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Abstract
The appropriate investigation of patients with suspected VAP is controversial. Because it is unlikely that any new diagnostic technique will become available in the near future with better performance characteristics than those currently available, physicians need to tailor their diagnostic approach depending on individual patients and clinical scenarios. The most crucial factor in deciding which diagnostic approach to take is the influence that any test result would have on management. If preliminary screening tests, including Gram stain, are used to determine whether to start antibiotic therapy, invasive diagnostic techniques have an advantage over ETA. Quantitative cultures of respiratory specimens have a higher specificity than qualitative cultures and should be used if there is any possibility that a negative culture result would result in the discontinuation of antibiotic therapy. Physicians are caught between the need to treat VAP promptly with appropriate antibiotics and the undeniable problems of multidrug-resistant bacteria and their association with inappropriate antibiotic use. When clinically possible, a diagnostic strategy should be chosen that maximizes the possibility of limiting broad-spectrum antibiotic use. To give physicians greater comfort in the ability to withhold or discontinue antibiotics safely, further research is needed into the appropriate diagnostic strategies in different clinical settings that make this possible. The studies by Fagon et al and Singh et al are important steps in this direction.
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Affiliation(s)
- G W Waterer
- Department of Medicine, University of Western Australia, Royal Perth Hospital, Western Australia.
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52
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Alvarez Lerma F, Torres Martí A, Rodríguez De Castro F. [Recommendations for diagnosing ventilator-associated pneumonia]. Arch Bronconeumol 2001; 37:325-34. [PMID: 11562318 DOI: 10.1016/s0300-2896(01)75102-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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53
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Ely EW, Smith AC, Chiles C, Aquino SL, Harle TS, Evans GW, Haponik EF. Radiologic determination of intravascular volume status using portable, digital chest radiography: a prospective investigation in 100 patients. Crit Care Med 2001; 29:1502-12. [PMID: 11505116 DOI: 10.1097/00003246-200108000-00002] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To answer the following questions: Can the digital chest roentgenogram (CXR) be used to differentiate patients' volume status? Do clinical data alter radiologists' accuracy in interpreting the digital CXR? DESIGN Prospective cohort study. SETTING Nine adult intensive care units of a tertiary care medical center. PATIENTS One hundred thirty-five consecutive patients with pulmonary artery catheters, of whom 35 were excluded because of unacceptable pulmonary artery occlusion pressure (PAOP) tracings. METHODS Each patient had a portable, anteroposterior, supine digital CXR. Clinicians evaluated volume status and then measured hemodynamic data within 1 hr of the CXR. Digital CXRs were independently interpreted on two separate occasions (with and without clinical information) by three experienced chest radiologists, and these interpretations were compared with hemodynamic data. RESULTS Of the 100 patients, 39 had PAOP >18 mm Hg, whereas 61 had PAOP <18 mm Hg. Radiologists' accuracy in differentiating volume status increased with incorporation of clinical data (56% without vs. 65% with clinical data, p =.009). Using objective receiver operating characteristic-derived cutoffs of 70 mm for vascular pedicle width and 0.55 for cardiothoracic ratio, radiologists' accuracy in differentiating PAOP >18 mm Hg from PAOP <18 mm Hg was 70%. The intrareader and the inter-reader correlation coefficients were very high. The likelihood ratio of the CXR in determining volume status using the objective vascular pedicle width and cardiothoracic ratio measures was 3.1 (95% confidence interval, 1.9-6.0), significantly higher than subjective CXR interpretations with and without clinical data (p <.001). CONCLUSIONS Differentiating intravascular volume status with portable, supine, digital CXRs may be improved by using objective cutoffs of vascular pedicle width >70 mm and cardiothoracic ratio >0.55 or by incorporating clinical data.
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Affiliation(s)
- E W Ely
- Department of Internal Medicine, Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt University Medical Center, 6th Floor Medical Center East, Nashville, TN 37232-8300, USA.
