Bronchoscopic Diagnosis of Pulmonary Infections Comparison of Protected-Specimen Brush and Cytology Brush With Lung Aspirates EUGENE C. FLETCHER, MD, Houston; JOHN A. MOHR, MD; DAVID C. LEVIN, MD, and D. J. FLOURNOY, PhD, Oklahoma City
In a recent study the use of a new plugged double-lumen protected-specimen brush with the flexible fiberoptic bronchoscope was advocated to isolate pathogens in lower respi- ratory tract infections while avoiding upper respiratory tract contamination. To compare the efficacy of this brush and a standard single-lumen cytology brush in identifying the etiologic agent in lower respiratory tract infections, we studied 18 patients with lung in- fections. Transthoracic lung aspiration was done in all but two patients in an attempt to identify the specific etiologic agent. In these two cases, cultures of specimens of blood or postmortem lung tissue yielded the causative organism. In 12 patients anaerobic or aerobic bacteria (or both) were identified, whereas one patient had a mixed bacterial and fungal infection. Using the cytology brush and the protected-specimen brush we identi- fied at least one pathogen in 10 of 12 and 10 of 13 cases, whereas both brushes missed one or more causative organisms in 8 of 12 and 8 of 13 cases, respectively. Nonetiologic organisms were found in 8 of 12 cases by the cytology brush and 8 of 13 cases by the protected-specimen brush. Quantitative culture techniques improved the specificity of the brush results in infections where aerobes predominated. Our data show that broncho- scopic cultures of lower respiratory tract infections do not consistently recover the causa- tive agent and are frequently subject to contamination by nonetiologic organisms. There was no difference between the brushes in avoiding contamination.
Identification of specific pathogens involved in lower fiberoptic bronchoscopy appears to be a more direct respiratory tract infections continues to pose a prob- method of sampling lower respiratory tract secretions lem. Sputum remains the most commonly used material but has been associated with contamination by non- for isolating microbes from the infected lung in spite causative organisms during its passage through the of its proved poor yield of the true pathogens"2 and nasopharynx.79 Additionally, local anesthetics used dur- too often findings of false pathogens.34 Transtracheal ing bronchoscopy have been shown to inhibit bacterial aspiration, which is thought to bypass the upper respi- and mycobacterial growth.9-"1 ratory tract, has also been shown to yield both false- Attempting to eliminate the problem of contamina- positive and false-negative results5-8 and may some- tion and inhibition of bacterial growth by local anes- times be complicated by laryngeal spasm, bleeding, thetics, Wimberley and co-workers'2 designed and car- local infection and subcutaneous emphysema.5 Flexible ried out limited in vitro and in vivo tests on a new
Refer to: Fletcher EC, Mohr JA, Levin DC, et al: Bronchoscopic diagnosis of pulmonary infections: Comparison of protected-specimen brush and cytology brush with lung aspirates. West J Med 1983 Mar; 138:364-370. From the Pulmonary and Infectious Disease Sections, Department of Medicine, the University of Oklahoma at Oklahoma City, Health Sciences Center and the Veterans Administration Medical Center, Oklahoma City. Dr Fletcher is now affiliated with the Veterans Administration Medical Center, Houston. This work was supported in part by US Public Health Service (NIH) grants HL 07210 and HL 07155 and by the Veterans Administration. Informed consent was obtained from all patients or guardians participating in this study. This protocol was approved by the Human Experimentation Committees of all institutions involved. Submitted, revised, August 9, 1982. Reprint requests to Eugene C. Fletcher, MD, Dept. 111I, Veterans Administration Medical Center, 2002 Holcombe Blvd, Houston, TX 77211.
