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Background:
The diagnosis of ventilator-associated pneumonia (VAP) remains a challenge, with clinicians mainly relying on clinical, radiological, and bacteriologic strategies to manage patients with VAP.
Aims:
To compare the results of non-bronchoscopic and bronchoscopic techniques of distal airway sampling for the diagnosis of VAP.
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Rationale: Current guidelines recommend patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia receive empirical antibiotics for suspected bacterial superinfection on the basis of weak evidence. Rates of ventilator-associated pneumonia (VAP) in clinical trials of patients with SARS-CoV-2 pneumonia are unexpectedly low....
Citations
... NBBL provides several advantages over EA and fiberoptic bronchoscopy. NBBL provides sterile, quantitative cultures with a yield similar to fiberoptic bronchoscopy at a lower cost (13)(14)(15). NBBL is safe and has been performed in critically ill patients for both clinical and research use (16)(17)(18). ...
... We found the presence of several alveolar immune cell populations, including: neutrophils, macrophages, monocytes, lymphocytes, and eosinophils (Fig. 4). These data show that the NBBL samples the alveolar space similar to that of a fiberoptic bronchoscopy as published (13)(14)(15). ...
OBJECTIVES
Diagnosis of pneumonia is challenging in critically ill, intubated patients due to limited diagnostic modalities. Endotracheal aspirate (EA) cultures are standard of care in many ICUs; however, frequent EA contamination leads to unnecessary antibiotic use. Nonbronchoscopic bronchoalveolar lavage (NBBL) obtains sterile, alveolar cultures, avoiding contamination. However, paired NBBL and EA sampling in the setting of a lack of gold standard for airway culture is a novel approach to improve culture accuracy and limit antibiotic use in the critically ill patients.
DESIGN
We designed a pilot study to test respiratory culture accuracy between EA and NBBL. Adult, intubated patients with suspected pneumonia received concurrent EA and NBBL cultures by registered respiratory therapists. Respiratory culture microbiology, cell counts, and antibiotic prescribing practices were examined.
SETTING
We performed a prospective pilot study at the Cleveland Clinic Main Campus Medical ICU in Cleveland, Ohio for 22 months from May 2021 through March 2023.
PATIENTS OR SUBJECTS
Three hundred forty mechanically ventilated patients with suspected pneumonia were screened. Two hundred fifty-seven patients were excluded for severe hypoxia (F io 2 ≥ 80% or positive end-expiratory pressure ≥ 12 cm H 2 O), coagulopathy, platelets less than 50,000, hemodynamic instability as determined by the treating team, and COVID-19 infection to prevent aerosolization of the virus.
INTERVENTIONS
All 83 eligible patients were enrolled and underwent concurrent EA and NBBL.
MEASUREMENTS AND MAIN RESULTS
More EA cultures (42.17%) were positive than concurrent NBBL cultures (26.51%, p = 0.049), indicating EA contamination. The odds of EA contamination increased by eight-fold 24 hours after intubation. EA was also more likely to be contaminated with oral flora when compared with NBBL cultures. There was a trend toward decreased antibiotic use in patients with positive EA cultures if paired with a negative NBBL culture. Alveolar immune cell populations were recovered from NBBL samples, indicating successful alveolar sampling. There were no major complications from NBBL.
CONCLUSIONS
NBBL is more accurate than EA for respiratory cultures in critically ill, intubated patients. NBBL provides a safe and effective technique to sample the alveolar space for both clinical and research purposes.
... To overcome the challenges of selecting optimum microbiological diagnostic procedures for HAP patients in the ICU, mBAL, as a simple, low cost method, with relatively minimal disturbance to oxygen levels and hemodynamics during the procedure, was used in our study. Previous studies, comparing the bronchoscope-guided BAL to the less invasive mBAL, had also reported a high concordance rate, ensuring effectiveness of the latter approach to access the distal airway secretions among HAP patients [24,25]. Our data revealed that the overall PPA and NPA for the detection of on-panel bacterial targets by BFPP were 100% and 90%, respectively. ...
Hospital-acquired pneumonia (HAP) is a substantial public health issue that is associated with high mortality rates and is complicated by an arsenal of microbial etiologies, expressing multidrug-resistant phenotypes, rendering relatively limited therapeutic options. BioFire FilmArray Pneumonia Panel plus (BFPP) is a simple multiplexed PCR system that integrates sample preparation, nucleic acid extraction, amplification, and analysis of microbial etiology, with a turnaround time of about one hour. In comparison to standard culture methods, BFPP is simpler, easier to perform, and can simultaneously detect the most common pathogens involved in lower respiratory tract infections (34 targets). Accordingly, we evaluated the diagnostic performance of the multiplexed BFPP for the rapid detection of 27 clinically relevant respiratory pathogens and 7 genetic markers among 50 HAP cases admitted to the intensive care unit (ICU), who submitted mini-bronchoalveolar (mBAL) specimens. In comparison to standard culture methods, BFPP showed an overall sensitivity of 100% [95% CI; 90–100] and overall specificity of 90% [95% CI; 87.4–92.5] among all the tested bacterial targets. BFPP identified 11 viral targets (22%) among the tested specimens. The BFPP semi-quantitative analysis showed a concordance rate of 47.4% among positive culture specimens. For the investigation of the antibiotic resistance genes, BFPP showed a positive percent agreement (PPA), a negative percent agreement (NPA), and an overall percent agreement (OPA), reaching 97% [95% CI; 90–100], 95% [95% CI; 91.5–97], and 95% [95% CI; 93–97], respectively, with standard antibiotic sensitivity testing. In conclusion, BFPP has the potential to enhance the rapid microbiological diagnosis of HAP cases, and could aid in tailoring appropriate antibiotic therapies.
Background: Despite its widespread use, there are no direct studies comparing mini-bronchoalveolar lavage (mini-BAL) to bronchoscopic bronchoalveolar lavage (BAL) for diagnosing pneumonia in ventilated patients. The aim of this study was to perform a systematic review of studies comparing ventilated patients undergoing both bronchoscopic BAL and mini-BAL, to determine the mini-BAL's diagnostic accuracy. Methods: We conducted a systematic review searching the databases PubMed (MEDLINE), EMBASE, Cochrane Library, Scopus, and clinicaltrials.gov from inception until January 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Search terms included variations on "pneumonia," "critical illness," and "mini-bronchoalveolar lavage." Article screening and data extraction were performed independently by 2 reviewers. Results: Our search yielded 4296 abstracts. This was narrowed to 6 studies in which each patient underwent both mini-BAL and bronchoscopic BAL in succession. Included patients had a mean APACHE II score of 20.02 ± 3.81 and 15.95 ± 11.46 ventilator days. The sensitivity of the mini-BAL for diagnosis of pneumonia was 0.90 (95% confidence interval [CI]: 0.778-1.000) and the specificity was 0.827 (95% CI: 0.716-0.938). Limitations included inconsistency in volume of saline instilled and heterogeneity in included patients Conclusion: This study is the first to compile data from multiple publications directly comparing the mini-BAL to bronchoscopic BAL for diagnosing pneumonia in ventilated patients. Our data demonstrate a high degree of both sensitivity and specificity of mini-BAL for the diagnosis of pneumonia in ventilated patients and indicate that mini-BAL could be considered as an acceptable alternative diagnostic study.
