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Early nonbronchoscopic bronchoalveolar lavage: Predictor of ventilator-associated pneumonia?

Minshall, Christian Todd MD, PhD; Eriksson, Evert A. MD; Hawkins, Kenneth S. BSRRT; Wolf, Steven MD; Minei, Joseph P. MD

Journal of Trauma and Acute Care Surgery: February 2013 - Volume 74 - Issue 2 - p 448–453
doi: 10.1097/TA.0b013e31827e212c
AAST 2012 PLENARY PAPER
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BACKGROUND Ventilator-associated pneumonia is a problem in trauma and emergency general surgery patients. Our hospital-acquired infection prevention committee approved the use of early nonbronchoscopic bronchoalveolar lavage (screening-BAL) in the surgical intensive care unit (SICU) to identify ventilated patients with bronchiolar bacteria before 48 hours. We reviewed the results of this quality improvement initiative.

METHODS All ventilated patients in the SICU (March 2011 to June 2012) underwent a screening-BAL 36 hours to 48 hours after intubation; quantitative culture results (>5 × 104 colony-forming unit per milliliter) were used to identify positive specimens. Clinical pneumonia was defined as clinical pulmonary infection score greater than 6 with a subsequent positive diagnostic-BAL result. Sequential organ failure assessment scores were averaged for the first 48 hours in the SICU. Continuous and dichotomous data were compared, and a multivariate regression analysis was performed on the screening-BAL and pneumonia results.

RESULTS Screening-BALs were performed in 150 patients (99 trauma and 51 emergency general surgery patients), 72 of these specimens had positive findings. Fifty-three clinical pneumonias were diagnosed, and 45 (positive predictive value, 0.85) identified the same organism as the screening-BAL. Clinical pneumonia developed in eight patients with a negative screening-BAL (negative predictive value, 0.85). Antibiotic therapy at the time of the screening-BAL was associated with a negative screen (odds ratio, 0.44; p = 0.026). Pneumonia developed on median postintubation Day 4 (2–15 days) in patients with a positive screening-BAL results as compared with day 7.5 in the patients with a negative screening-BAL results (3.5–15 days; p = 0.007). Field intubation is an independent risk factor (odds ratio, 3.5; p = 0.004).

CONCLUSION Positive screening-BAL results in trauma and emergency general surgery patients are associated with the development of ventilator-associated pneumonia by the same organism and may play a role in identifying patients at risk for pneumonia. Further studies must be conducted to evaluate the role of screening-BAL in this patient population.

LEVEL OF EVIDENCE Diagnostic/prognostic study, level III.

From the Division of Burn, Trauma, and Critical Care (C.T.M., S.W., J.P.M.), Department of Surgery, University of Texas Southwestern, Dallas, Texas; Department of Respiratory Care (K.S.H.), Parkland Memorial Hospital, Dallas Texas; and Division of General Surgery (E.A.E.), Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.

Submitted: September 26, 2012, Revised: November 2, 2012, Accepted: November 5, 2012.

This study was presented at the American Association for the Surgery of Trauma Annual Meeting in Kaui, Hawaii, September 12–15, 2012.

Address for reprints: Christian Todd Minshall, MD, PhD, UT Southwestern, 5323 Harry Hines Blvd, Dallas TX, 75390; email: Christian.minshall@utsouthwestern.edu.

© 2013 Lippincott Williams & Wilkins, Inc.