364 THE WESTERN JOURNAL OF MEDICINE BRONCHOSCOPIC DIAGNOSIS protected-specimen brush that is now marketed com- amination. With the patients seated, the skin was mercially (Medi-Tech BFW/ 1.0/70/90, Cooper Sci- cleansed with povidone-iodine and 70 percent alcohol entific Corporation, Watertown, Mass) for use with and anesthetized with 1 percent lidocaine. A 20-gauge the flexible bronchoscope. The system consists of an spinal needle on a 20-ml syringe containing 3 ml of inner brush surrounded by two telescoping polyethylene nonbacteriostatic saline was advanced into the lung catheters sealed at the tip by a water-soluble plug. The parenchyma and the saline injected. Immediate suction inner catheter and brush are successively "telescoped" was applied and the needle slowly withdrawn. If no into a diseased airway and the plug extruded for sam- material was recovered the procedure was repeated in pling. The brush and catheters are withdrawn in reverse the same or a slightly different location. A drop of the order and the brush used as a source for smear and aspirate was smeared on a sterile glass slide and ex- culture material. amined after Gram's method of staining. The remaining Although the protected-specimen brush appears to aspirate was inoculated into 1 ml of trypticase soy broth offer a new, accurate technique for sampling lower re- (Difco) and into 10 ml of prereduced chopped meat-glu- spiratory tract flora in lung infections, clinical testing cose broth (Carr Microbiologicals). Within 30 minutes of of the brush has been limited, and to our knowledge no collection, 0.01 -ml aliquots of the trypticase soy broth trials in humans have been done testing this brush suspension were plated on 5 percent sheep blood, against cultures of specimens taken from percutaneous chocolate and desoxycholate agar and incubated aero- needie aspiration of infected lungs. We therefore con- bically at 35°C. The chopped meat-glucose broth was ducted a prospective study to evaluate the effectiveness held at 350C until turbid, or at least five days, then of the protected brush versus an unprotected single- subcultured using 5 percent sheep blood agar (aerobic), catheter cytology brush (Medi-Tech BT/1.73/58/140) Schaedler's Brucella 5 percent sheep blood agar and in isolating pathogens from various lung infections. kanamycin-vancomycin blood agar (anaerobic, 350C) The isolated organisms obtained at bronchoscopy were for subsequent qualitative determination of anaerobic then compared with the organisms recovered by trans- organisms. thoracic lung aspiration. Flexible fiberoptic bronchoscopy was carried out with an Olympus BF-B2 fiberoptic bronchoscope. Pre- Materials and Methods medication consisted of 0.6 mg of atropine given intra- There were 18 patients, aged 17 to 86, who were muscularly and the inhalatio-n of nebulized 4 percent studied during hospital admissions for pulmonary in- lidocaine for 15 minutes before bronchoscopy. With a fections at the University Hospital, Oklahoma Chil- patient in the supine position, 10 ml of 2 percent vis- dren's Memorial Hospital and the Oklahoma City cous lidocaine was injected intranasally and a sterile Veterans Administration Medical Center between July flexible nasopharyngeal airway'5 inserted so that the 1, 1979, and May 1, 1980. All patients had clinical distal tip approached the vocal cords. After the bron- and roentgenographic signs of lower respiratory tract choscope was introduced through the nasopharyngeal infection and only those with severe, life-threatening airway and the cords visualized, 5 to 10 ml of 1 percent disease or underlying illnesses such as alcoholism or lidocaine was instilled onto the cords via the suction preexisting pulmonary disease were accepted for this channel. No additional lidocaine was used until after study. Patients with impaired clotting ability, advanced the bronchial brush specimens were obtained except in