Thursday, February 22, 2007

BAL in suspected VAP

A few years ago, Fagon et al published a large trial of BAL for evaluation of VAP in over 400 ICU patients in France. Compared to a noninvasive strategy, an invasive strategy was significantly associated with fewer deaths at 14 days, earlier attenuation of organ dysfunction, and less antibiotic use in patients suspected of having ventilator-associated pneumonia.
Recently a trial was published on the NEJM comparing quantitative BAL to endotracheal aspiration with nonquantitative culture of the aspirate. They found no significant difference in the primary outcome (28-day mortality rate), the rates of targeted therapy, days alive without antibiotics, maximum organ-dysfunction scores, length of stay in the ICU or hospital.
What is your routine practice in the ICU for VAP? Do you bronch everybody with suspected VAP?
(Dr. Kollef had an interesting editorial on the Canadian trial in the same issue of the NEJM).

2 comments - CLICK HERE to read & add your own!:

Jeff H said...

I don't. One of the limiting factors is the ability and willingness of labs to actually do quantitative cultures regularly. I'll only regularly bronch for VAP in immunosupressed patients or in patients failing to respond to empiric therapy. Of course, the problem with the latter approach is that by the time we've identified failure to respond to empiric therapy, we've lost the opportunity to institute "early and appropriate" therapy. So the hope is that early tracheal aspiriates will identify potential pathogens that the empiric therapy is not covering.

AK said...

While considering BAL or any other quantitative sampling method for VAP, I found this review helpful: Shigeki F and Yu V. Clin Infect Dis. 2006 Sep 1;43 Suppl 2:S106-13.

They point out problems related to the variety of techniques, equipment, and material submitted. A BAL may have a much more dilute concentration of bacteria than a PSB due to the larger volume-- this in turn can affect the quantitative cultures.

They also look at problems with other quantitative cultures: urine and catheters.