Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 15 , ISSUE 1 ( January, 2011 ) > List of Articles

RESEARCH ARTICLE

Comparison of bronchoscopic and non-bronchoscopic techniques for diagnosis of ventilator associated pneumonia

G. C. Khilnani, T.K.Luqman Arafath, Seema Sood, S.K Sharma

Keywords : Bronchoscopic brush, bronchoalveolar lavage, endotracheal aspirate, non-bronchoscopic bronchoalveolar lavage, ventilator associated pneumonia

Citation Information : Khilnani GC, Arafath T, Sood S, Sharma S. Comparison of bronchoscopic and non-bronchoscopic techniques for diagnosis of ventilator associated pneumonia. Indian J Crit Care Med 2011; 15 (1):16-23.

DOI: 10.4103/0972-5229.78218

License: CC BY-ND 3.0

Published Online: 01-06-2018

Copyright Statement:  Copyright © 2011; The Author(s).


Abstract

Background: The diagnosis of ventilator associated pneumonia (VAP) remains a challenge because the clinical signs and symptoms lack both sensitivity and specificity and the selection of microbiologic diagnostic procedure is still a matter of debate. Aims and Objective: To study the role of various bronchoscopic and non-bronchoscopic diagnostic techniques for diagnosis of VAP. Settings and Design: This prospective comparative study was conducted in a medical ICU of a tertiary care center. Materials and Methods: Twenty-five patients, clinically diagnosed with VAP, were evaluated by bronchoscopic and non-bronchoscopic procedures for diagnosis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of various bronchoscopic and non-bronchoscopic techniques were calculated, taking clinical pulmonary infection score (CPIS) of ≥6 as reference standard. Results: Our study has shown that for the diagnosis of VAP, bronchoscopic brush had a sensitivity, specificity, PPV and NPV of 94.9% [confidence interval (CI): 70.6-99.7], 57.1% (CI: 13.4-86.1), 85% (CI: 61.1-96) and 80% (CI: 21.9-98.7), respectively. Bronchoscopic bronchoalveolar lavage (BAL) had a sensitivity, specificity, PPV and NPV of 77.8% (CI: 51.9-92.6), 71.8% (CI: 24.1-94), 87.3% (CI: 60.4-97.8) and 55.5% (CI: 17.4-82.6), respectively. Sensitivity, specificity, PPV and NPV for non-bronchoscopic BAL (NBAL) were 83.3% (CI: 57.7-95.6), 71.43% (CI: 24.1-94), 88.2% (CI: 62.3-97.4) and 62.5% (CI: 20.2-88.2), respectively. Endotracheal aspirate (ETA) yield was only 52% and showed poor concordance with BAL (k-0.351; P-0.064) and NBAL (k-0.272; P-0.161). There was a good microbiologic concordance among different bronchoscopic and non-bronchoscopic distal airway sampling techniques. Conclusion: NBAL is an inexpensive, easy, and useful technique for microbiologic diagnosis of VAP. Our findings, if verified, might simplify the approach for the diagnosis of VAP.


