Benefit-to-risk balance of bronchoalveolar lavage in the critically ill. A prospective, multicenter cohort study

Abstract

Purpose: To assess the benefit-to-risk balance of bronchoalveolar lavage (BAL) in intensive care unit (ICU) patients.

Methods: In 16 ICUs, we prospectively collected adverse events during or within 24 h after BAL and assessed the BAL input for decision making in consecutive adult patients. The occurrence of a clinical adverse event at least of grade 3, i.e., sufficiently severe to need therapeutic action(s), including modification(s) in respiratory support, defined poor BAL tolerance. The BAL input for decision making was declared satisfactory if it allowed to interrupt or initiate one or several treatments.

Results: We included 483 BAL in 483 patients [age 63 years (interquartile range (IQR) 53-72); female gender: 162 (33.5%); simplified acute physiology score II: 48 (IQR 37-61); immunosuppression 244 (50.5%)]. BAL was begun in non-intubated patients in 105 (21.7%) cases. Sixty-seven (13.9%) patients reached the grade 3 of adverse event or higher. Logistic regression showed that a BAL performed by a non-experienced physician (non-pulmonologist, or intensivist with less than 10 years in the specialty or less than 50 BAL performed) was the main predictor of poor BAL tolerance in non-intubated patients [OR: 3.57 (95% confidence interval 1.04-12.35); P = 0.04]. A satisfactory BAL input for decision making was observed in 227 (47.0%) cases and was not predictable using logistic regression.

Conclusions: Adverse events related to BAL in ICU patients are not infrequent nor necessarily benign. Our findings call for an extreme caution, when envisaging a BAL in ICU patients and for a mandatory accompaniment of the less experienced physicians.

Keywords: Bronchoalveolar lavage; Fiberoptic bronchoscopy; Intensive care; Multicenter study.

Fig. 1

Study flow chart. a Among the 1234 bronchoalveolar lavages (BAL) performed during the study period, we did not record whether they comprised cellular analysis by a pathologist or if they were mini-BAL or BAL performed with or without bronchoscopy. b Patient recruitment exceeded the 500 expected, because we anticipated a number of non-workable case report forms

Fig. 2

Counts and percentages of grade 3 adverse event(s) during or after BAL according to physician’s experience and type of initial respiratory support. NS not significant. We defined the physician performing the BAL as an “experienced physician” when he/she was a pulmonologist or when he/she was an intensivist with the greatest experience (i.e., > 10 years in the specialty or > 50 BAL performed)

Fig. 3

Predicted probability of obtaining a BAL of good quality according to the amount of BAL fluid recovered in the whole study population. BAL bronchoalveolar lavage. For this estimation of the probability of obtaining a BAL of good quality, logistic regression adjusted for all covariables (see Table S6 in Online Resource 1) was used. The amount of BAL fluid recovered was transformed in cubic splines to account for non-linearity. The biphasic shape of the figure shows that below 60 mL of BAL fluid recovered, the estimated probability declines in parallel with the amount of fluid recovered