Konrad F, Deller A, Bigos K, Heeg K, Kilian J
Universitätsklinik für Anaesthesiologie, Klinikum der Universität Ulm.
Anaesthesist. 1990 Jan;39(1):53-9.
In the diagnosis and treatment of bacterial pneumonia, the isolation and resistance pattern of the causative organisms are very relevant. Bronchoalveolar lavage (BAL) with quantitative culture is the best technique to obtain material for bacteriological investigations in nonintubated medical patients and in a baboon model. The present study was designed to clarify the following questions: What is the value of BAL compared to tracheal secretion (TS) in ventilated patients with regard to antibiotic therapy? Is it possible to distinguish colonization and infection by investigation of BAL? MATERIAL AND METHODS. In 34 ventilated patients, we studied the diagnostic and therapeutic value of BAL in comparison to TS. Thirteen patients suffered from pneumonia, 9 patients were colonized, and in 12 pneumonia was uncertain. These terms are defined as follows: 1. Pneumonia: temperature over 38.5 degrees C, leukocyte count over 12,000/mm3, infiltrate in the x-ray compatible with pneumonia, purulent tracheal secretion, positive bacteriological findings. All criteria must be fulfilled. 2. Colonized patients: mechanical ventilation more than 7 days, no signs of infection, isolation of the same bacteria species in two previously obtained tracheal secretions. 3. Uncertain pneumonia: not all criteria mentioned above were fulfilled. BAL was performed in the usual manner. The bronchoscope was wedged into a distal airway and 6 x 20 ml of sterile, nonbacteriostatic saline (0.9% NaCl) was instilled through the suction channel and subsequently aspirated. All investigation materials were immediately processed in the bacteriological laboratory. From the BAL specimen Giemsa and Gram preparations were performed to look for contamination from the throat and intracellular bacteria. RESULTS. Patients with pneumonia: In all patients the TS and BAL were positive. Cultures from BAL and TS were in agreement in 77% of the cases. In 10 patients intracellular bacteria (BAL) were present, in two patients the Gram preparation was nonapplicable because of destroyed cells. In one patient Haemophilus spp. could be isolated in the BAL (10(5)/ml BAL), but not in TS, which definitely influenced therapy. Colonized patients: In all patients TS and BAL were positive, with exact agreement in 33% of the cases. The concentration of isolated bacteria (BAL) was not as high in these patients as in the patients with pneumonia (median: 8 X 10(3) vs 6 X 10(4]. However BAL allowed no differentiation between colonization and infection in individual cases. Uncertain pneumonia: TS was positive in 8 patients, no TS could be obtained in 4. BAL was sterile in 4. Only in 2 bacteria greater than or equal to 10(4)/ml were isolated and both patients had intracellular bacteria. The results (BAL) influenced therapy in 5 cases (4 patients received no antibiotics; in 1 patient the antibiotics were modified). CONCLUSION. BAL is very helpful in patients suspected of having pneumonia and in sepsis of unknown origin when pneumonia should be excluded...
在细菌性肺炎的诊断和治疗中，致病微生物的分离及耐药模式至关重要。对于未插管的内科患者及狒狒模型，采用定量培养的支气管肺泡灌洗（BAL）是获取用于细菌学检查材料的最佳技术。本研究旨在阐明以下问题：在接受机械通气的患者中，就抗生素治疗而言，BAL与气管分泌物（TS）相比有何价值？通过对BAL进行检查能否区分定植和感染？材料与方法。在34例接受机械通气的患者中，我们研究了BAL与TS相比的诊断和治疗价值。13例患者患有肺炎，9例患者为定植状态，12例患者肺炎情况不明。这些术语定义如下：1. 肺炎：体温超过38.5℃，白细胞计数超过12,000/mm³，X线检查有与肺炎相符的浸润影，气管分泌物脓性，细菌学检查结果阳性。所有标准均须满足。2. 定植患者：机械通气超过7天，无感染迹象，在之前两次获取的气管分泌物中分离出相同细菌种类。3. 肺炎情况不明：未满足上述所有标准。BAL按常规方式进行。将支气管镜楔入远端气道，通过吸引通道注入6×20ml无菌、无抑菌作用的生理盐水（0.9%氯化钠），随后吸出。所有检查材料立即在细菌学实验室进行处理。对BAL标本进行吉姆萨染色和革兰氏染色，以查找来自咽喉的污染菌和细胞内细菌。结果。肺炎患者：所有患者的TS和BAL均为阳性。BAL和TS培养结果在77%的病例中一致。10例患者的BAL中存在细胞内细菌，2例患者因细胞破坏革兰氏染色不适用。1例患者的BAL中分离出嗜血杆菌属（10⁵/ml BAL），但TS中未分离出，这肯定影响了治疗。定植患者：所有患者的TS和BAL均为阳性，33%的病例结果完全一致。这些患者中分离出细菌（BAL）的浓度不如肺炎患者高（中位数：8×10³ 对 6×10⁴）。然而，BAL在个别病例中无法区分定植和感染。肺炎情况不明患者：8例患者的TS为阳性，4例未获取到TS。4例患者的BAL无菌。仅2例患者分离出细菌≥(10⁴)/ml，且这2例患者均有细胞内细菌。BAL结果在5例患者中影响了治疗（4例患者未使用抗生素；1例患者调整了抗生素）。结论。对于怀疑患有肺炎的患者以及不明原因脓毒症且需排除肺炎的患者，BAL非常有帮助……
