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Minibronchoalveolar Lavage by Respiratory Therapists
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
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•Type with double-spacing
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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IN RESPONSE:
I agree that we currently lack adequate clinical data supporting the routine use of bronchoscopic or nonbronchoscopic lower-airway sampling for the evaluation of suspected ventilator-associated pneumonia [1]. This is due, in part, to the limitations of these techniques, including the need for physician performance of bronchoscopy, and the lack of outcome data suggesting any benefit from the use of these techniques compared with routine clinical management. Prospective trials are required to determine the clinical efficacy and cost-effectiveness of these diagnostic techniques.
Antibiotic administration is recognized as an important limitation of lower-airway sampling methods, which primarily result in false-negative cultures despite the histologic presence of pneumonia [2, 3]. Having readily available lower-airway sampling techniques such as minibronchoalveolar lavage or quantitative cultures of endotracheal aspirates, which do not depend on a physician, allows respiratory cultures to be more easily obtained before antibiotic therapy is begun or changed [4]. Additionally, obtaining endobronchial cultures from specific lung segments does not appear to be necessary because ventilator-associated pneumonia is a multifocal process usually involving dependent lung regions that can be blindly sampled by minibronchoalveolar lavage [3]. The pathophysiologic and histologic characteristics of ventilator-associated pneumonia, along with the results from a recent bronchoscopic study, do not support the need for selective endobronchial sampling of specific lung segments to establish this diagnosis [5].
The data from my study also suggest that minibronchoalveolar lavage, like quantitative cultures of endotracheal aspirates, may be more sensitive but less specific than the protected specimen brush technique [2]. The clinical importance of the differences in the operating characteristics of these diagnostic tests is currently unknown and awaits the results of prospective studies using appropriate patient outcomes as end points. Despite these limitations, continued investigation of nonbronchoscopic lower-airway sampling methods seems warranted to develop an accurate and accessible diagnostic test for patients with suspected ventilator-associated pneumonia.
Marin H. Kollef, MD
Washington University School of Medicine
St. Louis, MO 63110
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
