CHEST Elie Azoulay, MD, PhD; Jean-François Timsit, MD, PhD; Muriel Tafflet; Arnaud de Lassence, MD; Michael Darmon, MD; Jean-Ralph Zahar, MD; Christophe Adrie, MD, PhD; Maité Garrouste-Orgeas, MD; Yves Cohen, MD; Bruno Mourvillier, MD; and Benoît Schlemmer, MD; for the Outcomerea Study Group (MV) (VAP) MV >2d ( / ) MV 6 4y 803 214 (26.6%) (68.7%) (20.1%) (13.1%) (39.7% 8.3% P = 0.01) ICU / (24.1% 17.6% OR 1.58 95% CI 0.94 2. 68 P = 0.086 0) (9% 4.8% OR 2.22 95% CI 1.0 4. 92 P = 0.049) MV >2d ICU VAP (Candida); (mechanical ventilation); (pneumonia); (Pseudomonas); (ventilator-associated pneumonia) CI = confidence interval; LOD = logistic organ dysfunction; MV = mechanical ventilation; OR = odds ratio; SAPS = simplified acute physiology score; VAP = ventilator-associated pneumonia www.chestjournal.org.cn CHEST 2006 6 3 6 349
Vincent [1] ICU (MV) [1] ICU MV 28.7% 17.1% 2d (VAP) [2, 3] [7] ( ) El-Azizi [8] Neely [9] [10] [2, 3] Hogan [11, 12] ICU [4] VAP MV 2d MV ( ) [4 6] ( )VAP From the Medical ICU (Drs. Azoulay, Darmon, and Schlemmer), Saint Louis Teaching Hospital, Paris; Medical ICU (Dr. Timsit), Hospital Michallon, Grenoble; Department of Biostatistics (Ms. Tafflet), Outcomerea; Louis Mourier Teaching Hospital (Dr. de Lassence), Colombes; Microbiology Department (Dr. Zahar), Necker Teaching Hospital, Necker; Medical-Surgical ICU (Dr. Adrie), Delafontaine Hospital, Saint Denis; Medical- Surgical ICU (Dr. Garrouste-Orgeas), Saint Joseph Teaching Hospital, Paris; Medical-surgical ICU (Dr. Cohen), Avicenne Teaching Hospital, Bobigny; and Medical ICU (Dr. Mourvillier), Bichat Hospital, Paris, France. Outocomerea is supported by nonexclusive educational grants from the Centre National de Recherche Scientifique, Paris, France, and the Agence National de Valorisation de la Recherche, France. This study was also supported by a grant from Pfizer France. Correspondence to: Elie Azoulay, MD, PhD, Medical ICU, Saint Louis Teaching Hospital, 1 Ave Claude Vellefaux, 75010 Paris, France; e-mail: elie.azoulay@outcomerea.org 2000 1 2003 12 18 MV 2d HIV ( 3mo) ( 1 mg / kg) 6 ICU [13, 14] BAL [13, 14] 350
[15] ( VAP ) ( ) VAP ( ) 38.5 ºC 36.5 ºC ( ) 10 10 9 /L 4 10 9 /L VAP [16] ( )BAL ( 10 3 cfu / ml) ( 10 3 ICU cfu / ml) BALF ( 10 4 cfu / ml) ICU (Vigirea ) MV ( ) [17] McCabe Knaus ICU ( ) ( MV ) ( MACRO (SAS Institute ) ( Cary NC http://www.outcomerea.org/ehtm/ Swan-Gans ) matchmacro.pdf) ( ) ICU / 1 2 Kaplan-Meier 8:00 1 8:00 2 8:00 (SAPS ) [18, 19] SAS ICU 1 24 h (1: n) SAPS (logistic or- VAP [18, 19] gan dysfunction LOD) ICU VAP ICU VAP 2d VAP VAP MV VAP ICU 2003 ICU 2% ICU (OR) OR 0.67 1 κ SAPS 0.5 0.9 LOD ( ) www.chestjournal.org.cn CHEST 2006 6 3 6 351
ICU 1 ICU LOD OR 95% CI ICU 3 P 0.05 SAS (7.5% 2.9% P = 0.003 8) 4y 6 ICU 803 ICU 6 MV 2 d 214 2 (0.9%) (26.6%) 1 4 (0.7%) 1 30 MV 5d 19.54% (16.48 % 22.60%) 15 d 31.49% (27.10% 35.88%) 30 d 33.66% (28.76% 38.56%) (20%) 1 MV ICU (1 : n) 191 VAP 46 VAP (24.1%) (67.7%) VAP 5d(2 (13%) 7d) VAP 612 386 68 (17.6%) VAP / 386 85 2 191 386 39.7% VAP OR 49 8.3% 1.55 (95% CI 1.01 2.38 P = 0.047) 1 352
