Bronchoscopy was performed within 12 h after hospital admission. Patients were premedicated with salbutamol (200 jig) and atropine (0.5 mg). Lidocaine was aerosolized to nose and pharynx and 50 percent oxygen was delivered by mask. Next, intravenous midazolam (2 to 10 mg) was administered. A fiberoptic bronchoscope was inserted transnasally with the patient in a supine position. The inner channel was used neither for anesthetic injection nor for suction. The bronchoscope was placed in the bronchial orifice of the most affected lobe according to the chest radiograph. A telescoping protected brush catheter (130 Microbiology Brush, Mill-Rose Laboratories Inc, Mentor, Ohio) was inserted through the inner channel of the fiberoptic bronchoscope and advanced 2 to 3 cm beyond the tip of the instrument.
The distal plug was dislodged by advancing the inner catheter. The brush was then protracted into the bronchial lumen to collect the specimen and then retracted into the inner catheter. Next the inner catheter was withdrawn into the outer catheter, and the entire catheter was removed from the bronchoscope. After cleaning the catheter with 70 percent alcohol, the brush was removed with a sterile wire cutter, and immersed into 1 ml of thioglycolate. Then the bronchoscope was inserted into the same bronchus until wedged. A BAL was performed as follows: warmed sterile saline solution from three 60-ml syringes was successively injected and gently aspirated by hand. The recovered fluid was filtered in gauze, pooled on a sterile recipient, and a 1-mi aliquot was separated for microbiologic processing.