bullous disease or pleural effusions were excluded be- cases of extreme bronchial irritability. The broncho- cause of the risks involved with transthoracic lung as- pulmonary segment corresponding to the radiographic- piration. In two intubated patients who were being ally diseased area was visualized and entered with the mechanically ventilated, blood cultures in one and post- tip of the bronchoscope. mortem lung tissue culture obtained within two hours Four brush specimens (two by protected-specimen of death in the other provided etiologic organisms. Nine brush and two by cytology brush) were collected in patients had received antibiotics before study but were random order from each patient according to the included because there had been no clinical response methods described by Wimberley and colleagues12 and to therapy and the identity of the infecting agent was in the instructions accompanying the protected-specimen doubt at the time of the study. The study design was brush catheters. At the bedside, specimens from a pro- approved by the Human Experimentation Committees tected-specimen brush and a cytology brush were at the institutions involved and informed consent was smeared on sterile glass slides for subsequent Gram's obtained in all cases before participation. staining and the brushes placed in prereduced chopped Transthoracic lung aspiration was done in a manner meat-glucose broth for qualitative anaerobic organism similar to that described by previous authors.'3"l The determination in the same manner described for the area of consolidation was located by posteroanterior transthoracic lung aspirate specimens. The second brush and lateral chest roentgenograms and physical findings. of each type was placed directly into 1 ml of trypticase In two cases fluoroscopic guidance was used. In the soy broth, vortexed and 0.01-ml aliquots plated onto 5 other cases the infiltrates were situated directly adjacent percent sheep blood, chocolate and desoxycholate agars to the pleura and were large enough to allow adequate within 30 minutes of collection. The plates were incu- localization from the roentgenograms and physical ex- bated for 48 hours at 35°C. The number of colonies,
MARCH 1983 * 138 * 3 365 BRONCHOSCOPIC DIAGNOSIS after adjustment for dilution, were expressed as colony- group A 8-hemolytic streptococci respectively and one forming units (CFU) per milliliter. to mixed facultative and anaerobic bacteria and Coc- A suspension of Serratia marcescens was prepared cidioides immitis. Cultures of transthoracic lung aspirate to a concentration of 13 million CFU per ml. Three from the two remaining patients, both of whom had brushes of each type were dipped in the suspension, prior antibiotic treatment, showed no growth. placed in 1 ml of sterile water, vortexed and plated on In all, 36 organisms were identified in the cultures 5 percent sheep blood agar. Colony counts from the of transthoracic lung aspirate from 13 patients in whom plates were used to determine the mean volume sampled diagnoses were established. From the 12 patients in by each type of brush. whom the cytology brush was used (severe coughing Organisms isolated by transthoracic lung aspirate or forced termination of the procedure before cytology by blood culture (one case) were considered to be brush sampling in one patient) 16 isolates (44 percent) causative. Organisms isolated by bronchial brush that were identical to organisms obtained by transthoracic were not found in the needle aspiration culture material needle aspiration, while 20 additional isolates gave a were considered to be false-positive organisms. 