Safety of Broncho-alveolar Lavage in Ventilated Patients With Acute Respiratory Distress Syndrome

Abstract

To the Editor: Bronchoalveolar lavage (BAL) is an essential diagnostic tool in infiltrative lung disease. According to national standards,1 BAL should be well tolerated in ventilated patients provided appropriate precautions are taken, even in acute respiratory distress syndrome (ARDS).2 During BAL in a nonventilated patient, the standard 5.7-mm bronchoscope only occupies 10% to 15% of the tracheal cross-sectional area whereas in the intubated patient, it occupies 66% of a 7-mm endotracheal tube (ETT) and 40% of a 9-mm ETT.1 Therefore, transient desaturation during BAL is expected. However, there are also previous reports of acute changes in hemodynamic status, significant desaturation, and even cardiac arrest.3 One hundred forty-eight ventilated patients with ARDS in Intensive Care Unit (ICU) according to the 1994 consensus definition4 were bronchoscoped in the ICU with BAL for investigation of ventilator-associated pneumonia. Patients were preoxygenated and sedated with/without paralysis before BAL. During BAL, continuous oximetry, electrocardiogram, and hemodynamic monitoring were undertaken. The mean (SE) patient age was 60.9 years (1.31) (81 men and 67 women), with baseline PaO2/FiO2 141.6 mm Hg (6.01), APACHE2 19.7 (0.69), SAPS2 45.1 (1.26), and APACHE3 72.5 (2.3). The minimum ETT diameter was 8 mm. No deaths or major complications occurred in relation to BAL. Only 2 (bronchospasm and secretion retention) minor episodes of desaturation (fall in SpO2 of 6%) occurred both at 2 hours after BAL, a complication rate of 1.4% (P=0.49, Fisher exact). No associated significant hemodynamic alterations occurred. In conclusion, in keeping with national guidelines and many previous observational studies, bronchoscopy with BAL in ICU in ventilated ARDS patients (even with extreme hypoxemia as above) is safe provided adequate precautions are taken. These include hemodynamic stability of the patient before BAL, preoxygenation, an ETT of sufficient diameter and adequate sedation/paralysis with appropriate oxygenation and monitoring after BAL, especially in the first 2 hours. Andrew R. Medford, MD* Ann Brigid Millar, MD† *Chest Clinic, Derriford Hospital, Plymouth Devon †Department of Clinical Science at North Bristol, University of Bristol, Paul O'Gorman Lifeline Centre, Southmead Hospital, Westbury-on-Trym, Bristol Avon, England, UK