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54
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Torres A, Carlet J. Ventilator-associated pneumonia. European Task Force on ventilator-associated pneumonia. Eur Respir J 2001; 17:1034-45. [PMID: 11488306 DOI: 10.1183/09031936.01.17510340] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- A Torres
- Servei de Pneumologia, Institut Clinic de Pneumologia I Cirurgia Toracica, Hospital Clinic, Barcelona, Spain
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55
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Desai SR, Wells AU, Suntharalingam G, Rubens MB, Evans TW, Hansell DM. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary injury: a comparative CT study. Radiology 2001; 218:689-93. [PMID: 11230641 DOI: 10.1148/radiology.218.3.r01mr31689] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE To determine computed tomographic (CT) differences between acute respiratory distress syndrome (ARDS) due to pulmonary injury (ARDS(p)) and extrapulmonary injury (ARDS(ex)). MATERIALS AND METHODS CT appearances in 41 patients (27 male, 14 female; mean age, 47.1 years +/- 17.1 [SD]; age range, 17-79 years; those with ARDS(p), n = 16; those with ARDS(ex), n = 25) were categorized as typical or atypical of ARDS by two observers. The extent of individual CT patterns was also quantified. RESULTS Typical CT appearances were more frequent in ARDS(ex) than ARDS(p) (18 [72%] of 25 vs five [31%] of 16 patients, respectively; P <.01). Sensitivity, specificity, and accuracy of a typical CT pattern for the diagnosis of ARDS(ex) were 72%, 69%, and 71%, respectively. Atypical appearances were characterized by more extensive nondependent intense parenchymal opacification (IPO) (P =.03) and cysts (P =.05), whereas typical CT appearances had more extensive dependent IPO (P =.01). Typical appearances at CT were independently related to the cause of ARDS (odds ratio, 8.9; 95% CI: 1.8, 44.2; P <.01) but were independent of the time from intubation. Foci of nondependent IPO were more extensive in ARDS(p) (P =.05) than ARDS(ex), but this finding was ascribable to differences in time to CT (after intubation) between ARDS(p) and ARDS(ex). CONCLUSION The differentiation between ARDS(p) and ARDS(ex) can, with some caveats, be based on whether the CT appearances are typical or atypical of ARDS but not on any individual CT pattern in isolation.
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Affiliation(s)
- S R Desai
- Department of Radiology, Royal Brompton Hospital, Sydney St, London SW3 6NP, England
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56
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Lerma FÁ, Martí AT, De Castro FR. Recomendaciones para el diagnóstico de la neumonía asociada a ventilación mecánica. Med Intensiva 2001. [DOI: 10.1016/s0210-5691(01)79702-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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57
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Reed RL. Lung Infections and Trauma. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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58
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Cordero L, Sananes M, Coley B, Hogan M, Gelman M, Ayers LW. Ventilator-associated pneumonia in very low-birth-weight infants at the time of nosocomial bloodstream infection and during airway colonization with Pseudomonas aeruginosa. Am J Infect Control 2000; 28:333-9. [PMID: 11029131 DOI: 10.1067/mic.2000.109884] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To study retrospectively the incidence of ventilator-associated pneumonia (VAP) at the time of Pseudomonas aeruginosa nosocomial bloodstream infection (BSI) and at the time of P aeruginosa airway colonization. MATERIALS AND METHODS Fifteen very low-birth-weight infants who had P aeruginosa BSI and 33 others who did not but who had P aeruginosa airway-colonization were studied. We correlated clinical data, blood cultures (BCs), and tracheal cultures (TCs) with radiologic findings from radio-graphs taken within 2 days before, the day of, and 1 day after BCs or TCs were first positive for P aeruginosa. Chest radiographs were graded by using semiquantitative scores for bronchopulmonary dysplasia and for pneumonia. RESULTS Mean birth weight, gestational age, and age when BC or TC became positive were similar for patients with BSI and colonization. At the time of BSI, 2 infants had airway colonization with P aeruginosa; the TCs of the remaining 13 grew P aeruginosa as a new pathogen. Thirteen of 15 patients with BSI, but none of 33 infants with colonization, died within 2 days of positive BC. VAP was diagnosed in 13 of 15 patients with BSI and in 3 of 33 infants with colonization. CONCLUSION Mechanically ventilated very low-birth-weight infants whose TCs yield P aeruginosa but whose BCs remain negative infrequently have VAP are presumed airway-colonized and are expected to survive. Conversely, VAP is likely to be found when BCs and TCs simultaneously grow P aeruginosa, and high mortality is anticipated.