56 percent false-positive rate. From the 13 patients in whom the protected-specimen brush was used, 17 Results isolates (47 percent) were identical and 19 additional isolates gave a false-positive rate of 53 percent. The Culture of specimens of transthoracic lung aspirate difference between brush results was not statistically or blood established a bacteriologic diagnosis in four significant. of seven patients who had lobar pneumonia (Table 1). Quantitative culture results from six patients in whom In the remaining three, bacteriologic diagnoses were transthoracic lung aspiration showed aerobic organisms not established, two owing to no growth on cultures of to be causative are shown in Table 3. Quantities of transthoracic lung aspirate and one because aspiration 10,000 CFU per ml or less were considered not signifi- recovered only diphtheroids. cant. Three of six organisms isolated from cytology Culture of lung aspirate established a bacteriologic brush material were identical to those found by trans- diagnosis in 9 of 11 cases of necrotizing pneumonia or thoracic lung aspirate, whereas four of eight isolates lung abscess (Table 2). Six of these were due to from protected-specimen brush material were identical. anaerobic organisms, two to Staphylococcus aureus or One of six isolates from the cytology brush and three
TABLE 1.-Culture Results in Patients Who Had Lobar Infiltrates (N = 7) Transthoracic Needle Protected-Specimen Case Age, Sex Aspirate Cytology Brush Brush Clinical History 1 70 3 .. Hemophilus H parainfluenzae H parainfluenzae Alcoholism, COPD and bilateral parainfluenzae Bacteroides fragilis B fragilis pneumonia; respiratory failure; (blood) B-hemolytic streptococci B3-hemolytic streptococci temperature 41°C (106°F); me- Group A Group A chanical ventilation; no antibiotics; blood culture positive: H parain- fluenzae 2 44 8 .. Streptococcus S pneumoniae S pneumoniae Alcoholism; acute RLL pneunmonia; pneumoniae no antibiotics; blood culture posi- tive: S pneumoniae 3 66 8 .. S pneumoniae S pneumoniae E coli COPD; malaise, fever, chest pain, Peptostreptococcus sp Staphylococcus cough X 4 days; LLL pneumonia; Bacteroides corrodens epidermidis no antibiotics; blood culture posi- Escherichia coli a-hemolytic streptococci tive: S pneumoniae Neisseria sp 4 17 9 .. Pseudomonas no specimen P aeruginosa Acute febrile polyneuritis (Guillain- aeruginosa K pneumoniae Barre syndrome); tracheostomy; Klebsiella pneumoniae Pseudomonas fluorescens ventilator X 2 months; chronic bi- (autopsy) a-hemolytic streptococci lateral lobar pneumonia; broad- spectrum antibiotics; blood culture positive: K pneumoniae 5 86 6 .. Diphtheroids a-hemolytic streptococci a-hemolytic streptococci COPD; weakness, weight loss, pro y-hemolytic streptococci ductive cough X 2 weeks; LLL pneumonia; no antibiotics 6 56 6 .. No growth a-hemolytic streptococci no growth COPD; fever, chills, cough, chest pain, LLL consolidation, no anti- biotics 7 25 6 .. No growth a-hemolytic streptococci S epidermidis Drug abuse; fever, chills, malaise; Bacteroides superior segment LLL consolida- melaninogenicus tion; partially treated with broad- spectrum antibiotics COPD = chronic obstructive pulmonary disease; RLL =right lower lobe; LLL = left lower lobe; sp = species. 366 THE WESTERN JOURNAL OF MEDICINE BRONCHOSCOPIC DIAGNOSIS
TABLE 2.-Culture Results in Patients Who Had Necrotizing Pneumonia or Abscess (N = 11) Transthoracic Needle Protected-Specimen Case Age, Sex Aspirate Cytology Brush Brush Clinical History 8 50 8 . . a-Hemolytic a-hemolytic streptococci c-hemolytic streptococci Alcoholism; 1 month of fever, streptococci diphtheroids cough; RLL consolidation with Diphtheroids superior segment abscess; partially treated with antibiotics 9 26 8 .. a-Hemolytic a-hemolytic streptococci a-hemolytic streptococci Ethanol-related loss of conscious- streptococci V parvula ness 2 weeks before onset of LLL Veillonella parvula necrotizing pneumonia with supe- Hemophilus influenzae rior segment abscess; partially treated with antibiotics 10 76 e .. Proteus morganii P morganii P morganii COPD; 2 weeks of cough, fever, a-Hemolytic a-hemolytic streptococci a-hemolytic streptococci chest pain; LLL necrotizing