One- or Two-Segment BAL

nonsmokers.3 Although the tobacco lobby argues that ETS is at most an annoyance acceptable to most reasonable Americans, there is growing evidence that exposure to ETS represents a genuine health hazard. Children exposed to the smoke of family members suffer an increased number of respiratory tract infections, an increased incidence of asthma, and for those with asthma, a worsening of their condition. 4 Adults exposed to the smoke of spouses experience not only cough and eye irritation , but more importantly are at an increased risk for lung cancer. 3 The effects of ETS on adult asthmatics are not as well documented as those in children. Experimental exposure to ETS may induce an acute irritant response in some,5 whereas in others, there is a gradual deterioration in flow rates with one or more hours of exposure,5·6 suggestive of an inflammatory effect on the airways. In this issue of Chest (see page 746) , Jindal and colleagues demonstrate for the first time , a clinically significant effect of ETS in adult asthmatics. They show convincingly that exposure to the cigarette smoke of family members results in an increased number of acute episodes, increased steroid use , and increased emergency room visits. Thus, for those with asthma, exposure to ETS is more than an annoyance: it is clearly dangerous. The evolving governmental viewpoint is that any risk from ETS is unacceptable. However , only aminority of Americans presently share this view. Ultimately, the national consensus regarding the acceptability of ETS will determine the strength of ultimate governmental action. For this reason , studies such as those reported by Jindal et al are important. As Americans become convinced of the dangers of ETS, they will become less accepting of the lethal habits of their fellow citizens. Only then will they accept, and ultimately demand , the strongest of governmental action. Authur S. Banner, MD

Manchester, New Hampshire

Chief, Pulmonary Division, Veterans Affa irs Medical Center. R EFERENCES

1 US Public Health Service: Smoking and health: a report of the Advisory Committee to the Surgeon General of the Public Health Service, Washington, DC: 1964, PHS publication No. 1103 2 Bartecchi CE, MacKenzie TD, Schrier RW. The human costs of tobacco use. N Eng! J Med 1994; 330:907-12 3 E nvironmental Protection Agency. Respiratory health effects of passive smoking: lung cancer and other disorders. Washington, DC: Office of Health and Environmental Assessment, 1992 4 Tager lB. Health effects of " passive smoking" in children. Chest 1989; 96:1161-64 5 Danuser B, Weber A, Hartm an n AL, Krueger H. Effects of a bronchoprovocation challenge test with cigarette sidestream smoke o nsensitive and health y adults. Chest 1993; 103:353-58

6 Menon PK, Stankus RP, Rando RJ, Salvaggio JE,Lehrer SB. Asthmatic responses to passive cigarette smoke: persistence of reactivity and effect of medications. J Allergy Clin Immunol 1991; 88:861-69

One- or Two-Segment BAL More is Better? Bronchoalveolar lavage (BAL) in the diagnostic evaluation of pulmonary infections in the immunocompromised host (ICH) is now routinel y performed and widely accepted. Experience and familiarity with the technique over the past decade have res ulted in its wider application in the increasing numbers and subsets of ICH , le ading to improvement in the diagnostic yield.1•2 In some infections , such as Pneumocystis carinii in HIV -infected patients, BAL is now the preferred procedure with which other diagnostic modalities are compared. Careful analysis of BAL results in P carinii infection in various subsets of ICH has provided information about the differences in organism load and diagnostic yield, effect of therapy or prophylaxis on yield , host inflammatory response, and localization of the organisms in different lung zones. 3 -6 The standardization of BALin the ICH , however , is a difficult task . The most important factor to be considered is the variable infection rate and intensity of infection in the different subsets of ICH . Technical factors include sampling error resulting from the sele~tion of site, volume of fluid instilled and recovered , presence of airway obstruction, and adequacy of segmental wedging of bronchoscope. The effect of these variables in the diagnostic yield of various pulmonary infections in the ICH is largely unknown. An additional problem unique to the BAL diagnosis of certain infections, such as bacterial , opportunistic fungal , atypical mycobacterial , and cytomegalovirus (CMV ) pneumonia , is the issue of contamination from airways as opposed to true infection . Grebski and colleagues7 address the problem of site selection and report their findings for one-segment or two-segment BAL in the diagnosis of pulmonary infections in a mixed group of ICH. For P carinii pneumonia , most of the HIV -infected patients had two-segmental recovery of the organism, whereas two of five ICH without HIV infection had only one-segmental recovery of the organism. Meduri and colleagues8 found P carinii in only one segment in four of five patients without HIV infection undergoing two-segmental bilateral BAL. Levine and others9 reported only one-segmental (upper lobe) recovery of P carinii in 4 of 34 patients undergoing two-segmental (upper and middle or lower lobe) CHEST / 106 / 3 / SEPTEMBER, 1994