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Affiliation(s)
- L Cordero
- Newborn Services and the Department of Pediatrics, The Ohio State University Medical Center, Columbus, OH 43210-1228, USA
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59
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Abstract
Since its description in 1967, acute respiratory distress syndrome (ARDS) has become a widely recognized, if somewhat imperfectly understood, entity. This article reviews the imaging characteristics of ARDS as demonstrated on plain chest radiography, CT scan, radionuclide imaging, and MR imaging. The abnormalities displayed on these modalities are well understood even though there may be some dispute as to their relative importance in diagnosing and managing patients.
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Affiliation(s)
- P C Goodman
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
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60
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Mandell LA, Marrie TJ, Grossman RF, Chow AW, Hyland RH. Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases Society and the Canadian Thoracic Society. The Canadian Community-Acquired Pneumonia Working Group. Clin Infect Dis 2000; 31:383-421. [PMID: 10987698 DOI: 10.1086/313959] [Citation(s) in RCA: 403] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2000] [Indexed: 11/03/2022] Open
MESH Headings
- Adolescent
- Adult
- Aged
- Child
- Child, Preschool
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/microbiology
- Community-Acquired Infections/therapy
- Community-Acquired Infections/virology
- Evidence-Based Medicine
- Female
- Humans
- Infant
- Infant, Newborn
- Male
- Middle Aged
- Pneumonia/diagnosis
- Pneumonia/epidemiology
- Pneumonia/therapy
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/epidemiology
- Pneumonia, Bacterial/microbiology
- Pneumonia, Bacterial/therapy
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/epidemiology
- Pneumonia, Viral/therapy
- Pneumonia, Viral/virology
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Affiliation(s)
- L A Mandell
- Division of Infectious Diseases, Dept. of Medicine, McMaster University, Henderson Campus, Ontario L8V 1C3, Canada. lmandell@fhs. csu.mcmaster.ca
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61
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Abstract
Nosocomial infection in the critically ill results from defects in the intrinsic barriers to microbial invasion. The diagnosis is complicated by an inability to perform an adequate physical examination in a patient with several compounding findings, usually necessitating sophisticated technologies to aid in the diagnosis. Pneumonia, line sepsis, urosepsis, sinusitis, endocarditis, peritonitis, and acalculous cholecystitis are the more common infections that challenge the care of the critically ill. Antibiotic therapy is adjunctive to efforts to preserve the barrier, but should be started early, should be targeted as specifically as possible to the offending organisms, and should be dosed adequately to ensure an effective concentration in the infected tissue.
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Affiliation(s)
- R L Reed
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
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62
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Affiliation(s)
- M S Niederman
- Division of Pulmonary and Critical Care Medicine, Winthrop University Hospital, Mineola, NY, USA
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63
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64
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Butler KL, Sinclair KE, Henderson VJ, Mckinney G, Mesidor DA, Katon-Benitez I, Weaver WL. The Chest Radiograph in Critically Ill Surgical Patients is Inaccurate in Predicting Ventilator-Associated Pneumonia. Am Surg 1999. [DOI: 10.1177/000313489906500902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Chest radiographs (CXRs) are frequently obtained in surgical intensive care unit (SICU) patients when a diagnosis of ventilator-associated pneumonia (VAP) is suspected. The purpose of this study was to determine if the interpretation of the CXR correlated with a diagnosis of VAP in SICU patients. Prospective evaluation of 20 SICU patients clinically suspected of VAP was performed from July 1997 through December 1998. All patients required mechanical ventilation for at least 48 hours, and antibiotic use was discontinued 24 hours before entry into the study. Bronchoscopy with protected specimen brush (PSB) sampling of secretions from the right and left lung was performed. A positive PSB was present if quantitative analysis yielded ≥104 colony-forming units/mL of bacteria. VAP was diagnosed if either the right or left PSB was positive and ruled-out if both the right and left PSB yielded <104 colony-forming units/mL. Twelve of 20 patients (60%) were diagnosed to have VAP by PSB criteria. Eight of 20 patients (40%) had CXRs interpreted as negative for infiltrates; four patients had VAP by PSB criteria. There were four patients with focal infiltrates; two patients had VAP. The remaining eight patients had radiographs interpreted as bilateral infiltrates (one) or pulmonary edema (seven); of these, six patients (75%) had VAP. The sensitivity of the CXR in determining the presence of VAP was 25 per cent, the specificity was 75 per cent, and the accuracy was 0.45. The CXR does not improve the clinician's ability to diagnose VAP: a normal CXR does not exclude the presence of VAP and the finding of a focal infiltrate does not confirm the diagnosis of VAP.
