Mini-BAL: not a small matter
Critical Care volume 17, Article number: 428 (2013)
In the study by Lacroix and colleagues  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 ; 31.5% patients had altered mental status, contraindicating bi-level positive airway pressure (BiPAP) during mini-BAL . 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 . 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.
health care-associated pneumonia.
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
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
Nava S: Non-invasive ventilation in acute respiratory failure. Lancet 2009, 374: 250-259. 10.1016/S0140-6736(09)60496-7
Polverino E, Torres A: Diagnostic strategies for healthcare-associated pneumonia. Semin Respir Crit Care Med 2009, 30: 36-45. 10.1055/s-0028-1119807
The authors declare that they have no competing interests.
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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
- Blood Culture
- Airway Pressure
- Quality Measure
- Positive Airway Pressure