663

BAL in HIV -infected patients with and without aerosolized pentamidine prophylaxis. In these studies, bisegmental BAL was not associated with any increased complications. Bilateral BAL should be performed in the ICH without HIV -infection when P carinii is suspected. Patients with HIV infection who have atypical presentations and/ or who have received prophylactic therapy for P carinii where the diagnostic yield and organism load may be lower, should also be evaluated by site-directed , two-segment BAL. 4•9 An interesting recent observation in HIV -infected patients with P carinii pneumonia is the increased organism load in BAL recovered from the upper lobes compared with other lung lobes. This finding persisted irrespective of the location of radiographic infiltrates and the use of aerosolized pentamidine prophylaxis.7.l 0 Upper lobe BAL could lead to increased diagnostic sensitivity for P carinii in the ICH where the organism burden is likely to be lower, as is the case in patients without HIV infection. 6 If these observations are confirmed in other subsets of ICH, the current practice of performing BAL in the right middle lobe or lingula should be modified to include the upper lobes. Most cases of viral pneumonia in the ICH are believed to involve both lungs. Bilateral BALin the ICH with pneumonia often , however, reveals the CMV organisms only in one lung.8 Although the significance of recovery of CMV in BAL, particularly in HIV -infected patients, is uncertain and requires clinical correlation, the maximum yield is likely to result from bilateral sampling. A similar situation may exist with fungal and mycobacterial infections in the ICH. However, the information available is insufficient to justify recommendation for these infections . Community-acquired bacterial pneumonia typically presents with focal or multifocal infiltrates. Although these cases are commonly treated empirically, a site-directed single segmental BAL in the untreated patients would most likely yield the highest number of organisms. 7 In cases of bacterial pneumonia leading to ARDS and ventilator-associated pneumonia following ARDS , however, the localization of infection in the presence of diffuse bilateral infiltrates is often not possible. In this situation, bilateral BAL may frequently reveal infection in only one lung.l 1 The safety of performing BAL has been studied in a variety of pulmonary diseases including a large number of critically ill patients with ARDS.12.1 3 However, adding a second segmental BAL may increase the risk . Our experience in the past 5 years with bilateral BALin intubated, critically ill patients has not been associated with any demonstrable 664

increased risk. Since BAL is relatively well tolerated by the ICH, and alternative diagnostic techniques are often more invasive, it would be prudent to get the most while in there. Two-segment, bilateral or unilateral site-directed BAL should be considered whenever safe and feasible for the diagnosis of pulmonary infections in the ICH. The BAL specimens thus obtained should be pooled , except for quantitative bacterial culture, to reduce the cost of performing repeated tests. Muhammad K. Zaman, MD, FCCP Memphis, Tennessee Assistant Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Tennessee Medical Center. Reprint requests: Dr. Zaman , 956 Court Avenue, Room H-314, Memphis, TN 38104

REFERENCES

1 Stover DE, Zaman MB, Hajdu SI, Lange M, Gold J, Armstrong D. Bronchoalveolar lavage in the diagnosis of diffuse pulmonary infiltrates in the immunosuppressed host. Ann Intern Med 1984; 101:1-7 2 Broaddus C, Dake MD, Stulbarg MS, Blumenfeld LV, Hadley K, Golden J A, et al. Bronchoalveolar lavage and transbronchial biopsy for the diagnosis of pulmonary infections in the acquired immunodeficiency syndrome. Ann Intern Med 1985; 102: 747-52 3 KovacsJA, HieminzJW, Macher AM, Stover DE, Murray HW, Shelhamer J, et al. Pneumocystis carinii pneumonia: a comparison between patients with the acquired immunodeficiency syndrome and patients with other immunodeficiencies. Ann Intern Med 1984; 100:663-71 4 Jules-Elysee KM, Stover DE, Zaman MB, Bernard EM, White DA. Aerosolized pentamidine: effect on diagnosis and presentation of Pneumocystis carinii pneumonia. Ann Intern Med 1990; 112:750-57 5 Fahy JV, Chin DP, Schnapp LM, Steiger DJ, Schaumberg TH, Geaghan SM, et al. Effect of aerosolized pentamidine prophylaxis on the clinical severity and diagnosis of Pneumocystis carinii pneumonia. Am Rev Respir Dis 1992; 146:844-48 6 Limper AH, Offord KP, Smith TF, Martin WJ. Pneumocystis carinii pneumonia: differences in lung parasite number and inflammation in patients with and without AIDS. Am Rev Respir Dis 1989; 140:1204-09 7 Grebski E, Russi E, Speich R, Opravil M, Kuster H, Wiist J. The role of two-segment bronchoalveolar lavage in the diagnosis of pulmonary infections. Chest 1994; 106:414-20 8 Meduri GU, Stover DE, Greeno RA, Nash T, Zaman MB. Bilateral bronchoalveolar lavage in the diagnosis of opportunistic pulmonary infections. Chest 1991; 100:1272-76 9 Levine SJ, Kennedy D, Shelhamer JH, Kovacs JA, Feuerstein IM, Gill VJ, et al. Diagnosis of Pneumocystis carinii pneumonia by multiple lobe, site-directed bronchoalveolar lavage with immunofluorescent monoclonal antibody staining in human immunodeficiency virus-infected patients receiving aerosolized pentamidine chemoprophylaxis. Am Rev Respir Dis 1992; 146:838-43 10 Baughman RP, Dohn MN, Shipley R, Buchsbaum JA, Frame PT. Increased Pneumocystis carinii recovery from the upper lobes in pneumocystis pneumonia: the effect of aerosol pentamidine prophylaxis. Chest 1993; 103:426-32 Editorials

11 Brunson M, Meduri GU, Leeper KV, Wunderink RG, Stanley T. Pneumonia in ARDS: diagnositic and prognostic value of bilateral bronchoscopic sampling [Abstract]. Am Rev Respir Dis 1993; 147:A355 12 Reynolds HY. Bronchoalveolar lavage. Am Rev Respir Dis

1987; 135:250-63 13 Steinberg KP, Mitchell DR, Maunder RJ, Milberg JA, Whitcomb ME, Hudson LD. Safety of bronchoalveolar lavage in patients with adult respiratory distress syndrome. Am Rev Respir Dis 1993; 148:556-611

60th

Annual International Scientific Assembly October 30November 3, 1994 New Orleans For more information call 800 343-ACCP

AMERICAN COLLEGE OF CHEST PHYSICIANS

CHEST / 106 / 3 / SEPTEMBER, 1994

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