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Affiliation(s)
- Karyn L. Butler
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | | | | | - Gerald Mckinney
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | | | - Iva Katon-Benitez
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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65
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Abstract
Chest radiography is the imaging technique of choice in evaluating patients with suspected pneumonia because of its low radiation dose, low cost, and wide accessibility. In daily practice, radiographs are used to confirm the clinical diagnosis of pneumonia, characterize the extent and severity of disease, search for complications such as empyema, monitor the response to therapy, and examine for possible alternative or additional diagnoses. Although CT scan has no defined role in the routine assessment of patients with either community-acquired or nosocomial pneumonias, its advantages of superior contrast resolution and cross-sectional display can often be helpful in the analysis of complex cases, particularly when radiographic evidence of associated central obstruction, cavitation, lymphadenopathy, or empyema is equivocal. In the immunocompromised patient population, high-resolution CT has been shown to be more sensitive than plain film radiography in the early detection of pulmonary infections.
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Affiliation(s)
- D S Katz
- Department of Radiology, Winthrop-University Hospital, Mineola, New York, USA
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66
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Aquino SL, Dunagan DP, Chiles C, Haponik EF. Herpes simplex virus 1 pneumonia: patterns on CT scans and conventional chest radiographs. J Comput Assist Tomogr 1998; 22:795-800. [PMID: 9754119 DOI: 10.1097/00004728-199809000-00024] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The goal of our study was to describe the herpes simplex virus type 1 (HSV 1) pneumonia patterns on CT scans and chest radiographs. METHOD We retrospectively reviewed clinical records and chest radiographs of 24 patients with HSV 1 pneumonia and 10 with pneumonia from combined HSV and mixed flora infection. We also reviewed CT scans available for eight patients with HSV pneumonia and four with mixed pneumonia. RESULTS CT scans of eight patients with HSV pneumonia demonstrated multifocal segmental and subsegmental ground-glass opacities (n = 8), additional focal areas of consolidation (n = 6), scattered distribution (n = 6), and pleural effusions (n = 7). Chest radiographs (23 patients) showed patchy segmental and subsegmental ground-glass opacities and consolidation (n = 23), scattered distribution (n = 20), and pleural effusions (n = 12). Radiographic patterns for isolated HSV pneumonia and mixed flora pneumonia were not significantly different. CONCLUSION With a growing population of at-risk immunosuppressed patients, it is important to recognize CT and chest radiography patterns consistent with, although nonspecific for, HSV 1 pneumonia.
