Bronchoalveolar Lavage to Diagnose Respiratory Infections

ABSTRACT

Respiratory samples obtained by bronchoalveolar lavage (BAL) in infectious processes provide important microbiological and cytological information to manage this type of patient. Most of the clinical and experimental BAL investigations have been done in ventilator-associated pneumonia (VAP) and in immunosuppressed conditions. The impact of quantitative BAL bacterial cultures for managing VAP is still controversial. However, there is no doubt that this method provides sensitive and specific information on bacterial, viral, fungal, and noninfectious etiologies. The conclusion is that BAL has to be used in VAP depending on the clinical situation of the patient and taking into account the local expertise and laboratory facilities. In immunosuppressed patients with pulmonary infiltrates its utility has been clearly demonstrated. In this specific population the early use of the information provided by this method is related to a better outcome. In community-acquired pneumonia there is no strong information supporting its use. This technique has some side effects and contraindications that have been weighted individually in each patient.

Bronchoalveolar lavage - ventilator-associated pneumonia - immunosuppressed - pulmonary infiltrates

REFERENCES

• 1 Ewig S, Bauer T, Hasper E, Marklein G, Kubini R, Lüderitz B. Value of routine investigation in community-acquired pneumonia in a tertiary care centre.  Respiration. 1996;  63 164-169
• 2 Rasmusen T R, Korsgaard J, Møller J K, Sommer T, Kilian M. Quantitative culture of bronchoalveolar lavage fluid in community-acquired lower respiratory tract infections.  Respir Med. 2001;  95 885-890
• 3 Hohenthal U, Sipilä J, Vainionpää R et al.. Diagnostic value of bronchoalveolar lavage in community-acquired pneumonia in a routine setting: a study on patients treated in a Finnish university hospital.  Scand J Infect Dis. 2004;  36 198-203
• 4 Luna C M, Aruj P, Niederman M S et al.. Appropriateness and delay to initiate therapy in ventilator-associated pneumonia.  Eur Respir J. 2006;  27 158-164
• 5 Kollef M H, Sherman G, Ward S, Fraser V J. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients.  Chest. 1999;  115 462-474
• 6 Iregui M, Ward S, Sherman G, Fraser V J, Kollef M H. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia.  Chest. 2002;  122 262-268
• 7 Alaverz-Lermaf . Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group.  Intensive Care Med. 1996;  22 387-394
• 8 Luna C M, Vujacich P, Niederman M S et al.. Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.  Chest. 1997;  111 676-685
• 9 Kollef M, Niederman M S. Antimicrobial resistance in the ICU: the time for action is now.  Crit Care Med. 2001;  29(Suppl 4) N63
• 10 Kollef M H, Fraser V J. Antibiotic resistance in the intensive care unit.  Ann Intern Med. 2001;  134 298-314
• 11 Bonten M J, Bergmans D C, Stobberingh E E et al.. Implementation of bronchoscopic techniques in the diagnosis of ventilador-associated pneumonia to reduce antibiotic use.  Am J Respir Crit Care Med. 1997;  156 1820-1824
• 12 Fagon J Y, Chastre J, Wolf M et al.. Invasive and non-invasive strategies for management of suspected ventilator-associated pneumonia: a randomized trial.  Ann Intern Med. 2000;  132 621-630
• 13 Kollef M H, Kollef K E. Antibiotic utilizaton and outcomes for patients with clinically suspected ventilator-associated pneumonia and negative quantitative BAL culture results.  Chest. 2005;  128 2706-2713
