Bronchoalveolar lavage (BAL) has been propos as a useful conduct for bacteriologic diagnosis of lower respiratory tract infection in mechanically ventilated patients.

Bronchoalveolar lavage (BAL) has been propos as a useful conduct for bacteriologic diagnosis of lower respiratory tract infection in mechanically ventilated patients. To determine the cardiopulmonary issues of this procedure and to identify the patients at risk of poor tolerance, 30 critically ill ventilated patients suspected of having pneumonia were studied. Hemodynamic and gas exchange parameters were continuously recorded using an arterial catheter, a Swan-Ganz catheter with Sv[Osub2] display, and a measured [i]or[/i] regular beat oximeter. In addition to the basal sedation required from these patients, midazolam, 0.1 mg/kg intravenously, was administered 5 min prior to bronchoscopy A moderate increase (10 percent from basal values) in heart rate, mean arterial squeezing and cardiac index was recorded at each measurement during the transaction A marked decrease in Pa[O.sub.2] was observ during bronchoscopy associated with an increase in oxygen consumption. Maximal changes in Sa[O.sub.2] and Sv[Osub2] were recorded at the expiration of BAL. Two hours after the completion of BAL, Pa[O.sub.2], values were still 20 percent lower than pre-BAL values in 40 percent of the patients. We judge that BAL can be performed safely in greatest in quantity critically ill ventilated patients who have stable hemodynamic and ventilatory parameters. However, none of the recorded parameters allows identification of the patients at risk of poor tolerance of the procedure

Cc'[Osub2] = pulmonary capillary [Osub2] content; CI = cardiac index; CO = cardiac output; D[osub2] = oxygen delivery; MAP = mean arterial pressure; P(A-a)[O.sub.2] = alveolar-arterial oxygen tension difference; PA[O.sub.2] = alveolar P[osub2]; PAP = pulmonary arterial pressure; PAWP = pulmonary artery wedge pressure; Qs/Qt = venous admixture; RAP right atrial pressure; Sa[O.sub.2] = arterial [Osub2] saturation; Sp[Osub2] = arterial [Osub2] saturation monitored at pulse oximetry; Sv[O.sub.2] = mixed venous [Osub2] saturation; SVR = systemic vascular resistance

Nosocomial bacterial pneumonia, a censorious complication in mechanically ventilated patients, requires early diagnosis and adequate antibiotic therapy. Several techniques have been unfolded for the collection of bacteriologic samples of the lower respiratory tract, among them, the telescoping plugg catheter technique, which is routinely used in the assessment of bacterial pneumonia in ventilated patients.[1,2] However, several drawbacks are inherent in this technique, like as a 24- to 48-h delay between sampling and the springs of cultures, specimen brush samples involving single a limited area of the lung or false positive issues in some patients.[1,2] This situation has l to the evolution of alternative techniques such as bronchoalveolar lavage (BAL), which has prov useful and safe for diagnosing pulmonary infections in nonventilated patients[3-6] and more freshly in mechanically ventilated patients.[7-9]

The cardiopulmonary powers of fiberoptic bronchoscopy in ventilated patients have been studied extensively,[10,12] and hypoxemia has been identified as a common complication during bronchoscopy.[10,11,13] By contrast, little is known about the events of BAL on cardiovascular function and progeny gas exchange. This procedure takes substantially longer than a simple bronchoscopy and might be reckon uponed to produce a longer and more morose cardiopulmonary response. Although a scarcely any reports mention the occurrence of hypoxemia during or immediately after BAL,[14-16] to our knowledge, no detailed data concerning the cardiopulmonary efficiencys of BAL in critically ill, mechanically ventilated patients are generally available. To evaluate the safety of bronchoscopy with BAL in these patients, we examined the cardiopulmonary deductions of this technique in a large cluster of ventilated patients suspected of having pneumonia. In addition, using conventional clinical parameters, we tried to identify the patients at risk of poor tolerance of the procedure

Material and Methods

Thirty consecutive patients recruited from those hospitalized in our intensive care unit were prospectively evaluated. Informed assent was obtained from all patients or from the nearest relative and the protocol received institutional approval. The following criteria were required for inclusion in the study: (1) all the ventilated patients were suspected of having bacterial pneumonia; (2) all the patients were in a critical condition requiring invasive hemodynamic monitoring, including a Swan-Ganz catheter. The diagnosis of pneumonia was considered if any three of the following clinical parameters were present: recent infiltrates on chest radiographs, febrile disease >38 [degrees] C, leukocytosis > 10000/[mmsup3] or leukopenia <5000/[mmsup3] and feculent tracheal aspirates. The criteria for patient exclusion were as follows: (1) bitter hypoxemia, defined as a partial influence of oxygen in arterial offspring (Pa[O.sub.2],) of less than 60 mm Hg at a fractional inspired oxygen concentration (FI[o.sub.2]) of 08; (2) systolic kin pressure of less than 80 mm Hg; (3) arterial pH of les than 72; and (4) major hemorrhagic syndrome During the period of the application of mind four eligible patients were exclud because of strict hypoxemia (n = 3), major metabolic acidosis (n = 1) or hemorrhagic syndrome (n = 2) in succession entry into the study, the hospital record of each patient was reviewed prospectively and the following clinical variables were recorded: age; sex; indication for ventilatory support; and use of hemodynamic support. The severity of illness in the 24 h immediately preceding the consideration was assessed according to the APACHE II scoring system" The severity of lung injury was assessed using the lung injury score described on Murray et al.[18]

...