ABSTRACT
Introduction: Mortality due to Coronavirus Disease 2019 (COVID-19) is nearly 50% in the intensive care unit (ICU).1,5 There is limited evidence on the role of bronchoalveolar lavage (BAL) to guide appropriate therapy in critically ill COVID-19 infection.2,3,4 We present our experience on the role of BAL identifying bacterial co-infection and to confirm diagnosis of COVID-19 in the ICU. Methods: This is an IRB approved, retrospective study of critically ill COVID-19 patients from March 2020 through July 2020. Critical illness was defined by: hypoxemia requiring >40% oxygen, septic shock or severe organ failure. COVID-19 was detected using reverse transcriptase polymerase chain reaction (rTPCR) performed on nasopharyngeal (NP) swab, BAL, or Mini-BAL. The Halyard Sampling Catheter was used at the time of intubation by respiratory therapists (RT) for mini-BAL. Bronchoscopic BAL was performed by physicians using a disposable bronchoscope. Results: 102 Patients were included. Mean age was 65±15 years with 56% males. 57% were African American, 33% Caucasian, and 9% Hispanic. Hypertension was present in 81% while 68% had BMI >30, and 48% had diabetes. 71% required mechanical ventilation for a median duration of 6 days. Median ICU length of stay was 10 days (range 1-51). Of 72 patients requiring intubation, mini-BAL was performed in 41 (57%) while bronchoscopic BAL was obtained in 8 (11%). 24 out of 49 (49%) had positive cultures. Staphylococcus aureus was identified in 15 of 24;53% of which were methicillin resistant. Other bacterial cultures are presented in Figure 1. Bacterial pneumonia was present <48hours post intubation in 6 of 24 patients. Mortality for those requiring intubation was 38% but increased to 46% with bacterial co-infection. Due to limited reagent availability, COVID-19 testing was not performed on all BAL specimens. Two patients in this cohort had imaging and clinical presentation consistent with COVID-19 but had negative NP swabs. BAL confirmed COVID-19 in both cases. Conclusion: The majority of critically ill COVID-19 patients were obese, African American males with hypertension. Most required mechanical ventilation and culture proven bacterial pneumonia was present in 8% within 48 hours of intubation. BAL provided critical information on bacterial coinfection which contributed to increased mortality in COVID-19. Furthermore, BAL may have a limited role in confirming COVID-19 when NP swab is negative. We recommend that all patients with critical COVID-19 undergo BAL at the time of intubation as identification and treatment of concomitant bacterial pneumonia may impact survival. .