From the Division of Burn, Trauma, and Critical Care (C.M.S., R.D.F., J.M., C.T.M.), Department of Surgery, University of Texas Southwestern, Dallas, Texas; Department of Pharmacy Services (P.C., J.K., C.K.), Parkland Memorial Hospital, Dallas, Texas; Department of Respiratory Care (K.S.H.), Parkland Memorial Hospital, Dallas, Texas; Division of General Surgery (E.A.E.), Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
J Trauma Acute Care Surg. 2014 May;76(5):1264-9. doi: 10.1097/TA.0000000000000219.
We evaluated the role of serial catheter-directed bronchoalveolar lavage (CDBAL) in the diagnosis and management of pneumonia in ventilated surgical intensive care unit patients.
Intubated surgical intensive care unit patients were prospectively evaluated with serial CDBALs from September 1, 2012, to May 31, 2013. Initial CDBALs were performed if patients developed the following signs of pneumonia: white blood cell count greater than 11 or less than 4, temperature greater than 38.5°C or less than 36°C, qualitative purulent sputum, worsening oxygenation, or new infiltrate on plain chest x-ray. Subsequent CDBALs were performed every 4 days. Pneumonia was diagnosed using a Clinical Pulmonary Infection Score of greater than 6 and CDBAL cultures with greater than or equal to 10 colony-forming units of pathogenic organisms. Patients were also evaluated for sustained (≥48 hours) respiratory deterioration (increased FIO2 or positive end-expiratory pressure) corresponding to the National Healthcare Safety Network definition of ventilator-associated event (VAE).
A total of 159 patients were intubated for 5 days or longer, of whom 80 patients were diagnosed with clinical pneumonia. Of these patients, 67 had serial CDBALs performed, and 81 ventilator-associated pneumonias (VAPs) were diagnosed in these patients. Of the patients with VAP, 16 also met the National Healthcare Safety Network criteria for VAE. Patients with VAP that had sustained respiratory deterioration demonstrated resolution of their compromise 60 hours (interquartile range [IQR], 41-107 hours) after starting antibiotics. Of the patients with pneumonia, 66 (81%) had resolution of the pathogenic bacteria in subsequent CDBAL cultures or were extubated within 4 days (IQR, 4-5 days) after starting antibiotics. The duration of antibiotic therapy in this group was 8 days (IQR, 7-9 days). The remaining 15 patients had multiple positive serial CDBAL cultures that isolated the same organism despite antibiotic treatment. The duration of antibiotic therapy was 14 days (IQR, 10-19 days) in these patients. The culture results were used to adjust antibiotic regimens a median of one time (IQR, 1-2 times) in 13 (87%) and two or more times in 6 (40%) of these patients.
Serial CDBALs help guide antibiotic treatment duration in patients with pneumonia and VAE. Patients with sustained hypoxia or persistent bacterial growth may require prolonged therapy.
Diagnostic test, level III. Therapeutic study, level IV.
我们评估了连续经支气管镜肺泡灌洗（CDBAL）在诊断和治疗机械通气外科重症监护病房患者肺炎中的作用。
2012 年 9 月 1 日至 2013 年 5 月 31 日，对接受气管插管的外科重症监护病房患者进行前瞻性评估，进行连续 CDBAL，如果患者出现以下肺炎迹象，则进行初始 CDBAL：白细胞计数大于 11 或小于 4，体温大于 38.5°C 或小于 36°C，脓性痰，氧合恶化或胸片新浸润。随后每 4 天进行一次 CDBAL。肺炎的诊断依据临床肺部感染评分大于 6 分和 CDBAL 培养物中大于或等于 10 个致病生物体的菌落形成单位。患者还根据国家医疗保健安全网络（National Healthcare Safety Network，NHSN）定义的呼吸机相关事件（ventilator-associated event，VAE），评估是否存在持续（≥48 小时）呼吸恶化（增加吸氧浓度或呼气末正压）。
共有 159 例患者气管插管 5 天或更长时间，其中 80 例患者被诊断为临床肺炎。这些患者中有 67 例进行了连续 CDBAL，这些患者中有 81 例呼吸机相关性肺炎（ventilator-associated pneumonia，VAP）。在 VAP 患者中，16 例也符合 NHSN 呼吸机相关事件（VAE）的标准。发生 VAP 且持续呼吸恶化的患者，在开始抗生素治疗后 60 小时（四分位距[interquartile range，IQR]，41-107 小时），呼吸状况得到改善。在这些肺炎患者中，66 例（81%）在后续 CDBAL 培养中病原体得到清除，或在开始抗生素治疗后 4 天（IQR，4-5 天）内拔管。该组的抗生素治疗持续时间为 8 天（IQR，7-9 天）。其余 15 例患者尽管接受了抗生素治疗，但连续 CDBAL 培养中仍多次分离出相同的病原体。这些患者的抗生素治疗持续时间为 14 天（IQR，10-19 天）。这些患者的中位调整抗生素方案次数为 1 次（IQR，1-2 次），13 例（87%）中有 2 次或更多次调整方案，6 例（40%）中有 2 次或更多次调整方案。
连续 CDBAL 有助于指导肺炎和 VAE 患者的抗生素治疗持续时间。持续缺氧或持续细菌生长的患者可能需要延长治疗。
诊断性测试，III 级。治疗性研究，IV 级。