• 14 Fagon J Y. Diagnosis and treatment of ventilator-associated pneumonia: fiberoptic bronchoscopy with bronchoalveolar lavage is essential.  Semin Respir Crit Care Med. 2006;  27 34-44
• 15 Torres A, El-Ebiary M. Bronchoscopic BAL in the diagnosis of ventilator-associated pneumonia.  Chest. 2000;  117 198S-202S
• 16 Ioanas M, Ferrer R, Angrill J, Ferrer M, Torres A. Microbial investigation in ventilator-associated pneumonia.  Eur Respir J. 2001;  17 791-801
• 17 Kirtland S H, Corley D E, Winterbauer R H et al.. The diagnosis of ventilator-associated pneumonia: a comparison of histologic, microbiologic and clinical criteria.  Chest. 1997;  112 445-457
• 18 Marquette C H, Copin M C, Ballet F et al.. Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard.  Am J Respir Crit Care Med. 1995;  151 1878-1888
• 19 Torres A, el-Ebiary M, Padro L et al.. 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
• 20 Torres A, Fabregas N, Ewig S, de la Bellacasa J P, Bauer T T, Ramirez J. Sampling methods for ventilator-associated pneumonia: validation using different histologic and microbiological referents.  Crit Care Med. 2000;  28 2799-2804
• 21 Fabregas N, Ewig S, Torres A et al.. Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies.  Thorax. 1999;  54 867-873
• 22 Papazian L, Thomas P, Garbe L et al.. Bronchoscopic or blind sampling techniques for the diagnosis of ventilator-associated pneumonia.  Am J Respir Crit Care Med. 1995;  152 1982-1991
• 23 Chastre J, Fagon J Y, Bornet-Lecso M et al.. Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia.  Am J Respir Crit Care Med. 1995;  152 231-240
• 24 Nseir S, Marquette C H. Diagnosis of hospital-acquired pneumonia: postmortem studies.  Infect Dis Clin North Am. 2003;  17 707-716
• 25 Montravers P, Gauzit R, Dombret R. Cardiopulmonary effects of bronchoalveolar lavage in critically ill patients.  Chest. 1993;  104 1541-1547
• 26 Guerra L F, Baughman R. Use of bronchoalveolar lavage to diagnose pneumonia in mechanically ventilated patients.  Crit Care Med. 1990;  18 169-173
• 27 Hernández C, El-Ebiary M, Torres A. Side-effects of two different types of protected bronchoalveolar lavage in mechanically ventilated patients [abstract].  Am J Respir Crit Care Med. 1997;  155(Suppl) A397
• 28 Steinberg K P, Mitchell D R, Maunder R J et al.. Safety of bronchoalveolar lavage in patients with adult respiratory distress syndrome.  Am Rev Respir Dis. 1993;  148 556-561
• 29 Pugin J, Suter P. Diagnostic bronchoalveolar lavage in patients with pneumonia produces sepsis-like systemic effects.  Intensive Care Med. 1992;  18 6-10
• 30 Torres A, Martos A, Puig de la Bellacasa J et al.. Specificity of endotracheal aspiration, protected specimen brush, and bronchoalveolar lavage in mechanically ventilated patients.  Am Rev Respir Dis. 1993;  147 952-957
• 31 Bergmans D C, Bonten M J, de Leeuw P W, Stobberingh E E. Reproducibility of quantitative cultures of endotracheal aspirates from mechanically ventilated patients.  J Clin Microbiol. 1997;  35 796-798
• 32 Elatrous S, Boukef R, Ouanes Besbes L et al.. Diagnosis of ventilator-associated pneumonia: agreement between quantitative cultures of endotracheal aspiration and plugged telescoping catheter.  Intensive Care Med. 2004;  30 853-858
• 33 Valencia Arango M, Torres Marti A, Insausti Ordenana J et al.. Diagnostic value of quantitative endotracheal aspirate in ventilator-associated pneumonia: a multicenter study.  Arch Bronconeumol. 2003;  39 394-399
• 34 Heyland D K, Cook D J, Marshall J et al.. The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia.  Chest. 1999;  115 1076-1084
