EFEKTIVITAS TINDAKAN BRONHOALVEOLAR LAVAGE DALAM PENEGAKAN DIAGNOSIS TUBERKULOSIS PARU PADA PASIEN YANG KESULITAN MENGELUARKAN SPUTUM

Ade Yudisman¹, Prayudi Santoso², Arto Yuwono Soeroto²

¹Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran/ RSUP Dr Hasan Sadikin Bandung

²Divisi Respirologi dan Penyakit Kritis Respirasi, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran/ RSUP Dr Hasan Sadikin Bandung

 Corresponding Author:

Ade Yudisman. 1Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran/ RSUP Dr Hasan Sadikin Bandung Jl Pasteur No. 38, Bandung, 10430, Indonesia. E-mail: yudismanade@yahoo.com

Abstrak

Latar belakang: Pemeriksaan Bakteri Tahan Asam (BTA) dan Test Cepat Molekular (TCM) pada penegakkan diagnosis TB Paru memerlukan specimen sputum. Penegakkan diagnosis menjadi sulit, bila sputum tidak didapatkan. Hal ini dapat menimbulkan overdiagnosis atau overtreatment serta undertreatment, terutama pada kasus terduga TBC resisten obat atau TB paru kasus kambuh dengan gejala klinis dan hasil interpretasi foto toraks yang menggambarkan TB namun tidak berhasil mendapatkan hasil bakteriologis. Pada kasus pasien tersebut, maka sputum untuk pemeriksaan bakteriologis bisa didapat melalui prosedur Bronhoalveolar Lavage (BAL) dengan menggunakan bronkoskopi.  Hasilnya dapat membantu klinisi untuk tidak ragu-ragu memberikan terapi TB paru sensitif atau resisten obat, bahkan mungkin pasien tidak diberikan Obat anti Tuberkulosa (OAT) sama sekali. Metode: Penelitian kohort-retrospektif data primer yang diperoleh dari rekam medis dalam rentang januari 2023 sampai november 2024 di RSUD Cibabat. Subjek penelitian adalah pasien presumptive TB kasus baru dan kambuh dengan gejala klinis dan interpretasi gambaran toraks TB paru. Spesimen yang digunakan adalah hasil BAL menggunakan bronkoskopi fleksibel sebanyak > 5 cc. Spesimen dilakukan pemeriksaan BTA dengan pewarnaan Ziehl Neelsen (ZN), dan pemeriksaan TCM Ultra. Hasil: Dari 122 pasien presumptive TB baru, hasil dengan TCM positif 115 (94,3%), dan 7 (5,7%) yang negatif. Pada 34 pasien presumptive TB kambuh, subjek dengan hasil BTA positif adalah 4 (11,7%), sekaligus kesemuanya mendapatkan hasil TCM positif pula. Kesimpulan: BAL efektif untuk mendapatkan sputum bagi pasien yang tidak dapat mengeluarkan sputum spontan atau dengan kualitas buruk, sehingga menghindari keterlambatan diagnosis, mencegah overdiagnosis dan undertreatment. TCM sangat sensitif untuk kasus baru namun butuh hasil BTA positif pada diagnosis TB paru kasus kambuh.

Kata kunci: tuberkulosis paru, bronchoalveolar lavage, TCM, BTA, Brokoskopi

Abstract

Background: Bacteriological examinations of Acid-Fast Bacilli (AFB) and the Molecular Rapid Test (Xpert MTB/RIF test) for diagnosing pulmonary tuberculosis (TB) require sputum specimens. Diagnosis becomes challenging when sputum is unavailable, potentially leading to overdiagnosis, overtreatment, or undertreatment, particularly in cases of drug-resistant TB or recurrent pulmonary TB with clinical symptoms and chest radiographs suggestive of pulmonary TB but without bacteriological confirmation. In patients who have difficulty expectorating sputum, a specimen for bacteriological examination can be obtained through Bronchoalveolar Lavage (BAL) using bronchoscopy. The results can assist clinicians in making precise decisions, such as initiating therapy for drug-sensitive or drug-resistant pulmonary TB, or even refraining from administering Anti-Tuberculosis Drugs (ATDs) altogether. Methods: This retrospective cohort study utilized primary data collected from medical records between January 2023 and November 2024 at Cibabat General Hospital. The study subjects were presumptive new and recurrent pulmonary TB cases with clinical symptoms and chest X-ray interpretations suggestive of pulmonary TB, as reported in the Tuberculosis Information System of the Ministry of Health of the Republic of Indonesia. Specimens were obtained through BAL using flexible bronchoscopy, collecting >5 mL into sputum containers. The specimens were examined for AFB using Ziehl-Neelsen (ZN) staining and Xpert MTB/RIF test Ultra testing, including rifampicin resistance detection. Results: Among the group of presumptive new pulmonary TB cases, 115 (94.3%) of 122 subjects tested positive by Xpert MTB/RIF test, while only 7 (5.7%) were negative. In the group of presumptive recurrent pulmonary TB cases, 4 (11.7%) of 34 subjects tested positive for AFB, and all of these also tested positive by Xpert MTB/RIF test. Conclusion: BAL is a viable solution for obtaining sputum samples for bacteriological examination in patients unable to produce spontaneous or high-quality sputum. This approach can prevent delays in tuberculosis diagnosis, avoid overdiagnosis, and reduce undertreatment. Furthermore, MTB detection through BAL can identify drug resistance and assess the high risk of transmission. This facilitates timely diagnosis, appropriate therapy, and rapid contact investigation measures. While Xpert MTB/RIF test is highly sensitive for diagnosing new cases, positive AFB results remain critical for diagnosing recurrent pulmonary TB cases.

Keywords: pulmonary tuberculosis, bronchoalveolar lavage, AFB, bronchoscopy