Usefulness of a strategy based on bronchoscopy with direct examination of bronchoalveolar lavage fluid in the initial antibiotic therapy of suspectedventilator-associated pneumonia
Jf. Timsit et al., Usefulness of a strategy based on bronchoscopy with direct examination of bronchoalveolar lavage fluid in the initial antibiotic therapy of suspectedventilator-associated pneumonia, INTEN CAR M, 27(4), 2001, pp. 640-647
Objectives: To evaluate (a) the routine accuracy of bronchoalveolar lavage
by direct examination (BAL-D ) in diagnosing ventilator-associated pneumoni
a (VAP), and (b) the impact of a diagnostic strategy including clinical jud
gment, bronchoscopy. and BAL-D on the initial diagnosis and appropriateness
of treatment when VAP is suspected.
Design and setting: Prospective cohort study in two academic ICUs in Paris,
France.
Patients and participants: Mechanically ventilated patients with suspected
VAP underwent bronchoscopy with BAL and protected specimen brush (PSB). BAL
-D results were available within 2 h, BAL. on culture and PSB results after
24 h, and antibiotic susceptibility after 48 h. At each step in the strate
gy the senior and the resident in charge of the patient were asked their di
agnosis and their therapeutic plan on the basis of presently available data
. Definite diagnosis of suspected VAP was based on histology appearance of
cavitation, positive pleural fluid culture, results of PSB and BAL culture,
and follow-up.
Measurement and results: A total of 110 episodes of suspected VAP were stud
ied; 94 definite diagnoses were made (47 VAP, 47 no VAP). Using a threshold
1% of infected cells, BAL-D discriminated well between patients with and t
hose without VAP (sensitivity 93.6%, specificity 91.5%, area under the rece
iver-operating characteristic curve 0.953). The senior clinical judgment wa
s correct in 71% cases. It was correct in 78% and 94% of cases after airway
visualization and BAL-D findings, respectively. After BAL-D the positive a
nd negative predictive values in diagnosing VAP were 90% and 98%, respectiv
ely. However. the therapeutic plan was correct in only 65% using clinical j
udgment (15 untreated patients, 3 ineffective treatment, 15 useless treatme
nt), 66% using airway visualization (14 untreated VAP,4 ineffective treatme
nt, 14 useless treatment), and 88% using BAL-D results (1 untreated patient
s, 6 ineffective, 4 useless), according to definite diagnosis and final ant
ibiotic susceptibility testings.
Conclusions: A strategy based on bronchoscopy and BAL-D generally leads to
a rapid and appropriate treatment of nosocomial pneumonia in ventilated pat
ients.