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BAL vs. Endotracheal Aspiration in Ventilator-Associated Pneumonia

Mortality and antibiotic use were similar whether cultures were obtained by bronchoalveolar lavage or by endotracheal aspiration.

Ideally, culture results should guide the treatment of patients with ventilator-associated pneumonia (VAP). In this randomized multicenter study, researchers compared two methods for obtaining cultures from 740 mechanically ventilated adults with suspected VAP.

Patients underwent either bronchoalveolar lavage (BAL) with quantitative culture of BAL fluid or endotracheal aspiration with nonquantitative culture of aspirate. Each patient was also randomized to empirical therapy with meropenem alone or with meropenem plus ciprofloxacin; subsequently, antibiotic therapy was modified, based on culture results. Immunocompromised patients and patients already infected or colonized with pseudomonas or with methicillin-resistant Staphylococcus aureus were excluded.

Cultures were more likely to be positive in BAL patients than in endotracheal-aspiration patients (60% vs. 52%). About 74% of patients in each group received "targeted" antibiotic therapy (i.e., antibiotics were stopped or modified based on culture results). Twenty-eight–day mortality (the primary outcome) and duration of antibiotic therapy were virtually identical in the BAL and endotracheal-aspiration groups. Finally, mortality was similar whether patients received one-drug or two-drug initial empirical therapy.

Comment: These researchers expected to see increased use of targeted therapy and improved outcomes with BAL, compared with endotracheal aspiration. But that's not what happened: Outcomes were similar in the two groups. The findings suggest that when initial empirical therapy is adequate, and when antibiotics are adjusted appropriately, either diagnostic approach is acceptable. However, these conclusions might not apply to certain patients, because of the enrollment exclusions noted above.

— Allan S. Brett, MD

Published in Journal Watch General Medicine December 20, 2006

Citation(s):

The Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006 Dec 21; 355:2619-30.

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• Cos Omoko Kolloko...thanks alot
  Johny lahood zogby, pharmacyy, 17 Apr 2009 1:40 AM EST
  Cos Omoko f3ln...great effort in arabic :)