• 35 Sole-Violan J, Arroyo J, Bordes A, Cardeñosa J A, Rodríguez F. Impact of quantitative invasive diagnostic techniques in the management and outcome of mechanically ventilated patients with suspected pneumonia.  Crit Care Med. 2000;  28 2737-2741
• 36 Sanchez-Nieto J M, Torres A, Garcia-Cordoba F et al.. Impact of invasive and noninvasive quantitative culture sampling on outcome of ventilator-associated pneumonia: a pilot study.  Am J Respir Crit Care Med. 1998;  157 371-376
• 37 Ruiz M, Torres A, Ewig S et al.. Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome.  Am J Respir Crit Care Med. 2000;  162 119-152
• 38 The Canadian Critical Care Trials Group . A randomized trial of diagnostic techniques for ventilator-associated pneumonia.  N Engl J Med. 2006;  355 2619-2630
• 39 Shorr A F, Sherner J H, Jackson W L, Kollef M H. Invasive approaches to the diagnosis of ventilator-associated pneumonia: a meta-analysis.  Crit Care Med. 2005;  33 46-53
• 40 Kollef M H. Diagnosis of ventilator-associated pneumonia.  N Engl J Med. 2006;  355 2691-2693
• 41 Kahn F W, Jones J M. Analysis of bronchoalveolar lavage specimens from immunocompromised patients with a protocol applicable in the microbiology laboratory.  J Clin Microbiol. 1988;  26 1150-1155
• 42 Papazian L, Autillo Touati A, Thomas P et al.. Diagnosis of ventilator-associated pneumonia: an evaluation of direct examination and presence of intracellular organisms.  Anesthesiology. 1997;  87 268-276
• 43 Meduri G U, Reddy R C, Stanley T, El-Zeky F. Pneumonia in acute respiratory distress syndrome: a prospective evaluation of bilateral bronchoscopic sampling.  Am J Respir Crit Care Med. 1998;  158 870-875
• 44 Timsit J F, Cheval C, Gachot B et al.. Usefulness of a strategy based on bronchoscopy with direct examination of bronchoalveolar lavage fluid in the initial antibiotic therapy of suspected ventilator-associated pneumonia.  Intensive Care Med. 2001;  27 640-647
• 45 Allaouchiche B, Jaumain H, Chassard D, Bouletrau P. Gram stain on bronchoalveolar lavage fluid in the early diagnosis of ventilator-associated pneumonia.  Br J Anaesth. 1999;  83 845-849
• 46 Dupont H, Chalhoub V, Platefeve G et al.. Variation of infected cell count in bronchoalveolar lavage and timing of ventilator-associated pneumonia.  Intensive Care Med. 2004;  30 1557-1563
• 47 Meduri G U, Chastre J. The standardization of bronchoscopic techniques for ventilator-associated pneumonia.  Chest. 1992;  102 557S-564S
• 48 Gerbeaux P, Laedoray V, Boussuges A, Molenat F, Jean P, Sainty J M. Diagnosis of nosocomial pneumonia in mechanically ventilated patients: repeatability of the bronchoalveolar lavage.  Am J Respir Crit Care Med. 1998;  157 76-80
• 49 Baker A M, Bowton D L, Haponik E F. Decision making in nosocomial pneumonia: an analytic approach to the interpretation of quantitative bronchoscopic cultures.  Chest. 1995;  107 85-95
• 50 Gibot S, Cravoisy A, Levy B et al.. Soluble triggering receptor expressed on myeloid cells and the diagnosis of pneumonia.  N Engl J Med. 2004;  350 451-458
• 51 Millo J L, Schultz M J, Williams C et al.. Compartmentalisation of cytokines and cytokine inhibitors in ventilator-associated pneumonia.  Intensive Care Med. 2004;  30 68-74
• 52 Shorr A F, Moores L K, Edenfield W J. Mechanical ventilation in hematopoietic stem cell transplantation: can we effectively predict outcomes?.  Chest. 1999;  116 1012-1018
• 53 Shorr A F, Susla G M, O'Grady N P. Pulmonary infiltrates in the non-HIV- infected immunocompromised patient.  Chest. 2004;  125 260-271
• 54 Rañó A, Agustí C, Sibila O, Torres A. Pulmonary infections in non-HIV-immunocompromised patients.  Curr Opin Pulm Med. 2005;  11 213-217