pneu- streptococci Peptostreptococcus sp Peptostreptococcus sp monia; partially treated with anti- Peptostreptococcus sp Fusobacterium sp Fusobacterium sp biotics Fusobacterium sp B melaninogenicus Bacteroides Bacteroides ramosus melaninogenicus Bacteroides vulgatus Staphylococcus epidermidis B-Hemolytic streptococci group C or G Klebsiella pneumoniae 11 60 .. acr-Hemolytic Propionibacterium sp ar-hemolytic streptococci Alcoholism; COPD; productive streptococci B melaninogenicus Peptostreptococcus sp cough, chest pain, weight loss X 5 Clostridium histolyticum B fragilis diphtheroids weeks; superior segment LLL Propionibacterium sp Peptostreptococcus sp S pneumoniae abscess; no antibiotics; Peptostrep- B melaninogenicus diphtheroids H influenzae tococcus sp grown from blood Bacteroides fragilis Streptococcus pneumoniae following bronchoscopy H influenzae 12 55 8 .. Propionibacterium S epidermidis S epidermidis COPD; 5 weeks productive cough, fever, weight loss; RUL necrotizing pneumonia; partially treated with antibiotics 13 25 a .. /B-Hemolytic ,B-hemolytic streptococci /3-hemolytic streptococci 3 days of fever, chills, productive streptococci group A group A group A cough, DOE, sore throat; LLL y-hemolytic streptococci y-hemolytic streptococci pneumonia with large abscess; no a-hemolytic streptococci antibiotics; blood culture positive: p-hemolytic streptococci group A 14 63 8 .. y-Hemolytic a-hemolytic streptococci a-hemolytic streptococci COPD; post herniorrhaphy; necro- streptococci Neisseria sp Neisseria sp tizing pneumonia of LLL with su- Diphtheroids Lactobacillus Lactobacillus perior segment abscess; no anti- Fusobacterium H influenzae biotics necrophorus S pneumoniae Fusobacterium nucleatum 15 53 e .. a-Hemolytic a-hemolytic streptococci a-hemolytic streptococci COPD; chronic LLL abscess and streptococci S epidermidis bronchopleural fistula; productive S epidermidis cough; afebrile; no antibiotics /8-Hemolytic streptococci groups C and G Coccidioides immitis 16 51 ( .. Corynebacterium equi C equi C equi Immunosuppressed renal transplant Staphylococcus aureus a-hemolytic streptococci S epidermidis patient; cavitary lesion LUL; cough, Peptostreptococcus sp Fusobacterium sp hemoptysis, fever; partially treated with antibiotics 17 48 8 .. No growth y-hemolytic streptococci no growth Alcoholism; cough, chest pain; superior segment RLL abscess; partially treated with antibiotics 18 27 S .. No growth Lactobacillus Lactobacillus 1 year post radical neck resection; S aureus S epidermidis chronic aspiration; necrotizing LLL /3-hemolytic streptococci Veillonella sp pneumonia; partially treated with group D antibiotics Peptostreptococcus sp RLL = right lower lobe; LLL = left lower lobe; RUL = right upper lobe; DOE = dyspnea on exertion; COPD = chronic obstructive pulmonary disease; sp = species.
MARCH 1983 - 138 - 3 367 BRONCHOSCOPIC DIAGNOSIS
TABLE 3.-Culture Results From Aerobic, Quantitative Brush Specimens: Infections in Which Aerobic Organisms Were Considered Pathogenic Transthoracic Needle Cytology Brush Protected-Specimen Brush Aspirate (CFU/ml) (CFU/ml) fl-Hemolytic streptococci group A /3-hemolytic streptococci group A <10,000* ,-hemolytic streptococci group A < 10,000 Hemophiluts parainfluenzae (blood culture). H parainfluenzae 100,000 H parainfluenzae 100,000 /3-hemolytic streptococci group A 100,000 /3-hemolytic streptococci group A 100,000 Streptococcus pneumoniae S pneumoniae 100,000,000 5 pneumoniae 100,000 S pneumoniae S pneumoniae 100,000 no growth Pseudomonas aeruginosa no specimen P aeruginosa 1,000,000 Klebsiella pneumoniae K pneumoniae 100,000 Pseudomonas fluorescens 100,000 a-hemolytic streptococci 1,000,000 Corynebacterium equi C equi 1,000 C equi < 10,000 Staphylococcus aureus a-hemolytic streptococci <10,O0 Staphylococcus epidermidis 100 CFU = colony-forming units. *Species in concentrations of <10,000 CFU/ml considered not significant.
