REPLY
Minibronchoalveolar Lavage by Respiratory Therapists
Marin H. Kollef, MD
15 January 1996 | Volume 124 Issue 2 | Page 275
IN RESPONSE:
I agree that we currently lack adequate clinical data supporting the routine use of bronchoscopic or nonbronchoscopic lower-airway sampling for the evaluation of suspected ventilator-associated pneumonia [1]. This is due, in part, to the limitations of these techniques, including the need for physician performance of bronchoscopy, and the lack of outcome data suggesting any benefit from the use of these techniques compared with routine clinical management. Prospective trials are required to determine the clinical efficacy and cost-effectiveness of these diagnostic techniques.
Antibiotic administration is recognized as an important limitation of lower-airway sampling methods, which primarily result in false-negative cultures despite the histologic presence of pneumonia [2, 3]. Having readily available lower-airway sampling techniques such as minibronchoalveolar lavage or quantitative cultures of endotracheal aspirates, which do not depend on a physician, allows respiratory cultures to be more easily obtained before antibiotic therapy is begun or changed [4]. Additionally, obtaining endobronchial cultures from specific lung segments does not appear to be necessary because ventilator-associated pneumonia is a multifocal process usually involving dependent lung regions that can be blindly sampled by minibronchoalveolar lavage [3]. The pathophysiologic and histologic characteristics of ventilator-associated pneumonia, along with the results from a recent bronchoscopic study, do not support the need for selective endobronchial sampling of specific lung segments to establish this diagnosis [5].
The data from my study also suggest that minibronchoalveolar lavage, like quantitative cultures of endotracheal aspirates, may be more sensitive but less specific than the protected specimen brush technique [2]. The clinical importance of the differences in the operating characteristics of these diagnostic tests is currently unknown and awaits the results of prospective studies using appropriate patient outcomes as end points. Despite these limitations, continued investigation of nonbronchoscopic lower-airway sampling methods seems warranted to develop an accurate and accessible diagnostic test for patients with suspected ventilator-associated pneumonia.
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Author and Article Information
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Washington University School of Medicine; St. Louis, MO 63110
1. Niederman MS, Torres A, Summer W. Invasive diagnostic testing is not needed routinely to manage suspected ventilator-associated pneumonia. Am J Respir Crit Care Med. 1994; 150:565-79.
2. Torres A, el-Ebiary M. Pardo L, Gonzalez J, de la Bellacasa JP, Ramirez J, 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; 149:324-31.
3. Rouby JJ, Martin De Lassale E, Poete P, Nicholas MH, Bodin L, Jarlier V, et al. Nosocomial bronchopneumonia in the critically ill. Histologic and bacteriologic aspects. Am Rev Respir Dis. 1992; 146:1059-66.
4. el-Ebiary M, Torres A, Gonzalez J, de la Bellacasa JP, Garcia C, Jimenez de Anta MT, et al. Quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia. Am Rev Respir Dis. 1993; 148:1552-7.
5. Marquette CH, Herengt F, Saulnier F, Nevierre R, Mathieu D, Courcol R, et al. Protected specimen brush in the assessment of ventilator-associated pneumonia. Selection of a certain lung segment for bronchoscopic sampling is unnecessary. Chest. 1993; 103:243-7.
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