PDF Share
  1. Hubmayr RD, Burchardi H, Elliot M, Fessler H, Georgopoulos D, Jubran A, et al. Statement of the 4th International Consensus Conference in Critical Care on ICU-Acquired Pneumonia–Chicago, Illinois, May 2002. Intensive Care Med 2002;28:1521-36.
  2. Johanson WG, Jr., Pierce AK, Sanford JP, Thomas GD. Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med 1972;77:701-6.
  3. Andrews CP, Coalson JJ, Smith JD, Johanson WG Jr. Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury. Chest 1981;80:254-8.
  4. Fagon JY, Chastre J, Hance AJ, Domart Y, Trouillet JL, Gibert C. Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest 1993;103:547-53.
  5. Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis 1991;143:1121-9.
  6. Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med 2000;162:505-11.
  7. Zilberberg MD, Shorr AF, Micek ST, Mody SH, Kollef MH. Antimicrobial therapy escalation and hospital mortality among patients with health-care-associated pneumonia: a single-center experience. Chest 2008;134:963-8.
  8. Chastre J, Fagon JY, Bornet-Lecso M, Calvat S, Dombret MC, al Khani R, et al. Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 1995;152:231-40.
  9. Torres A, el-Ebiary M. Invasive diagnostic techniques for pneumonia: protected specimen brush, bronchoalveolar lavage, and lung biopsy methods. Infect Dis Clin North Am 1998;12:701-22.
  10. Marquette CH, Copin MC, Wallet F, Neviere R, Saulnier F, Mathieu D, et al. Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard. Am J Respir Crit Care Med 1995;151:1878-88.
  11. Michaud S, Suzuki S, Harbarth S. Effect of design-related bias in studies of diagnostic tests for ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;166:1320-5.
  12. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.
  13. Fartoukh M, Maitre B, Honore S, Cerf C, Zahar JR, Brun-Buisson C. Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med 2003;168:173-9.
  14. Woske HJ, Roding T, Schulz I, Lode H. Ventilator-associated pneumonia in a surgical intensive care unit: epidemiology, etiology and comparison of three bronchoscopic methods for microbiological specimen sampling. Crit Care 2001;5:167-73.
  15. Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C. Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 1993;94:281-8.
  16. Luna CM, Videla A, Mattera J, Vay C, Famiglietti A, Vujacich P, et al. Blood cultures have limited value in predicting severity of illness and as a diagnostic tool in ventilator-associated pneumonia. Chest 1999;116:1075-84.
  17. Marquette CH, Georges H, Wallet F, Ramon P, Saulnier F, Neviere R, et al. Diagnostic efficiency of endotracheal aspirates with quantitative bacterial cultures in intubated patients with suspected pneumonia. Comparison with the protected specimen brush. Am Rev Respir Dis 1993;148:138-44.
  18. Estella A, Monge MI, Perez Fontaina L, Sainz de Baranda A, Gala MJ, Moreno E. Bronchoalveolar lavage for diagnosing pneumonia in mechanically ventilated patients. Med Intensiva 2008;32:419-23.
  19. Heyland DK, Cook DJ, Marshall J, Heule M, Guslits B, Lang J, et al. The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia. Canadian Critical Care Trials Group. Chest 1999;115:1076-84.
  20. Balthazar AB, Von Nowakonski A, De Capitani EM, Bottini PV, Terzi RG, Araujo S. Diagnostic investigation of ventilator-associated pneumonia using bronchoalveolar lavage: comparative study with a postmortem lung biopsy. Braz J Med Biol Res 2001;34:993-1001.
  21. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006;355:2619-30.
  22. Rouby JJ, Martin De Lassale E, Poete P, Nicolas MH, Bodin L, Jarlier V, et al. Nosocomial bronchopneumonia in the critically ill. Histologic and bacteriologic aspects. Am Rev Respir Dis 1992;146:1059-66.
  23. Papazian L, Thomas P, Garbe L, Guignon I, Thirion X, Charrel J, et al. Bronchoscopic or blind sampling techniques for the diagnosis of ventilator-associated pneumonia. Am J Respir Crit Care Med 1995;152:1982-91.
  24. Kollef MH, Bock KR, Richards RD, Hearns ML. The safety and diagnostic accuracy of minibronchoalveolar lavage in patients with suspected ventilator-associated pneumonia. Ann Intern Med 1995;122:743-8.
  25. Rouby JJ, Rossignon MD, Nicolas MH, Martin de Lassale E, Cristin S, Grosset J, et al. A prospective study of protected bronchoalveolar lavage in the diagnosis of nosocomial pneumonia. Anesthesiology 1989;71:679-85.
  26. Fujitani S, Cohen-Melamed MH, Tuttle RP, Delgado E, Taira Y, Darby JM. Comparison of semi-quantitative endotracheal aspirates to quantitative non-bronchoscopic bronchoalveolar lavage in diagnosing ventilator-associated pneumonia. Respir Care 2009;54:1453-61.
  27. Fagon JY, Chastre J, Wolff M, Gervais C, Parer-Aubas S, Stephan F, et al. Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial. Ann Intern Med 2000;132:621-30.
  28. Chastre J, Viau F, Brun P, Pierre J, Dauge MC, Bouchama A, et al. Prospective evaluation of the protected specimen brush for the diagnosis of pulmonary infections in ventilated patients. Am Rev Respir Dis 1984;130:924-9.
  29. Torres A, el-Ebiary M, Padro L, Gonzalez J, de la Bellacasa JP, Ramirez J, et al. Validation of different techniques for the diagnosis of ventilator-associated pneumonia. Comparison with immediate postmortem pulmonary biopsy. Am J Respir Crit Care Med 1994;149:324-31.
  30. Baselski VS, el-Torky M, Coalson JJ, Griffin JP. The standardization of criteria for processing and interpreting laboratory specimens in patients with suspected ventilator-associated pneumonia. Chest 1992;102:571-9.
  31. Baker AM, Bowton DL, Haponik EF. Decision making in nosocomial pneumonia. An analytic approach to the interpretation of quantitative bronchoscopic cultures. Chest 1995;107:85-95.
  32. Croce MA, Swanson JM, Magnotti LJ, Claridge JA, Weinberg JA, Wood GC, et al. The futility of the clinical pulmonary infection score in trauma patients. J Trauma 2006;60:523-7.
  33. Schurink CA, Van Nieuwenhoven CA, Jacobs JA, Rozenberg-Arska M, Joore HC, Buskens E, et al. Clinical pulmonary infection score for ventilator-associated pneumonia: accuracy and inter-observer variability. Intensive Care Med 2004;30:217-24.
  34. Brun-Buisson C, Fartoukh M, Lechapt E, Honore S, Zahar JR, Cerf C, et al. Contribution of blinded, protected quantitative specimens to the diagnostic and therapeutic management of ventilator-associated pneumonia. Chest 2005;128:533-44.
  35. Fagon JY, Chastre J, Hance AJ, Guiguet M, Trouillet JL, Domart Y, et al. Detection of nosocomial lung infection in ventilated patients. Use of a protected specimen brush and quantitative culture techniques in 147 patients. Am Rev Respir Dis 1988;138:110-6.
  36. Medford AR, Husain SA, Turki HM, Millar AB. Diagnosis of ventilator-associated pneumonia. J Crit Care 2009;24:473.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.