TABLE 4.-Summary of Culture ResurIts by Case Results of sampling a standard suspension of S mar- (Diagnosis Verified by Transthoracic Needle Aspiration) cescens with three brushes of each type showed that Protected- Protected- the mean volume collected by the protected brush was Cytology Specimen C'ytology Specimen 0.001 whereas that collected by the cytology brush Brush Brush Brush* Brush* ml, waswa004ml0.004 ml. Isolated one of causal organisms 10/12 10/13 3/5 3/6 There were three complications among the 18 pa- Missed one or more tients studied. In one patient who was bronchoscoped causal organisms 8/12 8/13 3/5 3/6 under fluoroscopy, a small pneumothorax developed Isolated nonpathologic due to perforation of the pleura by one of the bronchial organisms ...... 8/12 8/13 1/5 2/6 brushes. Aspiration of the lung was withheld two days *Results from quantitative cultures, nonanaerobic infections. Species in and no intervening antibiotics were given until the concentrations 6f <10,000 colony-forming units per m:illiliter were excluded. pneumothorax resolved. One patient with an anaerobic lung abscess had acute bacteremia characterized by of eight from the protected brush gaive false-positive rigors, an elevated temperature of 40.5°C (105°F), results. confusion and positive blood cultures immediately fol- The results obtained from the 13 pzatients in whom lowing bronchoscopy. In one patient vasovagal syncope a diagnosis of bacterial pneumonia or hlung abscess was developed during needle aspiration. All symptoms re- verified by cultures of transthoracic luing aspirate are solved within ten minutes. summarized in Table 4. At least one c)f the organisms collected by lung aspiration was alsso obtained by the cytology brush in 10 of 12 cases
368 THE WESTERN JOURNAL OF MEDICINE BRONCHOSCOPIC DIAGNOSIS needle. We consider this unlikely because cases were bronchi before bronchoscopy in these severely ill, in- chosen for size and ease of roentgenographic anatomic hospital patients. Several authors4"8"9 have identified location. All but two of the infiltrates involved entire single or multiple bacterial species in the trachea and lobes and, along with the abscesses, were located adja- major bronchi in patients who have chronic bronchitis cent to the pleura for ease and safety of aspiration. but not in healthy subjects. Because most of our patients Two infiltrates that were smaller were aspirated under were smokers and nine had clinically evident chronic fluoroscopic guidance. The segmental bronchus that obstructive pulmonary disease, colonization may have corresponded to the area roentgenographically most played a role. Indeed, since the completion of our study, densely involved by infiltrate was sampled by brush the authors who designed the brush have published a under direct vision. study20 using the protected-specimen brush in 65 pa- A second explanation is that lidocaine administration tients who had pneumonia. In that study, there were suppressed bacterial growth. We do not consider this ten patients in whom control cultures (blood) showed likely because we were very conservative in our use of single causative organisms. The rate of false-positive lidocaine, restricting the volume to less than 10 ml in recovery was 44 percent, agreeing closely with the most cases. Also, our recovery rate of contaminant contamination rate in our study. In their study the use organisms was comparable to that of Irwin and associ- of quantitative cultures to eliminate organisms found ates,"' a study that did not use injected lidocaine. Lido- in concentrations of less than 10,000 CFU per ml suc- caine should have inhibited both contaminant and cessfully eliminated these bacteria from consideration pathogen growth equally. as pathogens. Our limited data also showed a reduction Third, the possibility that some of the infections were in false-positive organism recovery when the same rule nonbacterial in origin and the fact that 9 of the 18 was applied. However, it also reduced the recovery patients received some form of antibiotic therapy be- rate of "etiologic organisms." fore culture might have reduced brush recovery of We did not analyze data from the five cases in which pathogens. Both of these situations, however, would no specific cause was determined from cultures of trans- affect transthoracic lung aspiration as well as brush thoracic lung aspirate. Three of these