2003 OPEN FORUM Abstracts
USE OF MINI-BRONCHOALVEOLAR LAVAGE BY RESPIRATORY THERAPIST IS SAFE AND COST EFFECTIVE WHEN COMPARED TO BRONCHOSCOPY.
Edgar Delgado, RRT, Mark Cohen, RRT, Ray Tuttle, RRT, Joseph Darby, MD.
Departments of Respiratory Care and Critical Care Medicine. University of Pittsburgh Medical Center, Pittsburgh, PA.
The University of Pittsburgh Medical Center (Oakland campus) has 122 ICU beds with an average of 70-ventilator census per day. A total of 295 BAL procedures were performed during a 9-month interval. 223 BAL procedures were performed by the respiratory therapists (75.5%), and 72 procedures were performed as standard bronchoscopy (24.5%).
Methods: All respiratory therapists had three phases of training for the BAL procedure, which included Physician lecture, Procedure demonstration using manikin and return demonstration and competency verification via manikin simulation. Staff were monitored for 3 procedures and then operated independently. All patients were placed on 100% FiO2 and received sedation prior to the mini-BAL procedure. Continuous monitoring of oxygen saturation via pulse oximetry, arterial blood pressure, heart rate, and bleeding (monitored by tracheal aspirate) assessed the safety of the BAL procedures. Desaturation was defined as SpO2 < 90%, Hypotension as MAP < 60 mmHg, Bradycardia as HR < 60 bpm, Tachycardia as HR > 120 bpm. The BAL Cath by Kimberly-Clark (REF 141) was utilized for this project.
RESULTS: Respiratory therapists performed 223 mini BAL procedures. 91 procedures done through tracheostomy tubes and 132 through endotracheal tubes. Among patients having mini-BAL, 30 developed desaturation (13%), 3 developed hypotension (1.4%), 18 developed tachycardia (8%), 5 developed blood-tinged secretion (2.4%) and 7 developed bradycardia (2.4%). All adverse events were transient and resolved shortly after completion of the procedure. Furthermore, one patient developed tension pneumothorax (4 hours post BAL procedure), and the probability that this event was a result of the procedure could not be excluded.
Moreover, during QI/QA process for liver transplant ICUs it was noted that eight patient with coagulapathy (INR. >1.5 and Plts<50) underwent Mini-BAL procedure. Only four patients developed blood-tinged secretion, which resolved shortly after completion of the BAL procedure.
Conclusions: In mechanically ventilated patients with suspected VAP, the respiratory therapists performed Mini-Bronchoalveolar Lavage safely. Furthermore, cost of obtaining BAL was decreased 81.5% per procedure as compare to standard bronchoscopy.
This is a result of the reduced staff and equipment related expenses for this procedure versus the equipment, ancillary staff and physician fees for standard bronchoscopy.