Benefit-to-risk balance of bronchoalveolar lavage in the critically ill. A prospective, multicenter cohort study

Abstract

To assess the benefit-to-risk balance of bronchoalveolar lavage (BAL) in intensive care unit (ICU) patients. Methods: In 16 ICUs, we prospectively collected adverse events during or within 24 h after BAL and assessed the BAL input for decision making in consecutive adult patients. The occurrence of a clinical adverse event at least of grade 3, i.e., sufficiently severe to need therapeutic action(s), including modification(s) in respiratory support, defined poor BAL tolerance. The BAL input for decision making was declared satisfactory if it allowed to interrupt or initiate one or several treatments. Results: We included 483 BAL in 483 patients [age 63 years (interquartile range (IQR) 53-72); female gender: 162 (33.5%); simplified acute physiology score II: 48 (IQR 37-61); immunosuppression 244 (50.5%)]. BAL was begun in nonintubated patients in 105 (21.7%) cases. Sixty-seven (13.9%) patients reached the grade 3 of adverse event or higher. Logistic regression showed that a BAL performed by a non-experienced physician (non-pulmonologist, or intensivist with less than 10 years in the specialty or less than 50 BAL performed) was the main predictor of poor BAL tolerance in non-intubated patients [OR: 3.57 (95% confidence interval 1.04-12.35); P = 0.04]. A satisfactory BAL input for decision making was observed in 227 (47.0%) cases and was not predictable using logistic regression. Conclusions: Adverse events related to BAL in ICU patients are not infrequent nor necessarily benign. Our findings call for an extreme caution, when envisaging a BAL in ICU patients and for a mandatory accompaniment of the less experienced physicians.

Changes in the management and clinical outcomes of critically ill patients without COVID-19 during the pandemic

“…( 13 ) Five of 16 BALs performed in 2019 affected patient evolution since the antibiotic treatment was modified, whereas 1 of 3 BALs performed in 2020 led to a change in antibiotics. These results regarding the impact of BALs are consistent with findings from the meta-analysis by Kamel et al ( 14 ) After analyzing the results of the questionnaire, 80% of healthcare professionals perceived this reduction, but only 30% considered that it had any impact on patient evolution.…”

Systematic review of studies investigating ventilator associated pneumonia diagnostics in intensive care

“…Firstly, in a recent systematic review, when compared to the reference standard of histopathological examination of lung tissue, BAL culture had a sensitivity of 71.1% and specificity of 79.6% [ 86 ] echoing previous findings that microbiological examination does not correlate well with histopathological examination [ 32 ]. Secondly, the timing and nature of prior antibiotic therapy may adversely affect sample positivity [ 87 , 88 ], although this problem is conceivably solved by incorporating a criterion addressing percentage of host cells containing invading organisms, a measure not affected by prior antibiotic therapy [ 75 ]. Thirdly, the BAL procedure itself is not standardised, and the requirements for sample collection are not uniform.…”

Bronchoalveolar lavage under ultrasound monitoring of lungs for the treatment of neonatal atelectasis and lung consolidation

“…During lavage treatment, transcutaneous oxygen saturation (SpO 2 ) of the child should be >90% (29,30). The analysis of the effects of BAL (29)(30)(31)(32)(33)(34) has revealed the following: i) During the lavage process, the uncomfortable stress response of the child stimulates the body through the hypothalamic-pituitary-adrenal axis to produce glucocorticoids, which exert anti-inflammatory effects, conducive to alveolar recruitment; ii) lavage can reduce inflammation and cytokine levels, and can eliminate certain inflammation and cytotoxic factors, thereby reducing their harm to the body; iii) it can wash out inflammatory exudate, edema fluid, necrotic tissue, etc., which is conducive to alveolar recruitment; iv) lavage fluid from the lavage can be used for smears, stains, and pathogenic examinations to provide a basis for a clear diagnosis and treatment.…”

“…The results of the present study demonstrated that following BAL under ultrasound monitoring, the OI rapidly decreased with the prolonged treatment time, and the PS lavage group exhibited a greater decrease compared with the NS lavage group, indicating that BAL treatment was effective in improving oxygenation, and was beneficial for improving respiratory function (Table III). BAL is conducive to unblock the airway; lavage can dilute inflammation and cytotoxic factors, and can lavage out inflammatory exudate, edema fluid, necrotic tissue, etc., which is conducive to alveolar recruitment and clear diagnosis; PS can effectively improve lung compliance and oxygenation, mechanical ventilation can effectively improve ventilation, and the combined application of the three is more effective (20,29,30,32,33).…”