patients had re- culture results and thus were eliminated by considering ceived antibiotics before culture, which may have ac- only those cases where the needle aspiration collected counted for the lack of organism recovery. Alternatively, bacterial pathogens. the infections could have been of viral origin. It is We feel that the most likely explanation for the low tempting to speculate that in the face of negative lung brush versus aspiration recovery was the possibility that aspiration cultures, brush cultures should also be nega- sample quantity affected the yield. The amount of lower tive. This was true for two of the protected-specimen respiratory tract secretion recovered by the protected brush cultures. Because we do not know the primary brush and the cytology brush was probably about 0.001 pathogen it is difficult to comment on what may be ml and 0.004 ml, respectively, as determined by sam- contaminant. However, a recently reported study using pling and quantitative plating of a standard solution of the protected brush in 25 normal subjects with and S marcescens. The amount of pus or tissue fluid inocu- without experimentally induced rhinovirus infections lated into the trypticase soy broth and chopped meat found false-positive culture results in 84 percent of the glucose from the needle aspirate was 100 to 1,000 cases.2' times greater. Thus, it is possible that a smaller amount These findings show that bronchoscopic collection of of inoculum from the brushes accounted for the lower microbial specimens from patients with lower respira- pathogen recovery rate. tory tract infection is inaccurate because both types of The injection of lidocaine through the bronchoscope brushes failed to isolate many of the causal organisms lumen has been implicated as a possible source of brush and grew many organisms not isolated by lung aspirate contamination.12 We found it difficult, however, as cultures. There appears to be no difference in the did previous authors,'7 to bronchoscope and im- ability of either brush to collect the offending pathogen possible to cannulate segmental bronchi in these per- or avoid contamination by nonetiologic organisms. sons without instilling lidocaine. To reduce possible Needless to say, this problem has not yet been solved contamination, we used a sterile nasopharyngeal air- and further work-especially relating to the role of way to introduce the bronchoscope through the naso- quantitative cultures-needs to be done. It is important pharynx. This minimized the suction of upper respira- that some form of "control culture" such as trans- tory tract secretions into the biopsy channel and in thoracic lung aspirate or blood culture be used as a most cases we were able to guide the tip of the bron- comparison because the role of colonization of the choscope into close proximity with the vocal cord with- lower respiratory tract in acute and chronic infections out touching the mucosa. Further measures to reduce is still unknown. We wish to emphasize that this study contamination by nonetiologic organisms included using was designed to evaluate the bacteriologic results ob- the supine position for all bronchoscopies and avoiding tained by the various methods and not the value of brush contact with the trachea or major bronchi during these methods in affecting decisions regarding antibiotic sampling. therapy. Another explanation for contamination could be that REFERENCES 1. Barrett-Connor E: The nonvalue of sputum culture in the diagnosis nonetiologic organisms were already present in the of pneumococcal pneumonia. Am Rev Respir Dis 1971 Jun; 103:845-848
MARCH 1983 * 138 * 3 369 BRONCHOSCOPIC DIAGNOSIS
2. Rathbun HK, Giovani I: Mouse inoculation as a means of identify- 12. Wimberley N, Faling LJ, Bartlett JG: A fiberoptic bronchoscopy ing pneumococci in the sputum. Johns Hopkins Med J 1967; 120:46-48 technique to obtain uncontaminated lower airway secretions for bacterial 3. Finland M: Recent advances in epidemiology of pneumococcal in- culture. Am Rev Respir Dis 1979 Mar; 119:337-343 fections. Medicine 1942; 21:307-344 13. Sappington SW, Favorite GO: Lung puncture in Icbar pneumcnia. 