Objective
To discuss the two diagnostic procedures used most frequently to obtain uncontaminated
lower airway secretions during bronchoscopy.
Design
This article reviews the contributing risk factors of ventilator-associated pneumonia
(VAP) and the recent studies that have assessed the usefulness of the protected specimen
brush (PSB) and bronchoalveolar lavage (BAL) in the nonimmunocompromised host.
Results
A prompt, accurate diagnosis of VAP, including specific identification of the bacterial
pathogen, remains a common challenge in the intensive-care unit. Standard clinical
criteria are of suboptimal specificity for making decisions, including selecting antibiotic
therapy. Bronchoscopic techniques of lung secretion sampling can be used in the intensive-care
unit in an effort to overcome the effects of oropharyngeal contamination. The PSB
and BAL, used appropriately, can help intensive-care clinicians formulate specific
antimicrobial therapy. Evaluation of intracellular bacteria obtained by BAL has been
reported to be useful in guiding empiric antibiotic therapy while the final results
of cultures obtained with the PSB are pending. Prior antibiotic therapy, however,
may confound the interpretation and clinical utility of results.
Conclusion
Currently, for a patient taking antibiotic therapy, no reliable technique nor quantitative
culture threshold exists to help in diagnosing suspected VAP or in guiding antibiotic
therapy. If the clinical situation allows, antibiotic therapy should be discontinued
for 48 hours; then, the PSB, BAL, protected BAL, or endobronchial aspiration should
be used. These contemporary modalities, however, necessitate further clinical trials
before widespread use is warranted.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Mayo Clinic ProceedingsAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients.Am Rev Respir Dis. 1990; 142: 523-528
- Stress ulcer prophylaxis and ventilation pneumonia: prevention by antibacterial cytoprotective agents?.Infect Control Hosp Epidemiol. 1988; 9: 59-65
- Nosocomial pneumonia in patients receiving continuous mechanical ventilation: prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques.Am Rev Respir Dis. 1989; 139: 877-884
- Complications of assisted ventilation: a prospective study of 354 consecutive episodes.Am J Med. 1974; 57: 161-170
- Incidence of pneumonia in mechanically ventilated patients treated with sucralfate or cimetidine as prophylaxis for stress bleeding: bacterial colonization of the stomach.Am J Med. 1991; 91: 125S-131S
- Ventilator-associated pneumonia: a multivariate analysis.JAMA. 1993; 270: 1965-1970
- Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation.Am Rev Respir Dis. 1986; 133: 792-796
- Risk of acute stress bleeding and nosocomial pneumonia in ventilated intensive care unit patients: sucralfate versus antacids.Am J Med. 1987; 83: 117-124
- Nosocomial respiratory infections with gram-negative bacilli: the significance of colonization of the respiratory tract.Ann Intern Med. 1972; 77: 701-706
- Bacteriology of hospital-acquired pneumonia.Arch Intern Med. 1986; 146: 868-871
- Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients.Am Rev Respir Dis. 1987; 135: 426-432
- Bacteremic nosocomial pneumonia: analysis of 172 episodes from a single metropolitan area.Am Rev Respir Dis. 1984; 129: 668-671
- Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury.Chest. 1981; 80: 254-258
- Bronchoalveolar lavage.Am Rev Respir Dis. 1987; 135: 250-263
- Detection of nosocomial lung infection in ventilated patients: use of a protected specimen brush and quantitative culture techniques in 147 patients.Am Rev Respir Dis. 1988; 138: 110-116
- Causes of fever and pulmonary infiltrates in mechanically ventilated patients [abstract].Am Rev Respir Dis. 1991; 143: A109
- Hospital-acquired pneumonia: attributable mortality and morbidity.Am J Epidemiol. 1989; 129: 1258-1267
- Epidemiology of nosocomial ventilator-associated pneumonia.Infect Control Hosp Epidemiol. 1993; 14: 163-169
- Ventilator-associated pneumonia in patients with respiratory failure: a diagnostic approach.Chest. 1990; 97: 1208-1219
- The impact of tracheal intubation on host defenses and risks for nosocomial pneumonia.Clin Chest Med. 1991 Sep; 12: 523-543
- Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay.Am J Med. 1993; 94: 281-288
- Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia.Chest. 1993; 104: 1230-1235
- Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients.Chest. 1993; 103: 547-553
- The effect of antibiotic therapy on recovery of intracellular bacteria from bronchoalveolar lavage in suspected ventilator-associated nosocomial pneumonia.Chest. 1993; 103: 541-546
- The standardization of bronchoscopic techniques for ventilator-associated pneumonia.Chest. 1992; 102: 557S-564S
- Bacteriologic diagnosis of nosocomial pneumonia following prolonged mechanical ventilation.Am Rev Respir Dis. 1988; 137: 259-264
- Protected bronchoalveolar lavage: a new bronchoscopic technique to retrieve uncontaminated distal airway secretions.Am Rev Respir Dis. 1991; 143: 855-864
- A reappraisal of blind bronchial sampling in the microbiologic diagnosis of nosocomial bronchopneumonia: a comparative study in ventilated patients.Chest. 1993; 103: 236-242
- A fiberoptic bronchoscopy technique to obtain uncontaminated lower airway secretions for bacterial culture.Am Rev Respir Dis. 1979; 119: 337-343
- Prospective evaluation of the protected specimen brush for the diagnosis of pulmonary infections in ventilated patients.Am Rev Respir Dis. 1984; 130: 924-929
- Use of the protected specimen brush in patients with endotracheal or tracheostomy tubes.Chest. 1987; 91: 233-236
- Diagnosis of nosocomial pneumonia in mechanically ventilated patients: comparison of a plugged telescoping catheter with the protected specimen brush.Am Rev Respir Dis. 1991; 143: 1055-1061
- Diagnostic value of quantitative cultures of bronchoalveolar lavage and telescoping plugged catheters in mechanically ventilated patients with bacterial pneumonia.Am Rev Respir Dis. 1989; 140: 306-310
- Diagnostic efficiency of endotracheal aspirates with quantitative bacterial cultures in intubated patients with suspected pneumonia: comparison with the protected specimen brush.Am Rev Respir Dis. 1993; 148: 138-144
- Specificity of endotracheal aspiration, protected specimen brush, and bronchoalveolar lavage in mechanically ventilated patients.Am Rev Respir Dis. 1993; 147: 952-957
- Evaluation of the protected brush catheter and bronchoalveolar lavage in the diagnosis of nosocomial pneumonia.J Intensive Care Med. 1991; 6: 196-205
- Diagnosis of pneumonia in mechanically ventilated patients: repeatability of the protected specimen brush.Am Rev Respir Dis. 1993; 147: 211-214
- Is protected specimen brush a reproducible method to diagnose ICU-acquired pneumonia?.Chest. 1993; 104: 104-108
- Diagnostic value of telescoping plugged catheters in mechanically ventilated patients with bacterial pneumonia using the Metras catheter.Am Rev Respir Dis. 1988; 138: 117-120
- Role of bronchoalveolar lavage in the diagnosis of pneumonia.Chest. 1989; 95: 187S-190S
- Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host.Ann Intern Med. 1984; 101: 1-7
- Lung biopsy.Adv Intern Med. 1992; 37: 337-361
- Quantification of BAL cells containing intracellular bacteria rapidly identifies ventilated patients with nosocomial pneumonia.Chest. 1989; 95: 190S-192S
- Diagnosing bacterial respiratory infection by bronchoalveolar lavage.J Infect Dis. 1987; 155: 862-869
- Diagnosis of nosocomial bacterial pneumonia in intubated patients undergoing ventilation: comparison of the usefulness of bronchoalveolar lavage and the protected specimen brush.Am J Med. 1988; 85: 499-506
- Nosocomial bronchopneumonia in the critically ill: histologic and bacteriologic aspects.Am Rev Respir Dis. 1992; 146: 1059-1066
- Comparison of nonbronchoscopic bronchoalveolar lavage to open lung biopsy for the bacteriologic diagnosis of pulmonary infections in mechanically ventilated patients.Intensive Care Med. 1989; 15: 94-98
- Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid.Am Rev Respir Dis. 1991; 143: 1121-1129
- Diagnostic value of nonbronchoscopic bronchoalveolar lavage during mechanical ventilation [letter].Chest. 1988; 93: 223
- Validation of different techniques for the diagnosis of ventilator-associated pneumonia: comparison with immediate postmortem pulmonary biopsy.Am J Respir Crit Care Med. 1994; 149: 324-331
Article Info
Identification
Copyright
© 1994 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