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Affiliation(s)
- S L Aquino
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1088, USA
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67
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Meduri GU, Reddy RC, Stanley T, El-Zeky F. Pneumonia in acute respiratory distress syndrome. A prospective evaluation of bilateral bronchoscopic sampling. Am J Respir Crit Care Med 1998; 158:870-5. [PMID: 9731019 DOI: 10.1164/ajrccm.158.3.9706112] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We evaluated the diagnostic yield of bilateral bronchoalveolar lavage (BAL) in patients with acute respiratory distress syndrome (ARDS) with suspected ventilator-associated pneumonia (VAP) and compared BAL results from contralateral sites. Ninety-four ARDS patients with suspected VAP underwent 172 bronchoscopies (344 BALs). BAL was processed for quantitative cultures, total cell count and subjected to microscopic analysis for cell differential, presence of intracellular organisms (ICO), and Gram stain. The diagnostic threshold for VAP was a growth of >= 10(4) cfu/ml in BAL culture. Most episodes (68%) had bilateral insignificant bacterial growth. Forty (43%) patients had one or more episodes of VAP. Thirty-three of the 55 (60%) positive bronchoscopies had significant growth in only one side, 18 were right BAL, and 15 were left BAL. Episodes with bilateral significant growth were more likely to be polymicrobial, to have a bacterial growth >= 10(5) cfu/ml in the BAL, and to possess a higher percentage of neutrophils and ICO. Among 65 microorganisms recovered in significant concentration, Pseudomonas aeruginosa occurred in 43% and S. aureus in 15%. Overall, Gram stain had a sensitivity of 54% and a specificity of 87%; and Giemsa stain (> 2% ICO) had a sensitivity of 46% and a specificity of 93%. Antibiotic treatment was modified by the results of BAL cultures in 50 (91%) episodes of pneumonia. In patients with ARDS and suspected VAP, bilateral BAL quantitative bacterial cultures had significant growth on one side only in 19% and in both sides in 13%.
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Affiliation(s)
- G U Meduri
- Pulmonary and Critical Care Division, University of Tennessee; and Veterans Administration Medical Center, Memphis, Tennessee, USA.
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68
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Thomason JW, Ely EW, Chiles C, Ferretti G, Freimanis RI, Haponik EF. Appraising pulmonary edema using supine chest roentgenograms in ventilated patients. Am J Respir Crit Care Med 1998; 157:1600-8. [PMID: 9603144 DOI: 10.1164/ajrccm.157.5.9708118] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The role of portable, anteroposterior, supine chest X-rays (CXRs) in distinguishing hydrostatic pulmonary edema (HPE) from permeability pulmonary edema (PPE) in mechanically ventilated patients is controversial. We prospectively obtained and evaluated such CXRs in 33 supine, mechanically ventilated intensive-care-unit patients with pulmonary artery catheters. Three chest radiologists independently reviewed CXRs without clinical information and recorded the cardiothoracic (CT) ratio, vascular pedicle width (VPW), and other radiographic features commonly used to evaluate pulmonary edema. Hydrostatic pulmonary edema was associated with a larger CT ratio (p < 0.001), subjective impressions of cardiomegaly (p < 0.01), and increased VPW (p = 0.02). There was a significant correlation between the pulmonary artery occlusion pressure and the VPW (r = 0.45, p = 0.0076) and CT ratio (r = 0.52, p = 0.0016), as well as between the VPW and CT ratio (r = 0.49, p = 0.0032). Despite this detailed evaluation of the CXRs, the mean accuracy of the radiologists' clinical diagnosis of HPE versus PPE was 41%, and 15 of 19 (79%) of PPE patients showed one or more roentgenographic signs of volume overload. Receiver-operating-characteristic curves were constructed to determine optimum cut-off values of VPW and CT ratio associated with HPE. Hydrostatic pulmonary edema was found to correlate best using a VPW > 63 mm coupled to a CT ratio > 0.52 (p = 0.027). With this combination of objective criteria, radiologists' diagnostic accuracy could have been increased to 73%. We therefore conclude that measurements of CT ratio and VPW correlate with pulmonary artery occlusion pressure in supine, mechanically ventilated patients. Distinction of hydrostatic from permeability pulmonary edema is difficult using portable, supine CXRs, but readily assessed radiologic signs may contribute to the correct diagnosis.