4. Lees AW, McNaught W: Bacteriology of lower respiratory tract Am J Med Sci 1936; 191:225-234 secretions, sputum and upper respiratory tract secretions in "normal" 14. Gherman CR, Simon HJ: Pneumonia complicating severe underly- and chronic bronchitics. Lancet 1959 Dec; 2:1112-1115 ing disease: A current appraisal cf transthoracic lung puncture. Dis 5. Kalinske RW, Parker RH, Brandt D, et al: Diagnostic usefulness Chest 1965 Sep; 48:297-304 and safety of transtracheal aspiration. N Engl J Med 1967 Mar 16; 15. Wanner A, Zighelboim A, Sackner MA: Nasopharyngeal airway: 276:604-608 A facilitated access to the trachea. Ann Intern Med 1971 Oct; 75:593-595 6. Davidson M, Tempest B, Palmer DL: Bacteriologic diagnosis of 16. Irwin RS, Garrity FL, Erickson AD, et al: Sampling lower re- acute pneumonia: Comparison of sputum, transtracheal aspirates and spiratory tract secretions in primary lung abscess. Chest 1981 May; 79: lung aspirates. JAMA 1976 Jan; 235:158-163 559-565 7. Jordan GW, Wong GA, Hoeprich PD: Bacteriology of the lower 17. Teague RB, Wallace RJ Jr, Awe RJ: The use of quantitative sterile respiratory tract as determined by fiberoptic bronchoscopy and trans- brush culture and gram stain analysis in the diagnosis of lower respira- tracheal aspiration. J Infect Dis 1976 Nov; 134:428-435 tory tract infection. Chest 1981 Feb; 79:157-161 18. Brumfitt W, Willoughby MLN: An evaluaticn of sputum examina- 8. Fossieck BE Jr, Parker RH, Cohen MH, et al: Fiberoptic bron- tion in chronic bronchitis. Lancet 1957; 2:1306-1308 choscopy and culture of bacteria from the lower respiratory tract. Chest 19. Laurenzi GA, Potter RT, Kass EH: Bacteriologic flora of the 1977 Jul; 72:5-9 lower respiratory tract. N EngI J Med 1961 Dec; 265:1273-1278 9. Bartlett JG, Alexander J, Mayhew J, et al: Should fiberoptic bron- 20. Wimberley NW, Bass JB, Boyd BW, et al: Use of a bronchoscopic choscopy aspirates be cultured? Am Rev Respir Dis 1976 Jul; 114:73-78 protected catheter brush for the diagnosis of pulmonary infections. Chest 10. Ravin CE, Latimer JM, Matsen JM: In vitro effects of lidocaine 1982 May; 81:556-562 on anaerobic respiratory pathogens and strains of Hemophilus influenzae. 21. Halperin SA, Suratt PM, Gwaltney JM Jr, et al: Bacterial cultures Chest 1977 Oct; 72:439-441 of the lower respiratory tract in normal volunteers with and without 11. Hoeprich PD: Etiologic diagnosis of lower respiratory tract infec- experimental rhinovirus infection using a plugged double catheter system. tions. Calif Med 1970 Feb; 112:1-8 Am Rev Respir Dis 1982 Jun; 125:678-680
Medical Practice Questions EDITOR'S NOTE: From time to time medical practice questions from organizations with a legitimate interest in the information are referred to the Scientific Board by the Quality Care Review Commission of the California Medical Association. The opinions offered are based on training, experience and literature reviewed by specialists. These opinions are, however, informational only and should not be interpreted as directives, instructions or policy state- ments. Sleep Therapy QUESTION: Is sleep therapy considered to be experimental? What is the advised length of treatment? OPINION: In the opinion of the Advisory Panels on Chest Diseases, Internal Medicine, Neurology, Otolaryngology/Head and Neck Surgery and Pediatrics, the evaluation, diagnosis and treatment of sleep disorders is considered accepted medical practice when performed by persons with special clinical expertise and knowledge in this field. Criteria for evaluation and diagnosis should include the following: docu- mentation of a historical/physical examination review to establish the likelihood of a sleep disorder, a screening sleep study and more detailed study of patients (after these first two steps) to define the type of disorder. The length of treatment required in the management of sleep disorders varies with the diagnosis. Therapy for narcolepsy, nocturnal myclonus and some sleep apnea syndromes, for example, may require a lifetime of treatment. Other problems such as medication dependency or difficulty maintaining sleep may be treated successfully on a short-term basis. The appropriate duration of treatment varies from case to case. Therapy for sleep disorders also varies with the problem. Treatment options may range from behavioral treatments such as weight loss to surgical interventions such as a tracheostomy, septoplasty, tonsillectomy or palatopharyngoplasty. Sleep disorder clinics usually submit their therapeutic recommendations to the patient's referring physician for continued follow-up and management.
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