Skip to main content

Mini-BAL: not a small matter

In the study by Lacroix and colleagues [1] in the previous issue of Critical Care, we appreciate the early use of the mini-bronchoalveolar lavage (mini-BAL) to diagnose health care-associated pneumonia (HCAP). However, some limitations of the study create difficulties in initiating this protocol in our institution.

Hospitalized/intubated patients with HCAP were not studied. These patients represent a significant fraction of those undergoing blood culture/mini-BAL for diagnosis.

In our population, emergency physicians dispense broad-spectrum antibiotics expediently as a quality measure; therefore, subsequent mini-BAL may yield few results. The article did not present final antibiotic selections, patient outcomes, or antibiotic de-escalation. We cannot estimate the final cost of the antibiotic course or compare it with the cost of mini-BAL/bronchoscopy. The antibiotics might not be more cost-effective than the procedure.

Mini-BAL without bronchoscopy may be cost-effective but has low yield [2]; 31.5% patients had altered mental status, contraindicating bi-level positive airway pressure (BiPAP) during mini-BAL [3]. We do not know whether sedation (which may be risky) was used.

Results of mini-BAL culture are compared with those of blood cultures. Blood cultures in community-acquired pneumonia/HCAP (CAP/HCAP) have limitations. Only high-risk patients benefit from blood culture in diagnosing CAP. Also, with prior antibiotics, blood culture sensitivity for CAP/HCAP diagnosis decreases [4]. We do not know whether HCAP organisms were distinguished from colonizing flora.

We applaud the trial as conducted but feel that the inclusion of a comparison of cost, technical descriptions of the mini-BAL in regard to the need for bronchoscopy and sedation, inclusion of hospitalized/intubated patients, choice of antibiotics/de-escalation, and use of antibiotics prior to enrollment would more effectively support the authors' conclusions.

Abbreviations

BAL:

bronchoalveolar lavage

CAP:

community-acquired pneumonia

HCAP:

health care-associated pneumonia.

References

  1. 1.

    Lacroix G, Prunet B, Bordes J, Cabon-Asencio N, Asencio Y, Gaillard T, Pons S, D'Aranda E, Kerebel D, Meaudre E, Goutorbe P: Evaluation of early mini-bronchoalveolar lavage in the diagnosis of health care-associated pneumonia: a prospective study. Crit Care 2013, 17: R24. 10.1186/cc12501

    PubMed Central  Article  PubMed  Google Scholar 

  2. 2.

    Colucci G, Domenighetti G, Della Bruna R, Bonilla J, Limoni C, Matthay MA, Martin TR: Comparison of two non-bronchoscopic methods for evaluating inflammation in patients with acute hypoxaemic respiratory failure. Crit Care 2009, 13: R134. 10.1186/cc7995

    PubMed Central  Article  PubMed  Google Scholar 

  3. 3.

    Nava S: Non-invasive ventilation in acute respiratory failure. Lancet 2009, 374: 250-259. 10.1016/S0140-6736(09)60496-7

    Article  PubMed  Google Scholar 

  4. 4.

    Polverino E, Torres A: Diagnostic strategies for healthcare-associated pneumonia. Semin Respir Crit Care Med 2009, 30: 36-45. 10.1055/s-0028-1119807

    Article  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Mousumi Sircar.

Additional information

Competing interests

The authors declare that they have no competing interests.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Sircar, M., Parziale, A., Westrol, M. et al. Mini-BAL: not a small matter. Crit Care 17, 428 (2013). https://doi.org/10.1186/cc12595

Download citation

Keywords

  • Pneumonia
  • Blood Culture
  • Airway Pressure
  • Quality Measure
  • Positive Airway Pressure