Comparison of Ballard catheter bronchoalveolar lavage with bronchoscopic bronchoalveolar lavage

Background Bronchoscopic bronchoalveolar lavage (BAL) in mechanically ventilated patients requires a large endotracheal tube, physician expertise, expensive equipment, and support staff. Methods The Ballard BAL catheter is a disposable coude tip 16F device that can be attached to the endotracheal tube and ventilator circuit without loss of positive end-expiratory pressure (PEEP) and also allows supplemental delivery of oxygen between the 12F inner and outer catheters. The catheter is directed into the selected bronchus. The inner catheter with mushroom tip is then advanced until it wedges by feel. Thirteen patients at a tertiary care, university hospital, had BAL performed through both the bronchoscope and Ballard BAL catheter using five aliquots of 20 mL of normal saline solution each. The return was quantified and submitted for blinded, paired laboratory investigations, including Gram stain and quantitative culture, and special stains and cultures as clinically appropriate. Results The procedure was well tolerated in all patients with no difference between devices in oxygen saturations; however, air leaks occurred in patients undergoing bronchoscopy and compromised safety in one. Two patients required reintubation to facilitate passage of the bronchoscope. The bronchoscopic BAL return averaged 49 mL (range, 5 to 85 mL) while BAL catheter averaged 37 mL (range, 18 to 70 mL) both being sufficient for all desired investigations except one patient who had undergone bronchoscopy. All were of excellent quality based on microscopy. The BAL results were concordant in nine patients: two Pneumocystis carinii , one Candida, one Streptococcus agalactiae , one Streptococcus pneumoniae , and no infection in four. Diagnoses of tuberculosis and Enterococcus (confirmed by blood culture) were obtained by the Ballard BAL catheter only. Kaposi's sarcoma and metastatic histiosarcoma were visualized by bronchoscope only. Two patients had compassionate plea use of the Ballard BAL catheter because of a small endotracheal tube. Hemorrhage secondary to lupus was documented in one and nosocomial infection was excluded in the other. Conclusions The Ballard BAL catheter allows easy, safe BAL, without loss of diagnostic yield, when visualization is not required in mechanically ventilated patients. The Ballard BAL catheter allows maintenance of PEEP when used with the supplied adapter and can be used with small endotracheal tubes.