Objective: To evaluate the clinical utility
of bronchoscopy with protected brush catheter (PBC) and BAL for
patients with ventilator-associated pneumonia (VAP).
Design: Prospective cohort study.
Ten tertiary care ICUs in Canada.
mechanically ventilated patients with a clinical suspicion of VAP who
underwent bronchoscopy were compared with 49 patients with a clinical
suspicion of pneumonia who did not.
Measurements and results: We compared antibiotic
use, duration of mechanical ventilation, ICU stay, and mortality. In
addition, for patients who received bronchoscopy, we administered a
questionnaire (before and after bronchoscopy) to evaluate the effect of
PBC or BAL on (1) physician perception of the probability of VAP, (2)
physician confidence in the diagnosis of VAP, and (3) changes to
antibiotic management. After bronchoscopy results became available,
from the physician’s perspective, the diagnosis of VAP was deemed much
less likely (p < 0.001), confidence in the diagnosis increased
(p = 0.03), and level of comfort with the management plan increased
(p = 0.02). Following the results of invasive diagnostic tests, in
the group that underwent bronchoscopy, patients were receiving fewer
antibiotics (31/92 vs 9/49, p = 0.05) and more patients had treatment
with all their antibiotics discontinued (18/92 vs 3/49, p = 0.04)
compared with the group that did not undergo bronchoscopy. Duration of
mechanical ventilation and ICU stay were similar between the two
groups, but mortality was lower in the group that underwent
bronchoscopy with PBC or BAL (18.5% vs 34.7%, p = 0.03).
Conclusions: Invasive diagnostic testing may increase
physician confidence in the diagnosis and management of VAP and
allows for greater ability to limit or discontinue antibiotic
treatment. Whether performing PBC or BAL affects clinically important
outcomes requires further study.
MOD = multiple organ dysfunction; PBC = protected brush catheter;
VAP = ventilator-associated pneumonia