Bronchoscopy with bronchoalveolar lavage via the laryngeal mask airway in high-risk hypoxemic immunosuppressed patients.
OBJECTIVE
Fiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL) are major tools in the diagnosis of pulmonary complications in immunocompromised patients. Nevertheless, severe hypoxemia is an accepted contraindication to FOB in nonintubated patients. The purpose of this study was to evaluate the feasibility and safety of laryngeal mask airway (LMA)-supported FOB with BAL in immunosuppressed patients with suspected pneumonia and severe hypoxemia.


METHODS
Prospective, clinical investigation.


METHODS
Medical intensive care unit of a university hospital.


METHODS
Forty-six immunosuppressed patients admitted to our intensive care unit with suspected pneumonia and Pao2/Fio2 < or = 125.


METHODS
After the administration of 0.3 mg x kg(-1) of etomidate, the patients were ventilated manually while receiving 1.0 Fio2. After the administration of 2.5 mg x kg(-1) of propofol, followed by an infusion of 9.1 +/- 2.3 mg x kg(-1) x hr(-1) of propofol, the LMA (size 3 or 4) was placed and connected to a bag-valve unit to allow manual ventilation with 1.0 Fio2. The FOB was introduced through a T-adapter attached to the LMA, and BAL was carried out with 150 mL of sterile 0.9% saline solution by sequential instillation and aspiration of 50-mL aliquots.


RESULTS
Three patients developed transient laryngospasm during passage of the bronchoscope via the LMA, which resolved with deepening of anesthesia. Changes in mean blood pressure, heart rate, Pao2/Fio2, and Paco2 values induced by the procedure did not reach significance. Seven patients (15%) presented hypotension (mean blood pressure, <60 mm Hg) maintained for 120 +/- 40 secs, which required plasma expanders in three cases. Oxygen desaturation to <90% occurred in six patients (13%) during BAL. Nevertheless, the lowest Sao2 during the procedure was significantly higher than the initial Sao2 (94% +/- 4% vs. 90% +/- 2%). No patient required tracheal intubation during the 8 hrs after the procedure. BAL had an overall diagnostic yield of 65%. Because of the results obtained by using the BAL analysis, treatment was modified in 33 (72%) cases.


CONCLUSIONS
Application of the LMA appears to be a safe and effective alternative to intubation for accomplishing FOB with BAL in immunosuppressed patients with suspected pneumonia and severe hypoxemia.
Hilbert
G
G
Medical Intensive Care Unit, Pellegrin Hospital, Bordeaux, France.
Gruson
D
D
Vargas
F
F
Valentino
R
R
Favier
J C
JC
Portel
L
L
Gbikpi-Benissan
G
G
Cardinaud
J P
JP
D000368:Aged; D018686:Anesthetics, Intravenous / Q000627:therapeutic use; D001784:Blood Gas Analysis; D018893:Bronchoalveolar Lavage / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D001999:Bronchoscopy / Q000009:adverse effects / Q000379:methods*; D000075202:Contraindications; D005045:Etomidate / Q000627:therapeutic use; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007022:Hypotension / Q000209:etiology; D000860:Hypoxia / Q000150:complications* / Q000276:immunology; D016867:Immunocompromised Host / Q000276:immunology; D017214:Laryngeal Masks; D007826:Laryngismus / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000150:complications* / Q000175:diagnosis* / Q000276:immunology; D015742:Propofol / Q000627:therapeutic use; D011446:Prospective Studies; D012307:Risk Factors; D012449:Safety
D018686:Anesthetics, Intravenous; D015742:Propofol; D005045:Etomidate