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Affiliation(s)
- J W Thomason
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1054, USA
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69
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Affiliation(s)
- W T Miller
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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70
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Abstract
Proper positioning and assessment of abnormalities and complications of the above-mentioned devices have a significant impact on the management of critically ill patients in the intensive care unit (ICU). The timely assessment of new or rapidly evolving findings is critical. Optimal radiographic technique, availability of images to the clinicians, and rapid reporting by the radiologist all serve to maximize the efficacy of bedside chest radiography in the ICU. Sometimes, changes in cardiopulmonary status may only be appreciated on chest radiographs (CXRs). Complications from ventilatory assistance, such as barotrauma, occur frequently and must be detected promptly. The position of monitoring devices, an important component of critical care management, is best checked radiographically. Indications for CXRs and the recommended frequency for repeat follow-up CXRs are based on the existing literature and the consensus of an expert panel formed by the American College of Radiology.
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Affiliation(s)
- C I Henschke
- Department of Radiology, New York Hospital-Cornell University Medical Center, New York 10021, USA
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71
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Wearden PD, Chendrasekhar A, Timberlake GA. Comparison of nonbronchoscopic techniques with bronchoscopic brushing in the diagnosis of ventilator-associated pneumonia. THE JOURNAL OF TRAUMA 1996; 41:703-7. [PMID: 8858032 DOI: 10.1097/00005373-199610000-00018] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the diagnostic accuracy of quantitative cultures obtained via nonbronchoscopic protected specimen brushing (PSB) and nonbronchoscopic bronchoalveolar lavage (BAL) compared with quantitative cultures obtained by bronchoscopic PSB in surgical patients suspected of ventilator-associated pneumonia. DESIGN Prospective, crossover controlled study of 15 ventilated surgical intensive care unit patients in a university teaching hospital. METHODS Fifteen consecutive ventilated patients suspected of ventilator-associated pneumonia on the basis of leukocytosis, purulent sputum, and appearance of chest roentgenogram were enrolled. All patients underwent nonbronchoscopic PSB and BAL followed by bronchoscopic PSB. The duration of each procedure was noted. Culture results were considered positive only if greater than 10(4) colony forming units (CFU) per milliliter were present. MAIN RESULTS Perfect concordance was noted between bronchoscopic PSB and nonbronchoscopic BAL (kappa = 1.0). The concordance between bronchoscopic PSB and nonbronchoscopic PSB was 93% ((kappa = 0.86). The nonbronchoscopic procedures were performed in significantly less time than the bronchoscopic procedure. CONCLUSION Nonbronchoscopic PSB and BAL provide similar microbiologic data to bronchoscopic PSB in the diagnosis of ventilator-associated pneumonia while shortening procedure time significantly.
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Affiliation(s)
- P D Wearden
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, USA
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72
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Meduri GU, Belenchia JM, Massie JD, Eltorky M, Tolley EA. The role of gallium-67 scintigraphy in diagnosing sources of fever in ventilated patients. Intensive Care Med 1996; 22:395-403. [PMID: 8796389 DOI: 10.1007/bf01712154] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the diagnostic value of gallium-67 scintigraphy in febrile ventilated patients by correlating the findings of 67Ga scintigraphy to sources of fever and pulmonary density, as determined by a comprehensive protocolized diagnostic evaluation. DESIGN Prospective observational study. PATIENTS Thirty-two intubated patients on mechanical ventilation for > or = 3 days with fever (> or = 38.3 degrees C) and a new or progressive density on chest radiograph. Twenty patients (21 tests) had adult respiratory distress syndrome (ARDS). INTERVENTION Diagnostic evaluation for fever included bronchoscopy with protected specimen brushing and (protected) bronchoalveolar lavage (BAL); computed tomography (CT) of sinuses; cultures of blood, urine, and central lines; and CT of the abdomen in high-risk patients. MEASUREMENTS AND RESULTS Uptake of 67Ga was reported as either focal or diffuse pulmonary uptake and extrapulmonary uptake. The combined causes of fever were pneumonia (9), fibroproliferation of late ARDS (7), abdominal process (4), sinusitis (4), urinary tract infection (3), and others (6). Causes of the pulmonary densities were pneumonia (9), ARDS (13), atelectasis (7), congestive heart failure (3), and empyema (1). Marked and diffuse pulmonary uptake was found only in patients with ARDS; however, it was not useful in discriminating those patients with pulmonary fibroproliferation as the sole cause of fever (p = 0.167) from those with infection. 67Ga scintigraphy was inadequate for detecting pneumonia but valuable in identifying extrapulmonary sites of infection in patients with ARDS (p = 0.021). CONCLUSIONS 67Ga scintigraphy should be considered only as an adjunct diagnostic test in the febrile, ventilated patient who has no obvious source of fever, despite a negative evaluation that includes testing for pneumonia, sinusitis, and urinary tract infection, conditions that are rarely detected by 67Ga scintigraphy.
