Study design (if review, criteria of inclusion for studies)
Randomized controlled studies
List of included studies (1)
Children and adults with CF
Therapies guided by the results of bronchoscopy (including bronchoalveolar lavage or protected bronchial brush sampling) vs therapies guided by the results of any other type of sampling (including cultures from sputum, throat swab and cough swab).
Primary outcomes: lung function (FEV1, FVC), infant lung function (FEV0,5, FVC, FEF25-75, FEF75), LCI; CT; weight (kg or percentile), BMI (percentile)
The search identified 11 studies, but we only included one study enrolling infants with cystic fibrosis under six months of age and diagnosed through newborn screening (170 enrolled); participants were followed until they were five years old (data from 157 children). The study compared outcomes following therapy directed by bronchoalveolar lavage for pulmonary exacerbations with standard treatment based on clinical features and oropharyngeal cultures. We considered this study to have a low risk of bias; however, the statistical power to detect a significant difference in the prevalence of Pseudomonas aeruginosa was limited due to the prevalence (of Pseudomonas aeruginosa isolation in bronchoalveolar lavage samples at five years age) being much lower in both the groups compared to that which was expected and which was used for the power calculation. The sample size was adequate to detect a difference in highâresolution computed tomography scoring. The quality of evidence for the key parameters was graded as low except highâresolution computed tomography scoring and cost of care analysis, which were graded as moderate quality. At five years of age, there was no clear benefit of bronchoalveolar lavageâdirected therapy on lung function z scores or nutritional parameters. Evaluation of total and component highâresolution computed tomography scores showed no significant difference in evidence of structural lung disease in the two groups. In addition, this study did not show any difference between the number of isolates of Pseudomonas aeruginosa per child per year diagnosed in the bronchoalveolar lavageâdirected therapy group compared to the standard therapy group. The eradication rate following one or two courses of eradication treatment was comparable in the two groups, as were the number of pulmonary exacerbations. However, the number of hospitalizations was significantly higher in the bronchoalveolar lavageâdirected therapy group, but the mean duration of hospitalizations was significantly less compared to the standard therapy group. Mild adverse events were reported in a proportion of participants, but these were generally wellâtolerated. The most common adverse event reported was transient worsening of cough after 29% of procedures. Significant clinical deterioration was documented during or within 24 hours of bronchoalveolar lavage in 4.8% of procedures.
This review, limited to a single, wellâdesigned randomized controlled study, shows no clear evidence to support the routine use of bronchoalveolar lavage for the diagnosis and management of pulmonary infection in preâschool children with cystic fibrosis compared to the standard practice of providing treatment based on results of oropharyngeal culture and clinical symptoms. No evidence was available for adult and adolescent populations.