2003 OPEN FORUM Abstracts
Mini-Bronchoalveolar Lavage Using the Combi-Cath Catheter System ? Improved Outcome
Jeffrey Davis, RRT, Thomas Keys, M.D., Judy Michener, RRT, Jean-Pierre Yared, M.D.
Background: Diagnostic sputum sampling for identification of pulmonary pathogens has been routinely performed using standard Clinical Practice Guidelines for artificial airway suctioning techniques in the Cardiovascular Intensive Care Unit (CVICU) at the Cleveland Clinic Foundation (CCF). Annually, The CCF Microbiology Department processes approximately 1200 CVICU requests for culture and gram stain. Of these requests, approximately 13% are rejected due to contamination by upper airway flora; approximately 50% of the 1200 cultures are of value for considering a diagnosis of lower respiratory tract infection.
OBJECTIVE: The goal in the CVICU was to 1.) improve the practice of lower respiratory tract sampling by utilizing the "mini-Bronchoalveolar Lavage (MBAL)" technique with the "Combicath" catheter and 2.) decrease cost by establishing specific criteria for obtaining specimens. The MBAL can be considered the "Gold Standard" of sputum culture collection, second to directed BAL via bronchoscopy. Alveolar washing with a sterile catheter placed in distal bronchus helps to avoid contamination of culture by upper airway flora.
METHOD: In April, 2003, a CVICU policy was initiated that all sputum culture requests would be ordered by CVICU Critical Care Staff Physicians or consultant Infectious Disease Staff Physicians. Criteria for obtaining lower respiratory secretions are 1.) temperature >38.5C or < 36C, 2.) WBC >10K or < 1K, 3.) a new or progressive infiltrate (s) on chest X-ray or 4.) grossly purulent secretions. A 10 patient study was piloted to compare cultures with standard suctioning and sampling techniques versus MBAL technique.
RESULTS: In the 10 patient cohort compared to the MBAL, standard sampling practice yielded 4 upper airway contaminants (false positive) and 3 who had no growth whereas there was growth in the MBAL sample (False Negative).
CONCLUSION: Significant improvement in patient care combined with cost savings can be achieved by combining specific criteria for sputum sampling with the MBAL technique.