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Affiliation(s)
- G U Meduri
- Department of Medicine, University of Tennessee, Memphis, USA
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73
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Shifrin RY, Choplin RH. ASPIRATION IN PATIENTS IN CRITICAL CARE UNITS. Radiol Clin North Am 1996. [DOI: 10.1016/s0033-8389(22)00668-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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74
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Henschke CI, Yankelevitz DF, Wand A, Davis SD, Shiau M. ACCURACY AND EFFICACY OF CHEST RADIOGRAPHY IN THE INTENSIVE CARE UNIT. Radiol Clin North Am 1996. [DOI: 10.1016/s0033-8389(22)00664-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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75
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Lipchik RJ, Kuzo RS. NOSOCOMIAL PNEUMONIA. Radiol Clin North Am 1996. [DOI: 10.1016/s0033-8389(22)00666-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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76
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Winer-Muram HT, Rubin SA, Kauffman WM, Jennings SG, Arheart KL, Sandlund JT, Bozeman PM. Childhood lymphoma: diagnostic accuracy of chest radiography for severe pulmonary complications. Clin Radiol 1995; 50:842-7. [PMID: 8536395 DOI: 10.1016/s0009-9260(05)83105-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION We sought to determine whether chest radiography can be reliably used to distinguish persistent or relapsing pulmonary lymphoma from a variety of infectious and noninfectious pulmonary conditions that can occur in children receiving treatment for lymphoma. METHODS We studied chest radiographs of 37 patients (30 with non-Hodgkin's lymphoma, and seven with Hodgkin's disease) who died of paediatric lymphoma or of treatment complications. Pulmonary findings at autopsy comprised lung tumour (n = 14), pleural tumour (n = 12), pneumonia (n = 22), adult respiratory distress syndrome (ARDS; n = 16), haemorrhage (n = 27), and infarction (n = 13). Using a 4-point scale and without knowledge of autopsy findings, three radiologists independently rated antemortem radiographs for the presence of pulmonary tumour, pleural tumour, pneumonia in general, pneumonia caused by viral, bacterial, fungal, and protozoan pathogens, ARDS, pulmonary haemorrhage, and pulmonary infarction. Diagnostic accuracy was defined by the area under the receiver-operating-characteristic curve (AZ). RESULTS Diagnostic accuracy was good for pulmonary tumour (AZ, 0.71 +/- 0.6), protozoan pneumonia (AZ, 0.77 +/- 0.06), and ARDS (AZ, 0.86 +/- 0.07) but poor for all other conditions. The absence of both pleural effusions and mediastinal/right hilar lymphadenopathy was significantly associated (P < or = 0.04) with the absence of lung tumour. DISCUSSION The pulmonary processes in these patients can all demonstrate diffuse airspace opacification, and many patients had multiple lung abnormalities at autopsy. The radiologist-readers were unable to identify which pulmonary conditions were responsible for radiographic findings in most patients. The readers were able to identify patients who did not have pulmonary lymphoma. If pulmonary involvement with lymphoma is unlikely, bronchoscopy with bronchoalveolar lavage may be sufficient to establish a diagnosis. When pulmonary lymphoma is a clinical consideration, open lung biopsy is usually required for diagnosis.
