The Longitudinal Impact of Respiratory Viruses on Bronchiolitis Obliterans Syndrome After Allogeneic Hematopoietic Cell Transplantation (The RV-BOS Study)

Study Overview
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Brief Summary
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This observational trial studies whether respiratory viruses are the cause of lung disease (bronchiolitis obliterans syndrome [BOS] or graft-versus-host disease of the lung) and changes in lung function in patients who have received a donor stem cell transplant. Patients with chronic graft-versus-host disease (cGVHD) are at higher risk of developing BOS. Studies have also shown that patients who had a respiratory viral illness early after their transplant are at higher risk of developing lung problems later on. Patients who are at risk and who already have BOS might benefit from being monitored more closely. Spirometry is a way of assessing a patient's lung function and is often used to diagnose lung disease. Spirometry measured at home with a simple handheld device may reduce the burden of performing pulmonary function testing at a facility and potentially help patients get their lung disease diagnosed and treated sooner.

Detailed Description
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OUTLINE: Patients undergo home spirometry measurements with a portable handheld spirometer and complete questionnaires weekly, a nasal swab for viral polymerase chain reaction (PCR) surveillance bi-weekly, and undergo blood collection and nasal swabs every 3 months for up to 1 year.

Official Title
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The Longitudinal Impact of Respiratory Viruses on Bronchiolitis Obliterans Syndrome After Allogeneic Hematopoietic Cell Transplantation (The RV-BOS Study)

Conditions
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Bronchiolitis Obliterans Syndrome, Hematopoietic and Lymphoid Cell Neoplasm

Intervention / Treatment
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* Procedure: Home spirometry
* Procedure: Biospecimen Collection
* Other: Questionnaire Administration


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Allogeneic HCT recipients with any indication, graft source, donor type, or conditioning regimen Age 8 and older COHORT 1 Inclusion criteria: One or more of the following clinical scenarios that encompass increased risk for BOS: A diagnosis of cGVHD as per NIH criteria through 5 years of diagnosis. i. New diagnosis of cGVHD within 3 months. ii. A diagnosis of cGVHD > 3 months < 5 years with a new FEV1 decline of >10% in absolute compared with prior 2 years PFT. iii. A recent documented respiratory infection of any etiology that has been clinically managed and stabilized or improving as determined by a clinician, within 8 weeks. iv. Progression of flare of chronic GVHD requiring an alteration in therapy as determined by a clinician, within 3 months. At Day 80 evaluation. D80 designates a time frame D70-120 posttransplant to account for local variations in posttransplant care. i. FEV1 decline of 10% in absolute values compared with pretransplant baseline. ii. Documented posttransplant RVI. iii. Lower respiratory tract disease (LRTD) of any etiology. COHORT 2 inclusion criteria: Newly diagnosed BOS within 6 weeks of clinical recognition. This may include the following scenarios: Early BOS, ie patients with new airflow decline and obstruction, not yet meeting the FEV1 cut-off of < 75% predicted by FEV1, in the absence of other etiologies as determined by clinical investigations including chest imaging and microbiologic studies. NIH-defined BOS: i. FEV1 < 75% predicted, with a decline in absolute FEV1 > 10% compared to pretransplant baseline or within the prior 2 years. Absolute decline in FEV1 should remain >10% after bronchodilator response. ii. FEV1/FVC or FEV1/VC <0.7, or Lower Limit of Normal as per accepted reference standards. Reference standards may include National Health and Nutrition Examination Survey III or Global Lung Initiative. iii. Absence of an alternative diagnosis, including COPD exacerbation, asthma, and active respiratory tract infection, as determined by appropriate clinical investigationsthat may include chest imaging, microbiologic cultures, and/or bronchoscopy. iv. One of two supportive features of BOS: a. Evidence of air trapping by PFTs: RV>120%, or elevated RV/TLC (>20% of predicted value) b. High resolution chest CT with inspiratory and expiratory cuts that show findings that are consistent with small airways disease including (but not exclusive of) air trapping, bronchial wall thickening, or bronchiectasis. BOS with atypical spirometric pattern i. FEV1 <80%, with a preserved FEV1/FVC ratio (>0.7) and TLC >80% in the absence of other clinically determined lung disease. Clinical or suspected diagnosis of BOS not otherwise meeting above criteria. Patient should have an Android or iOS-based smartphone with reliable access to Wi-Fi for data to be transmitted electronically. Android smartphones should have a software version of 4.0 or higher; iOS phones should have a version of 8.0 or higher. Patient should be willing and able to communicate electronically in English. Exclusion Criteria: Life expectancy < 2 years. Diagnosis of active hematologic relapse or malignancy requiring active treatment that will affect that patient's ability to comply with study procedures. Patient should not have a clinically acute active lower respiratory tract infection or a clinically acute active noninfectious respiratory condition (i.e. COPD exacerbation, pleural effusion) at the time of enrollment. However, patient may become eligible once these conditions have stabilized or resolved as noted above. Inability or unwillingness to perform the study procedures, most of which are performed at home. Lack of a personal iOS or Android smartphone. Inability or unwillingness to communicate electronically.

Ages Eligible for Study
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Minimum Age: 8 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Screening (spirometry measurements)<br>Patients undergo home spirometry measurements with a portable handheld spirometer and complete questionnaires weekly, a nasal swab for viral polymerase chain reaction (PCR) surveillance bi-weekly, and undergo blood collection and nasal swabs every 3 months for up to 2 years. | Procedure: Home spirometry<br>* Undergo spirometry measurements<br>* Other names: SPIROMETRY;Procedure: Biospecimen Collection<br>* Undergo nasal and/or oral swabs, and blood collection<br>* Other names: Specimen Collection;Other: Questionnaire Administration<br>* Complete questionnaires<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence of bronchiolitis obliterans syndrome (BOS) | Diagnosed by National Institute of Health criteria or clinical diagnosis in the absence of alternative diagnosis. | Up to 2 years | 
| Pulmonary impairment | Defined by temporal decline in forced expiratory volume in the first second (FEV1) determined by assessment of spirometry data. | Up to 2 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time from respiratory viral infection and chronic graft-versus-host disease to FEV1 decline |  | Up to 2 years | 
| FEV1 (percent predicted) at clinical recognition of BOS |  | Up to 2 years | 
| Incidence of asymptomatic and symptomatic viral infections | Will be determined by the longitudinal follow-up of this observational study. | Up to 2 years | 
| Incidence of late onset noninfectious pulmonary complications | Will be determined by the longitudinal follow-up of this observational study. Follow-up of clinical encounters will provide an epidemiology of the incidence of noninfectious and infectious pulmonary complications. | Up to 2 years | 
| Incidence of non-viral infectious pulmonary complications | Will be determined by the longitudinal follow-up of this observational study. Follow-up of clinical encounters will provide an epidemiology of the incidence of noninfectious and infectious pulmonary complications. | Up to 2 years | 
| Establishment of a biorepository that includes blood samples, respiratory viral samples, and nasal microbiome samples from patients with clinically recognized BOS | The biorepository including self-collected samples will be catalogued and organized in a central location that can be easily accessed through a gatekeeper system. | Up to 2 years |