• 55 Feller-Kopman D, Ernst A. The role of bronchoalveolar lavage in the immunocompromised host.  Semin Respir Infect. 2003;  18 87-94
• 56 Rañó A, Agusti C, Benito N et al.. Prognostic factors of non-HIV immunocompromised patients with pulmonary infiltrates.  Chest. 2002;  122 253-261
• 57 Rañó A, Agustí C, Jimenez P et al.. Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures.  Thorax. 2001;  56 379-387
• 58 Hohenadel I A, Kiworr M, Genitsariotis R, Zeidler D, Lorenz J. Role of bronchoalveolar lavage in immunocompromised patients with pneumonia treated with broad spectrum antibiotic and antifungal regimen.  Thorax. 2001;  56 115-120
• 59 von Eiff M, Zuhlsdorf M, Roos N, Thomas M, Buschner T, van de Loo J. Pulmonary infiltrates in patients with haematologic malignancies: clinical usefulness of noninvasive bronchoscopic procedures.  Eur J Haematol. 1995;  54 157-162
• 60 Glazer M, Breuer R, Berkman N et al.. Use of fiberoptic bronchoscopy in bone marrow transplant recipients.  Acta Haematol. 1998;  99 22-26
• 61 Stover D E, Zaman M B, Hajdu S I, Lange M, Gold J, Armstrong D. Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host.  Ann Intern Med. 1984;  101 1-7
• 62 Jain P, Sandur S, Meli Y, Arroliga A C, Stoller J K, Mehta A C. Role of flexible bronchoscopy in immunocompromised patients with lung infiltrates.  Chest. 2004;  125 712-722
• 63 Huaringa A J, Leyva F J, Signes-Costa J et al.. Bronchoalveolar lavage in the diagnosis of pulmonary complications of bone marrow transplant patients.  Bone Marrow Transplant. 2000;  25 975-979
• 64 Agusti C, Rañó A, Filella X et al.. Pulmonary infiltrates in patients receiving long-term glucocorticoid.  Chest. 2003;  123 488-498
• 65 Campbell J H, Blessing N, Burnett A K, Stevenson R D. Investigation and management of pulmonary infiltrates following bone marrow transplantation: an eight year review.  Thorax. 1993;  48 1248-1251
• 66 White P, Bonacum J T, Miller C B. Utility of fiberoptic bronchoscopy in bone marrow transplant patients.  Bone Marrow Transplant. 1997;  20 681-687
• 67 Sternberg R I, Baughman R P, Dohn M N, First M R. Utility of bronchoalveolar lavage in assessing pneumonia in immunosuppressed renal transplant recipients.  Am J Med. 1993;  95 358-364
• 68 Gruson D, Hilbert G, Valentino R et al.. Utility of fiberoptic bronchoscopy in neutropenic patients admitted to the intensive care unit with pulmonary infiltrates.  Crit Care Med. 2000;  28 2224-2230
• 69 Weiss S M, Hert R C, Gianola F J, Clark J G, Crawford S W. Complications of fiberoptic bronchoscopy in thrombocytopenic patients.  Chest. 1993;  104 1025-1028
• 70 Peikert T, Rana S, Edell E S. Safety, diagnostic yield, and therapeutic implications of flexible bronchoscopy in patients with febrile neutropenia and pulmonary infiltrates.  Mayo Clin Proc. 2005;  80 1414-1420
• 71 Baughman R P, Dohn M N, Frame P T. The continuing utility of bronchoalveolar lavage to diagnose opportunistic infection in AIDS patients.  Am J Med. 1994;  97 515-522
• 72 Antonelli M, Conti G, Rocco M et al.. Noninvasive positive-pressure ventilation vs. conventional oxygen supplementation in hypoxemic patients undergoing diagnostic bronchoscopy.  Chest. 2002;  121 1149-1154
• 73 Maitre B, Jaber S, Maggiore S M et al.. Continuous positive airway pressure during fiberoptic bronchoscopy in hypoxemic patients: a randomized double-blind study using a new device.  Am J Respir Crit Care Med. 2000;  162 1063-1067
• 74 Hilbert G, Gruson D, Vargas F et al.. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure.  N Engl J Med. 2001;  344 481-487