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Affiliation(s)
- H T Winer-Muram
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN
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Affiliation(s)
- F A Chambers
- Department of Intensive Care and Anaesthesia, Mater Hospital, Dublin
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Abstract
Lower respiratory tract infections are characterized by significant morbidity and mortality but also by a relative inability to establish a specific etiologic agent on clinical grounds alone. With the recognized shortcomings of expectorated or aspirated secretions toward establishing an etiologic diagnosis, clinicians have increasingly used bronchoscopy to obtain diagnostic samples. A variety of specimen types may be obtained, including bronchial washes or brushes, protected specimen brushings, bronchoalveolar lavage, and transbronchial biopsies. Bronchoscopy has been applied in three primary clinical settings, including the immunocompromised host, especially human immunodeficiency virus-infected and organ transplant patients; ventilator-associated pneumonia; and severe, nonresolving community- or hospital-acquired pneumonia in nonventilated patients. In each clinical setting, and for each specimen type, specific laboratory protocols are required to provide maximal information. These protocols should provide for the use of a variety of rapid microscopic and quantitative culture techniques and the use of a variety of specific stains and selective culture to detect unusual organism groups.
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Affiliation(s)
- V S Baselski
- Department of Pathology, University of Tennessee, Memphis 38163
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Meduri GU, Mauldin GL, Wunderink RG, Leeper KV, Jones CB, Tolley E, Mayhall G. Causes of fever and pulmonary densities in patients with clinical manifestations of ventilator-associated pneumonia. Chest 1994; 106:221-35. [PMID: 8020275 DOI: 10.1378/chest.106.1.221] [Citation(s) in RCA: 259] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Ventilator-associated pneumonia, a leading cause of sepsis in patients with acute respiratory failure, is difficult to distinguish clinically from other processes affecting patients receiving mechanical ventilation. We conducted a prospective study of patients with suspected ventilator-associated pneumonia to identify the causes of fever and densities on chest radiographs and to evaluate the diagnostic yield and efficiency of tests used alone and in combination. METHODS The 50 patients entered into the study underwent a systematic diagnostic protocol designed to identify all potential causes of fever and pulmonary densities. Diagnoses responsible for fever were established by strict diagnostic criteria for 45 of the 50 patients. The prevalence of specific conditions and diagnostic yield of individual tests were used to formulate a simplified diagnostic protocol. RESULTS The diagnostic protocol identified 78 causes of fever (median 2 per patient). Infections were the leading causes of fever and pulmonary densities. Of the 45 patients with fever, 37 had one or more infections identified (67 sources). Most infections (84 percent) were one of four types:pneumonia, sinusitis, catheter-related infection, or urinary tract infection. Ventilator-associated pneumonia occurred in only 42 percent. All but nine infections (87 percent) were directly or indirectly related to insertion of a catheter or a tube. Concomitant infections were frequent (62 percent), particularly in patients with sinusitis (100 percent), catheter-related infections (93 percent), and pneumonia (74 percent). Of concomitant infections, 60 percent were caused by a different pathogen. Noninfectious causes of fever were more common in the 22 patients with adult respiratory distress syndrome. Histologically proved pulmonary fibroproliferation was the only cause of fever in 25 percent of patients with adult respiratory distress syndrome. Radiographic densities were caused by an infection in only 20 patients (19 pneumonia, 1 empyema). In more than 50 percent of the 25 patients without adult respiratory distress syndrome, congestive heart failure, and atelectasis were the sole causes of pulmonary densities, and fever always originated from an extrapulmonary site of infection. Used in combination, bronchoscopy with protected sampling, computed tomographic scan of the sinuses, and cultures of maxillary sinus aspirate, central intravenous or arterial lines, urine, and blood identified 58 of the 78 sources of fever (74 percent). CONCLUSIONS The observations in this study document the complex nature of acute respiratory failure and fever and underscore the need for accuracy in diagnosis. The frequent occurrence of multiple infectious and noninfectious processes justifies a systematic search for source of fever, using a comprehensive diagnostic protocol. A simplified diagnostic protocol was devised based on the diagnostic value of individual tests.
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Affiliation(s)
- G U Meduri
- University of Tennessee Health Science Center, Memphis
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