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.
Since its introduction 1967, fiberoptic bronchoscopy has proved to be a valuable diagnostic method for many pulmonary lesions. The technique has also been safe for the patient, with an incidence of major complications of only about 0.1 percent. Initially, FOB had little to offer as a diagnostic tool for pulmonary infections, since contamination of the instrument during passage through the upper airways made the results of cultures of bronchial secretion difficult to interpret. During the last ten years, however, with the use of protected catheters and quantitative cultures, bronchoscopy has been shown to be a reliable diagnostic method for establishing the etiology of pneumonia. Several investigators have, with somewhat varying results, used these techniques in selected groups of patients, with single- or double-sheathed, plugged or nonplugged catheters and with or without quantitative cultures. Obtaining high specificity quantitative cultures seems to be necessary.The low quantity (about 1 |xl) of bronchial secretion sampled with the protected brush is, by somebut not all authors, claimed to give rise to a low sensitivity. An antibacterial effect of topical anesthetics has been demonstrated in vitro, but is probably of small importance in vivo.
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Today, bronchoscopy is established as a diagnostic tool in immunocompromised patients with CAP and in patients with nosocomial pneumonia, especially in intensive care. However, the place of FOB in the diagnostic arsenal in the management of immunocompetent patients with CAP has not been evaluated. To use this technique in all patients hospitalized with CAP would be both unethical and uneconomic. Therefore, our purpose was to study prospectively a model for performing bronchoscopy in selected groups of patients with CAP as a supplement to noninvasive methods for obtaining an etiologic diagnosis.