CHEST Guidelines-Rebuttal-From-Drs-Mooney-and Collard_2017

Rebuttal-From-Drs-Mooney-and Collard_2017_che (1)

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The article explores the debate on using bronchoalveolar lavage (BAL) in diagnosing idiopathic pulmonary fibrosis (IPF). BAL, an invasive procedure analyzing cells from the lungs, can aid in distinguishing IPF from other diseases like chronic hypersensitivity pneumonitis (HP) but is not conclusive on its own.<br /><br />Wells and Kokosi advocate for BAL usage due to its potential to rationalize further tests and reduce unnecessary surgical lung biopsies (SLBs). They emphasize BAL's role in guiding SLB choices and identifying inciting antigens, particularly important given the associated mortality risk of SLB in severe IPF cases, which can approach 2%. The introduction of antifibrotic therapies exclusive to IPF underscores the need for accurate diagnosis.<br /><br />Mooney and Collard, however, argue against the routine use of BAL, citing insufficient data on BAL lymphocytosis's specificity for non-IPF diseases, potentially misguiding diagnosis and treatment. They note that while BAL can suggest HP, it may also misclassify IPF patients, depriving them of essential treatments. They call for a prospective evaluation of BAL's test characteristics within the current IPF classification framework to determine its reliability and necessity in routine diagnostics.<br /><br />The consensus among authors is that BAL could help exclude chronic HP by assessing lymphocyte counts, yet its reliability needs further verification. Two common scenarios in IPF evaluation involve patients with definite or possible radiographic patterns. In these cases, BAL's findings must significantly raise IPF probability to avoid SLBs, yet present data shows BAL lacks sufficient specificity.<br /><br />A future task is distinguishing between scenarios where diagnosis is clear and where it's not, to avoid "meaningless mean recommendations" and ensure diagnostic clarity.

Keywords

bronchoalveolar lavage

idiopathic pulmonary fibrosis

chronic hypersensitivity pneumonitis

surgical lung biopsies

antifibrotic therapies

diagnostic accuracy

lymphocytosis

radiographic patterns

test specificity

diagnostic clarity