Nonbronchoscopic Bronchoalveolar Lavage Improves Respiratory Culture Accuracy in Critically Ill Patients.
Nonbronchoscopic Bronchoalveolar Lavage Improves Respiratory Culture Accuracy in Critically Ill Patients.
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DOI：
10.1097/cce.0000000000001008
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发表时间：
2023-11
影响因子：
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通讯作者：
Scheraga, Rachel G.
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文献类型：
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作者：
Jeng, Margaret;Orsini, Erica M.;Yerke, Jason;Mehkri, Omar;Mireles-Cabodevila, Eduardo;Khouli, Hassan;Mujanovic, Samin;Wang, Xiaofeng;Duggal, Abhijit;Vachharajani, Vidula;Scheraga, Rachel G.
由于诊断方式有限，对于危重插管患者来说，肺炎的诊断具有挑战性。气管内抽吸物 (EA) 培养是许多 ICU 的护理标准；然而，频繁的 EA 污染会导致不必要的抗生素使用。非支气管镜支气管肺泡灌洗 (NBBL) 可获得无菌肺泡培养物，避免污染。然而，在气道培养缺乏金标准的情况下，配对 NBBL 和 EA 采样是提高培养准确性和限制危重患者抗生素使用的一种新方法。我们设计了一项试点研究来测试 EA 和 NBBL 之间的呼吸培养准确性。疑似肺炎的成人插管患者由注册呼吸治疗师同时接受 EA 和 NBBL 培养。检查了呼吸培养微生物学、细胞计数和抗生素处方实践。我们在俄亥俄州克利夫兰市的克利夫兰诊所主院医疗 ICU 进行了一项为期 22 个月的前瞻性试点研究，从 2021 年 5 月到 2023 年 3 月。对 340 名疑似肺炎的机械通气患者进行了筛查。 257 名患者因严重缺氧（Fio2 ≥ 80% 或呼气末正压≥ 12 cm H2O）、凝血功能障碍、血小板低于 50,000、治疗团队确定的血流动力学不稳定以及 COVID-19 感染而被排除，以防止病毒雾化。所有 83 名符合条件的患者均入选并同时接受 EA 和 NBBL。更多 EA 培养物 (42.17%) 比同时进行的 NBBL 培养物 (26.51%, p = 0.049) 呈阳性，表明 EA 污染。插管后 24 小时，EA 污染的几率增加了八倍。与 NBBL 培养物相比，EA 也更容易被口腔菌群污染。如果与 NBBL 培养阴性配对，EA 培养阳性患者的抗生素使用量呈减少趋势。从 NBBL 样本中回收了肺泡免疫细胞群，表明肺泡取样成功。 NBBL 没有出现严重并发症。对于危重插管患者的呼吸道培养，NBBL 比 EA 更准确。 NBBL 提供了一种安全有效的技术来对肺泡腔进行采样，用于临床和研究目的。
Diagnosis of pneumonia is challenging in critically ill, intubated patients due to limited diagnostic modalities. Endotracheal aspirate (EA) cultures are standard of care in many ICUs; however, frequent EA contamination leads to unnecessary antibiotic use. Nonbronchoscopic bronchoalveolar lavage (NBBL) obtains sterile, alveolar cultures, avoiding contamination. However, paired NBBL and EA sampling in the setting of a lack of gold standard for airway culture is a novel approach to improve culture accuracy and limit antibiotic use in the critically ill patients. We designed a pilot study to test respiratory culture accuracy between EA and NBBL. Adult, intubated patients with suspected pneumonia received concurrent EA and NBBL cultures by registered respiratory therapists. Respiratory culture microbiology, cell counts, and antibiotic prescribing practices were examined. We performed a prospective pilot study at the Cleveland Clinic Main Campus Medical ICU in Cleveland, Ohio for 22 months from May 2021 through March 2023. Three hundred forty mechanically ventilated patients with suspected pneumonia were screened. Two hundred fifty-seven patients were excluded for severe hypoxia (Fio2 ≥ 80% or positive end-expiratory pressure ≥ 12 cm H2O), coagulopathy, platelets less than 50,000, hemodynamic instability as determined by the treating team, and COVID-19 infection to prevent aerosolization of the virus. All 83 eligible patients were enrolled and underwent concurrent EA and NBBL. More EA cultures (42.17%) were positive than concurrent NBBL cultures (26.51%, p = 0.049), indicating EA contamination. The odds of EA contamination increased by eight-fold 24 hours after intubation. EA was also more likely to be contaminated with oral flora when compared with NBBL cultures. There was a trend toward decreased antibiotic use in patients with positive EA cultures if paired with a negative NBBL culture. Alveolar immune cell populations were recovered from NBBL samples, indicating successful alveolar sampling. There were no major complications from NBBL. NBBL is more accurate than EA for respiratory cultures in critically ill, intubated patients. NBBL provides a safe and effective technique to sample the alveolar space for both clinical and research purposes.