When a patient comes to the ICU with a suspected respiratory infection, the critical care physician traditionally prescribes a broad-spectrum antibiotic. Often this empiric therapy was given up to 7 to 10 days while awaiting laboratory confirmation of the specific organism or organisms driving the infection. Now with advances in microbial diagnostics and more rapid assay results, the critical care team can start targeted antimicrobial therapy sooner. But that’s not the only factor driving greater efficiency.
In this Q & A with Eric C. Feucht, MD, Critical Care Medicine and Medical Director of Respiratory Therapy at Metro Health Hospital in Ann Arbor, Michigan, he explains how use of disposable bronchoscopes at the bedside in the ICU are a ‘game changer’ in terms of more convenient, more efficient and more precise prescribing of antimicrobial therapy.
Q: How long have you used a single-use device like the Ambu aScope in your critical care practice?
A: We moved from a standard diagnostic bronchoscope to the Ambu aScope about four years ago at a previous institution, and then adopted it when we came to Metro Health Hospital. We’ve used it almost exclusively for about four years.
Q: What are the advantages for you compared to reusable scopes?
A: The two main advantages are: it is so quick, efficient and available that it allows us—in the patient who has a suspected pulmonary infection—to get in and get the appropriate microbiological sampling—often before the time the first dose of antibiotic is administered.
We’re getting pure, raw, respiratory tract samples and still giving antibiotics in a timely fashion to meet our sepsis guideline endpoints. That’s a major advantage.
The second advantage, which is probably equally important, is it’s a disposable scope. In the ICU, we’re dealing with resistant organisms, and reusable scopes can be colonized. They can have their channels contaminated. With single-use scopes, you use it and throw it away. And you have a sterile new scope for the next patient. It’s great from an infection prevention point of view, as far as we’re concerned, as well.
Q: Do you have any examples of where you used the disposable scope in a patient with a suspected pulmonary infection?
A: I can give you a great example because we’re going through flu season right now. We are frequently getting patients coming in with severe pneumonia, bilateral infiltrates from the community, that look and sound like the flu. But we also wonder if they have a secondary bacterial infection. So it’s our practice when those patients come to the ICU intubated to use the bronchoscope for sampling.
We will get Gram stains back within an hour or two, and if they have no organisms from our guide BAL [bronchoalveolar lavage] Gram stains, then we will hold the antibiotics and only treat them with antivirals. We can narrow down our antibiotics very quickly and very effectively.
Likewise, if we suspect someone has a hospital-acquired, healthcare-associated or ventilator-associated pneumonia, we can use a quick Gram stain to hone in on whether it’s a Gram positive or Gram negative organism, and really narrow down the spectrum of our antibiotics. We can do this often within the timeframe of a single dose.
Q: Is this a rapid test you’re doing on your own or are you relying on a lab to test and return the results?
A: It’s going to our local laboratory; they do a Gram stain and return it to us within an hour. We are neurotic enough with our antimicrobial stewardship that our lab does Gram stains 24/7. Often we can avoid people being on unnecessary broad-spectrum antibiotics.
Q: What are the advantages for the patient who would otherwise be treated with empiric, broad-spectrum antimicrobials?
A: Using the bronchoscope to focus down our antibiotics to the most appropriate avoids unnecessary expense and unnecessary exposure to risks associated with unnecessary therapy.
Q: So how much time are you saving compared to when you used reusable scopes?
A: I think the efficiency of the care is much better because the scopes are up on the unit, the respiratory therapists are up on the unit, and when we need to get it done, we can have all the people ready and at the bedside within 5 or 10 minutes. It allows us to be very efficient in our workflow.
Q: So you’re not relying on working in a different setting?
A: We don’t rely on an endoscopy staff—the setup and maintenance of the Ambu equipment is done by a respiratory therapist in the ICU 24/7, so it’s always immediately available. It is right there.
Q: Do you have any specific patient examples where this worked particularly well?
A: It’s great in our viral pneumonia patients. There was data that came out about 2 years ago that suggests that viral pneumonias are now the most common cause of pneumonia in hospitalized adults. Whether it’s rhinovirus, adenovirus, human metapneumovirus, influenza or parainfluenza—we’re seeing more and more of that now that we have the diagnostic tools. Even a couple of years ago we didn’t have the molecular techniques to detect these viruses.
So being able to get a bronchoscope in, and exclude bacterial superinfection, means we often can manage these people very effectively with just supportive care and/or antivirals. In the past, the same patients might have been treated 7 to 10 days with broad-spectrum antimicrobials.
Q: Is there anything else you’d like to let your critical care colleagues know about your experience with the aScope?
A: Between the standard diagnostic scope and the therapeutic scope with the larger working channel, we’re able to insert all of our foreign body retrieval tools* through it. It’s great for the difficult or threatened airway because, again, it’s immediately available. You don’t have to have your endoscopy staff come in at 2 a.m. from the community if we have a foreign body in the lung. We can do everything we need to do with the therapeutic scope right there at the bedside.
So the convenience and the safety of having the scopes right here has been a game changer for us.
Dr. Feucht’s opinions do not necessarily reflect those of Metro Health Hospital.
*For aScope channel diameters, refer to IFUs at www.ambuusa.com