranulomas. Videofluoroscopic swallow, barium esophagram and fiberoptic endoscopic evaluation of swallowing (FEES) were performed when clinically indicated.
      RESULTS: Pathologic review identified aspiration in 40 patients (20.7%); 153 patients (79.3%) had no evidence of aspiration. Pathologic aspiration was present in 12/52 (23.1%) patients in whom videofluoroscopic swallow was performed. Sensitivity, specificity, positive and negative predictive value of any aspiration (thin, thick or puree) for the diagnosis of pathologic aspiration was 25%, 67%, 18% and 75%, respectively. Pathologic aspiration was present in 15/60 (25%) patients in whom barium esophagram was performed. Sensitivity, specificity, positive and negative predictive value of radiographic reflux for the diagnosis of pathologic aspiration was 13%, 88%, 28% and 75%, respectively. Pathologic aspiration was present in 9/49 (18.3%) patients in whom FEES was performed. Sensitivity, specificity, positive and negative predictive value of thin liquid aspiration for the diagnosis of pathologic aspiration was 44%, 45%, 15% and 78%, respectively.
      CONCLUSIONS: Imaging and endoscopic techniques have suboptimal sensitivity for the diagnosis of biopsy proven aspiration in lung transplant recipients. Bronchoscopy and transbronchial biopsy for pathologic review may be appropriate for patients in whom aspiration is undiagnosed but strongly suspected.
      CLINICAL IMPLICATIONS: Aspiration has a high incidence in lung transplant recipients with the potential to adversely impact otucomes. Standard imaging and endoscopic techniques may have reduced sensitivity for the diagnosis of aspiration in lung transplant recipients. A high index of suspicion for undiagnosed aspiration may be warranted in this population.
      DISCLOSURES: No relevant relationships by Viju Ananthanarayanan, source=Web Response
      No relevant relationships by Colby Baker, source=Web Response
      Advisory relationship with United Therapeutics Please note: 6.2020 to 3.30.2021 Added 04/28/2021 by James Gagermeier, source=Web Response, value=Consulting
      No relevant relationships by Love Patel, source=Web Response
      No relevant relationships by Karen Sayad, source=Web Response
      No relevant relationships by Mukund Venu, source=Web Response
      No relevant relationships by Krishnan Warrior, source=Web Response