2001 OPEN FORUM Abstracts
Adequacy of Non-Bronchoscopic,Protected Bronchoalveolar Lavage (NB-PAL) Specimens Obtained by RespiratoryCare Practitioners (RCP) for Diagnosing Ventilator Associated Pneumonia (VAP)
Robert S. Campbell,RRT, FAARC, Gary Banks RRT, Richard D. Branson, RRT, FAARC, Joseph S. SolomkinMD University of Cincinnati, Cincinnati, OH 45267
Background: Diagnosisof VAP is difficult and may be aided by obtaining NB-PAL specimens. Over 20%of non-protected, blindly obtained VAL specimens are inadequare. (Spencer etal, AJRCCM 98:A313) Potential advantages of NB-PAL are: collection of specimensby bedside staff, specimen collection prior to initiating antibiotic therapy,reduction in # of inadequate or contaminated specimens, and more appropriateselection of initial empiric antibiotic therapy. We report oure experiencesusign NB-PAL specimens obtained by RCPs for the diagnosis of VAP.
Method: Following an initialone hour in-service, RCPs began collecting NV-PAL specimens inICU pts with clinicalsigns of VAP (WBC>10k, T>38.5C, infiltrate on CXR, and purulent sputum).Specimens were obtained using an 8 French, plugged, telescoping catheter (CombiCath,PlastiMed) utilizing a lavage volume of 20 ml. Specimens were considered adequateif >1 ml was retrieved and no epithelial cells were observed on initial directobservation. We recorded aspirated lavage volume, gram stain results, # of inadequatespecimens, final culture results, appropriateness of initial empiric antibiotictherapy, and any complications (SpO2 <92%, 10%Æ in HR or ABP sustained >5 min, bleeding, pneumothorax, etc.) observed during the NB-PAL procedure
Results: One hundred andfive pts were studied during a six-month period ending 30-April-01. Lavage volumeaspirated during the NV-PAL procedure was 2.1±0.6 ml. Four (3.8%) ofthe NB-PAL specimens were inadequate due to presence of epithelial cells andall specimens were >1 ml. Of the remaining 101 specimens, 34 were positivefor VAP (organisms > 104cfu/ml on final culture) and 35 negativefor VAP (no growth on final culture) The remaining 32 (31.7%) specimens wereindeterminate (101-103 cfu/ml on final culture). Gram stain resuls were correlatedwith the final culture result in 90 cases, partially correlated in 3 cases,and not correlated in 8 cases. Initial empiric antibiotic therapy guided bythe Gram stain was appropriate in 97 cases. No episodes of hypoxemia were reported,as pts were ventilated with FIO2 of 1.0 prior to and during the procedure. Minorbleeding was reported in 9 patients and significant hemodynamic changes werereported in 4 cases and all were resolved without clinical sequelae. Durationof the procedure was <10 minutes in all cases.
Conclusion: NV-PAL specimen collectionby RCPs can be performed safely and quickly. The NV-PAL procedure is well tolerated,and yields an acceptable specimen for microbiological analysis in over 95% ofcases. Use of a polyethylene glycol plug at the tip of the catheter may reducethe number of inadequate or contaminated specimens. Grams stain results fromNB-PAL specimens strongly correlate with final culture result and may be usedto guide initial empiric antibiotic therapy. NB-PAL specimens are useful diagnostictools that aid in the diagnosis of VAP in over two-thirds of our Surgical ICUpts with suspected VAP.