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Open Access

Mini-BAL: not a small matter

  • Mousumi Sircar1Email author,
  • Andrew Parziale1,
  • Michael Westrol2,
  • Ashish Tikotekar3 and
  • Amay Parikh3
Critical Care201317:428

Published: 22 April 2013


PneumoniaBlood CultureAirway PressureQuality MeasurePositive Airway Pressure

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.



bronchoalveolar lavage


community-acquired pneumonia


health care-associated pneumonia.


Authors’ Affiliations

Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, USA
Department of Emergency Medicine, Robert Wood Johnson Medical School, New Brunswick, USA
Pulmonary and Critical Care Division, Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, USA


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© BioMed Central Ltd 2013