Relationship between tracheobronchoscopic score and bronchoalveolar lavage red blood cell numbers in the diagnosis of exercise-induced pulmonary hemorrhage in horses

Background Exercise-induced pulmonary hemorrhage (EIPH) is diagnosed and its severity assessed by post-exercise tracheobronchoscopy, and enumeration of bronchoalveolar lavage fluid red blood cells (BALFRBC). Minimal information is available regarding the relationship of tracheobronchoscopy score to BALFRBC number. Objective Evaluate the relationship between BALFRBC number and tracheobronchoscopy scores and determine their diagnostic sensitivities. Animals Nine sedentary horses, 21 fit Thoroughbreds, 129 Barrel Racers. Methods Normal BALFRBC number and the effect of bronchoalveolar lavage (BAL) on it were evaluated by performing 2 BALs 24 hours apart in sedentary horses. Tracheobronchoscopy followed by BAL was performed 247 times on 150 horses after treadmill, racetrack, or barrel racing exercise. Lastly, a BALFRBC diagnostic threshold number that optimized the geometric mean of the sensitivity and precision (F1-score) was determined using Bayesian analysis. Results No increase in BALFRBC occurred after the second BAL (mean +/- SD, 304 +/- 173/mu L). Tracheobronchoscopy scores ranged from 0 (n = 112) to 4 (n = 4) and BALFRBC ranged from 102 to 4605268/mu L. Spearman correlation between tracheobronchoscopy score and BALFRBC was weak (P < .001; rs = 0.42) with large ranges of BALFRBC associated with each tracheobronchoscopy score. The highest F1-score occurred for a BALFRBC threshold number = 992/mu L. Seventy-five tracheobronchoscopy scores equaled 0 although BALFRBC number was >= 992/mu L. Sensitivity of tracheobronchoscopy for diagnosing EIPH was poor (0.59; 95% confidence intervals [CI], 0.49-0.68), compared to BALFRBC number >= 992/mu L (0.93; 95% CI, 0.88-0.96). Conclusions and Clinical Importance False negatives are common with tracheobronchoscopy. Follow-up determination of BALFRBC may be indicated for tracheobronchoscopy scores = 0 before EIPH can be ruled out.