Limits...
Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients.

Schnabel RM, van der Velden K, Osinski A, Rohde G, Roekaerts PM, Bergmans DC - BMC Pulm Med (2015)

Bottom Line: The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned.Factors associated with complications were analysed by logistic regression. a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h.Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered.

View Article: PubMed Central - PubMed

Affiliation: Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands. r.schnabel@mumc.nl.

ABSTRACT

Background: Flexible, fibreoptic bronchoscopy (FFB) and bronchoalveolar lavage (BAL) have been used for diagnostic purposes in critically ill ventilated patients. The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned. Nevertheless, BAL can provide extra information for the differential diagnosis of respiratory disease and good antibiotic stewardship. These benefits should outweigh potential hazards caused by the invasiveness of this diagnostic technique. The focus of the present study was on the clinical course and complications of patients following BAL procedures up to 24 h.

Methods: Hundred sixty-four FFB guided BAL procedures for suspected pneumonia were analysed in an observational study. The clinical course of patients was monitored by respiratory and haemodynamic data before BAL, 1 and 24 h after BAL. Complications were defined and registered. Factors associated with complications were analysed by logistic regression.

Clinical course: a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h. Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered. Haemodynamic complications: there were no cases of hypertension and cardiac rhythm disturbances; haemodynamic instability within the first 24 h after BAL was recorded in 22 %; this was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 - 8.3). The incidence of bacteraemia was 7 %. There was no case of procedure related death.

Discussion: Frequently occurring haemodynamic and respiratory instability but no cases of cardiac rhythm disturbances, bleeding, pneumothorax or procedure related death were attributable to diagnostic FFB and BAL. The procedures should be conducted under careful supervision by experienced physicians. Only a randomized controlled trial that compares diagnostic FFB and BAL with a non-invasive strategy could ultimately establish the safety profile and clinical utility of these procedures in critically ill ventilated patients.

No MeSH data available.


Related in: MedlinePlus

Results – Odds ratios and 95 % confidence interval for respiratory complications1 of BAL. 1 Decrease of the PaO2/FiO2 > 25 % compared to baseline within 1 h after BAL
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
getmorefigures.php?uid=PMC4588466&req=5

Fig1: Results – Odds ratios and 95 % confidence interval for respiratory complications1 of BAL. 1 Decrease of the PaO2/FiO2 > 25 % compared to baseline within 1 h after BAL

Mentions: The following complications of diagnostic FFB and BAL were registered. 1. Respiratory complications: hypo-oxygenation (SaO2 ≤ 88 %) during BAL and/or bronchospasm was documented in 9 % of patients; a decrease of >25 % PaO2/FiO2 ratio compared to baseline was registered in 29 % of patients 1 h after BAL; in half of these patients a persisting decrease of >25 % PaO2/FiO2 ratio was found 24 h after BAL; no cases of clinically significant bleeding requiring interruption of the procedure or treatment were reported. Further analysis could not establish a significant correlation of respiratory complications with demographic or clinic items [Fig. 1]. 2. Haemodynamic complications: no patients had hypertension or cardiac rhythm disturbances during the FFB and BAL procedure; hemodynamic instability (as defined in the methods section) was found in 5 % of patients 1 h after BAL and 7 % of patients 24 h after BAL. However, 22 % of patients had hemodynamic instability at any time during the first 24 h after BAL. This was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 - 8.3) [Fig. 2]. Multiple logistic regression revealed that the correlation was independent from age and gender (OR 2.3; 95 % CI 1 – 5.6 / OR 2.8; 95 % CI 1.1 – 6.7) and the APACHE II score at admission (OR 3.5; 95 % CI 1.5 – 8.5 / OR 3.5; 95 % CI 1.4 – 8.6) 3. Bacteraemia: newly positive blood cultures were observed in 7 % of patients. 4. Death: no case of procedure related death was reported.Fig. 1


Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients.

Schnabel RM, van der Velden K, Osinski A, Rohde G, Roekaerts PM, Bergmans DC - BMC Pulm Med (2015)

Results – Odds ratios and 95 % confidence interval for respiratory complications1 of BAL. 1 Decrease of the PaO2/FiO2 > 25 % compared to baseline within 1 h after BAL
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4588466&req=5

Fig1: Results – Odds ratios and 95 % confidence interval for respiratory complications1 of BAL. 1 Decrease of the PaO2/FiO2 > 25 % compared to baseline within 1 h after BAL
Mentions: The following complications of diagnostic FFB and BAL were registered. 1. Respiratory complications: hypo-oxygenation (SaO2 ≤ 88 %) during BAL and/or bronchospasm was documented in 9 % of patients; a decrease of >25 % PaO2/FiO2 ratio compared to baseline was registered in 29 % of patients 1 h after BAL; in half of these patients a persisting decrease of >25 % PaO2/FiO2 ratio was found 24 h after BAL; no cases of clinically significant bleeding requiring interruption of the procedure or treatment were reported. Further analysis could not establish a significant correlation of respiratory complications with demographic or clinic items [Fig. 1]. 2. Haemodynamic complications: no patients had hypertension or cardiac rhythm disturbances during the FFB and BAL procedure; hemodynamic instability (as defined in the methods section) was found in 5 % of patients 1 h after BAL and 7 % of patients 24 h after BAL. However, 22 % of patients had hemodynamic instability at any time during the first 24 h after BAL. This was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 - 8.3) [Fig. 2]. Multiple logistic regression revealed that the correlation was independent from age and gender (OR 2.3; 95 % CI 1 – 5.6 / OR 2.8; 95 % CI 1.1 – 6.7) and the APACHE II score at admission (OR 3.5; 95 % CI 1.5 – 8.5 / OR 3.5; 95 % CI 1.4 – 8.6) 3. Bacteraemia: newly positive blood cultures were observed in 7 % of patients. 4. Death: no case of procedure related death was reported.Fig. 1

Bottom Line: The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned.Factors associated with complications were analysed by logistic regression. a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h.Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered.

View Article: PubMed Central - PubMed

Affiliation: Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands. r.schnabel@mumc.nl.

ABSTRACT

Background: Flexible, fibreoptic bronchoscopy (FFB) and bronchoalveolar lavage (BAL) have been used for diagnostic purposes in critically ill ventilated patients. The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned. Nevertheless, BAL can provide extra information for the differential diagnosis of respiratory disease and good antibiotic stewardship. These benefits should outweigh potential hazards caused by the invasiveness of this diagnostic technique. The focus of the present study was on the clinical course and complications of patients following BAL procedures up to 24 h.

Methods: Hundred sixty-four FFB guided BAL procedures for suspected pneumonia were analysed in an observational study. The clinical course of patients was monitored by respiratory and haemodynamic data before BAL, 1 and 24 h after BAL. Complications were defined and registered. Factors associated with complications were analysed by logistic regression.

Clinical course: a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h. Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered. Haemodynamic complications: there were no cases of hypertension and cardiac rhythm disturbances; haemodynamic instability within the first 24 h after BAL was recorded in 22 %; this was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 - 8.3). The incidence of bacteraemia was 7 %. There was no case of procedure related death.

Discussion: Frequently occurring haemodynamic and respiratory instability but no cases of cardiac rhythm disturbances, bleeding, pneumothorax or procedure related death were attributable to diagnostic FFB and BAL. The procedures should be conducted under careful supervision by experienced physicians. Only a randomized controlled trial that compares diagnostic FFB and BAL with a non-invasive strategy could ultimately establish the safety profile and clinical utility of these procedures in critically ill ventilated patients.

No MeSH data available.


Related in: MedlinePlus