Category: Disease - Part 4

DISCUSSION part 2

In two of the remaining 11 patients, the result of FOB was considered as possibly false negative. One patient (No. 2) recovered only after a change of treatment from oral penicillin to cefuroxime and from another (No. 10), pneumococcal antigen was detected in sputum after bronchoscopy had been performed. It is possible that an increased sensitivity could have been obtained by the use of bronchoalveolar la­vage. However, culture results from BAL fluid may be difficult to interpret since strict quantitation is impossible to perform because the amount of bronchial secretion sampled with the lavage is un­known.

Although, during the main study, patients with probable atypical pneumonia received erythromycin or tetracycline as initial therapy (30 patients, 11 percent) mycoplasmal pneumonia was the most com­mon cause of both early and late therapy failure, with eight of 18 and five of 19 cases, respectively. Of these 13 patients, ten were preliminarily identified clinically and only three underwent bronchoscopy (No. 1, 6, 14). However, a sensitive and rapid diagnostic method for Mycoplasma would clearly facilitate the handling of these patients.

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In this prospective study, we tried to evaluate the usefulness of diagnostic FOB in patients with CAP A significant decline in arterial oxygen pressure (Pa02) is common following FOB, with a subsequent risk of cardiac arrhythmia in particular. This could be especially hazardous in patients with pneumonia, in whom fever, tachycardia, and an already lowered Pa02 are common. However, by adding supplemental oxygen to patients at risk, no cardiac complications were seen in any of our patients, nor were there any other complications, which supports the safety of the bronchoscopic procedure reported earlier.

Injection of lidocaine through the inner channel of the bronchoscope has been claimed to introduce a larger amount of bacterial contaminants into the lower airways than if the anesthesia is performed by nebu- lization. However, Winterbauer et al found injec­tion of lidocaine to be a minor problem if the volume was small (<=3 ml) and if there was no suction through the side channel until the PB culture was obtained.

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Bronchoscopy Before Start of Antibiotic Therapy

A presumptive etiologic diagnosis, valuable for the management of the patients, was obtained in all of the six patients examined before the start of antibiotic therapy (Table 4). The PB culture was positive in four of the patients, whereas in one patient (No. 21), S pneumoniae was found only in cultures from bron­chial secretion. In the last patient (No. 24), a bronchial tumor was found, but no infectious agent.

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Diagnostic Fiberoptic Bronchoscopy and Protected Brush Culture: RESULTS

Demographic Data The mean age of the 24 patients, 13 women and 11 men, undergoing bronchoscopy was 53 years (SD ± 16). Ten were smokers and one was a known alcoholic. Eight patients had a known pre-existing medical condition, and two of these were immunocom­promised.

Patient Compliance and Complications

Consent was given by all patients to whom FOВ was suggested because of therapy failure. Six of eight patients who were asked to participate in the study before antibiotic therapy was started agreed to bron­choscopy. No complications were seen during or after bronchoscopy in any of the 24 patients.

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Contraindications to Bronchoscopy

Absolute contraindications were bleeding abnormalities, severe cardiac disease, acute asthma, and allergy to local anesthetics. High age (>=70 years) and severe hypoxia (PaOz<8kPa) were relative contraindications. Bronchoscopy Procedure Before the bronchoscopy, the patient fasted for at least three hours. Prothrombin value and blood platelets were measured and a blood-gas analysis was performed. The only premedication given was atropine, 0.5 mg intramuscularly, one half hour before the bronchoscopy. During the bronchoscopy, the patient was observed with continuous electrocardiogram, and if necessary, received extra oxygen through a nasal catheter.

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Patients with CAP treated in the Department for Infectious Diseases at Danderyd Hospital were included in the study.

Pilot study: to test the planned bronchoscopy procedure, seven CAP patients received bronchoscopy between October 1985 and December 1986.

Main study: during a ten-month period in 1987, all adult (>=18 years) patients (HIV patients excluded for technical reasons) hos¬pitalized with clinical signs of a community-acquired lower respiratory tract infection and a pulmonary x-ray film showing new infiltrates, or infiltrates resolving after treatment, were included in a study of the etiology and prognosis of CAP.

Repeated samples were obtained from blood and sputum for bacteriologic culture. Sputum was cultured quantitatively after washing and deeming its purulehce. Sputum and urine specimens were also examined for the presence of pneumococcal capsular polysaccharide antigen by coagglutination (Capsular-CoA). Serolog¬ical tests with paired sera were performed for Mycoplasma pneumoniae, Chlamydia psittaci, Legionella species, and respiratory viruses.

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Diagnostic Fiberoptic Bronchoscopy and Protected Brush Culture

Community-acquired pneumonia remains one of the most common causes of morbidity and hos­pitalization, especially among elderly people.

Although Streptococcus pneumoniae is still the most common causative agent among adults who are hos­pitalized because of CAP, there are a number of less common pathogens for which treatment with penicil­lin is not adequate. Therefore, the precise identifi­cation of the agent(s) causing the pneumonia is most important. Yet this identification is often difficult. The definitive diagnosis by means of a positive blood or pleural culture is achieved too infrequently and rou­tine sputum is often unobtainable or nondiagnostic.

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