Background-In a retrospective study the value of bronchoalveolar lavage (BAL) in the diagnosis of pneumonia was investigated in 95 immunocompromised patients suVering from haematological disorders and receiving a regimen of broad spectrum antibiotics and antifungal agents (BSAR). Methods-With the exception of four afebrile patients, all had fever, raised C reactive protein (CRP) levels, and new infiltrates visible on chest radiography. All patients underwent BAL to identify the organism causing the pneumonia and surveillance cultures were performed regularly for pathogens at diVerent sites. Following classification of the isolates, patients with positive cultures were subdivided into two groups, pathogenic or contaminated. We investigated whether relevant pathogens were cultured only from the BAL fluid and whether they were susceptible to BSAR. Results-Although 77 of the 95 patients were thrombocytopenic, bleeding during BAL occurred in only 15% of all patients. Ten days after the procedure the fever improved in 88% of patients, radiographic findings improved in 71%, and CRP levels improved in 75% of patients; 22% of patients died within 28 days. Pathologically relevant isolates were found in 65% of all patients. Respiratory pathogens were detected only in the BAL fluid of 29 of the 95 patients (35% Gram positive species, 40% Gram negative species, 11% Mycobacterium, 11% fungi, and 3% cytomegalovirus). In 16 of these 29 patients (55%) the pathogens cultured only from the BAL fluid were resistant to treatment. Pathogens detected only in the BAL fluid were not susceptible to a standard broad spectrum antibiotic and antifungal regimen including teicoplanin, ceftriaxon, tobramycin, and amphotericin B in 12 of the 29 patients (41%). Conclusions-Our data suggest that 12 patients were treated with broad spectrum antimicrobial agents which were not directed at the appropriate organism on in vitro sensitivity tests without BAL. BAL is a relatively safe procedure in the diagnosis of pneumonia, supplying important information in immunocompromised patients as well as in immunocompromised patients receiving BSAR. (Thorax 2001;56:115-120)

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Supported by two case reports we show that resistance to atracurium can develop postoperatively. Both patients had septic complications after elective thoracic surgery. A 39-year-old patient developed a bronchial fistula and a superinfection of the remaining thoracic cavity after pneumonectomy. At the time of rethoracotomy the neuromuscular blocking potency of atracurium had changed drastically: onset time was lengthened (7 vs. 3.5 min), recovery period (DUR 10%) was reduced (14 vs. 28 min) and the maintenance dose had to be tripled (14.3 vs. 5.0 micrograms/kg per minute). Following superior lobe resection in a 56-year-old patient, middle lobe gangrene occurred which had to be removed. In contrast to the first anaesthesia the intubation dose of atracurium had to be increased significantly (70 vs. 40 mg), and even with this amount the neuromuscular blocking effect was not complete. Furthermore to accomplish a convenient state of relaxation the maintenance dose had to be raised considerably (11.8-16.5 vs. 5.5 micrograms/kg per minute). These reports show that even within a short period of time resistance to atracurium can develop and we must suppose that the severe inflammatory reaction caused these changes.

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Our results support the hypothesis that patients with a purulent intrathoracic disease show a clear reduction in neuromuscular blocking potency of atracurium.