1 (1) (n =214) (n =589) P (2) / 54 52 (24.3) 213 (36.2) 0.002 54 77 116 (54.2) 294 (49.9) 0.3 77 46 (21.5) 82 (19.9) 0.01 10 (4.7) 14 (2.4) 0.1 ICU 71 (33.2) 129 (21.9) 0.001 1 55 (25.7) 142 (24.1) 0.6 33 (15.4) 199 (33.8) 0.000 1 114 (53.3) 204 (34.6) 0.000 1 80 (37.4) 334 (46.7) 0.000 1 SAPS ( ) 45 (33 60) 47 (36 61) 0.2 LOD ( ) 5 (3 7) 6 (3 8) 0.038 (3) 150 (71.1) 365 (63.5) 0.047 ARDS (4) 89 (42.2) 222 (38.6) 0.44 144 (67.3) 340 (57.7) 0.014 ICU3 d 176 (82.2) 429 (72.8) 0.006 2 ( ) 25 (11.7) 38 (6.4) 0.015 33 (15.4) 53 (9) 0.009 27 (12.7) 37 (6.3) 0.003 49 (22.9) 78 (13.2) 0.000 9 16 (7.5) 17 (2.9) 0.003 8 MV 13 (7 24) 6 (3 12) 0.000 1 MV /ICU 82 (67 97) 75 (58 96) 0.008 VAP 51 (23.8) 114 (19.3) 0.01 VAP 19 (8.8) 30 (5) 0.1 ICU 17 (9 32) 9 (5 17) 0.000 1 36 (19 74) 22 (9 45) 0.000 1 ICU 78 (36.4) 190 (32.3) 0.3 93 (43.5) 214 (36.3) 0.067 (1) (2) (%) χ 2 Fish (3) Wilcoxon / 300 mm Hg (4) / 200 mm Hg VAP VAP ( OR 2.22 95% CI 1.00 4.92 P = 0.049) ICU www.chestjournal.org.cn CHEST 2006 6 3 6 353
2 / (1 : n) /% / 1 ICU 100 VAP 191 46 VAP (24.1%) MV 386 68 VAP (17.1%) OR 1.55 (95% CI 1.01 2.38 P = 0.047) OR 1.58 (95% CI 0.94 2.68 P = 0.086) 2 ICU 100 211 19 VAP (9%) MV VAP 394 19 VAP (4.8%) OR 1.99 (95% CI 1.01 3.93 P = 0.047) OR 2.22 (95% CI 1.00 4.92 P = 0.049) 3 ICU 100 207 18 VAP (8.7%) MV VAP 398 28 VAP 7 OR 1.38 (95% CI 0.71 2.69 P =0.3) OR 1.27 (95% CI 0.57 2.85 P =0.6) [1,7,8] [16, 20] ( / ) VAP [2,3,21,22] VAP (9% MV 4.8% P =0.049) 25% MV ICU VAP VAP [23, 24] [25] VAP [12] [11] (3-oxo-C12 homoserine lactone) [2, 3] [11] Spinelli [10] (2 -phosphotransferase) RNA [5, 26 28] RNA [29, 30] MV [8] VAP 354
3 2 / ( VAP ) (1) (n = 211) (n =394) P (2) / 69 (55 76) 64 (50 74) 0.01 ICU 55 (26) 95 (24.1) 0.1 64 (30.3) 106 (26.9) 0.35 32 (15.2) 123 (31.2) 0.000 1 113 (53.6) 148 (37.5) 0.000 1 69 (32.7) 205 (52) 0.000 1 SAPS ( ) 45 (35 58.5) 48 (36 61) 0.33 LOD ( ) 5 (3 7) 5 (3 8) 0.11 48 h MV 175 (82.9) 350 (89) 0.57 (3) 156 (73.9) 257 (65.2) 0.22 ARDS (4) 93 (44.1) 160 (40.6) 0.37 147 (69.6) 245 (62.2) 0.10 ICU 3 d 166 (78.6) 303 (76.9) 0.27 VAP 48 (22.7) 69 (17.5) 0.07 VAP 19 (9) 19 (4.8) 0.04 (1 4) 1 [31] Piarroux [32] ( ) ICU 6 ICU VAP 1 Vincent JL, et al. JAMA 1995;274:639 644 590 VAP 3 Rello J, et al. Chest 1998;114:146 149 323 330 5 Pittet D, et al. Ann Surg 1994;220:751 758 MV 6 Ibanez-Nolla J, et al. J Infect 2004;48:181 192 9 Neely AN, et al. Infect Immun 1986;52:200 204 14141 2 el-ebiary M, et al. Am J Respir Crit Care Med 1997;156:583 4 Olaechea PM, et al. Eur J Clin Microbiol Infect Dis 2004;23: 7 Adair CG, et al. Intensive Care Med 1999;25:1072 1076 8 El-Azizi MA, et al. J Appl Microbiol 2004;96:1067 1073 10 Spinelli SL, et al. Proc Natl Acad Sci U S A 1998;95:14136 11 Hogan DA, et al. Mol Microbiol 2004;54:1212 1223 12 Hogan DA, et al. Science 2002;296:2229 2232 13 Chastre J, et al. Am J Respir Crit Care Med 2002;165:867 VAP 903 15 Ascioglu S, et al. Clin Infect Dis 2002;34:7 14 VAP 14 Bornstain C, et al. Clin Infect Dis 2004;38:1401 1408 16 Azoulay E, et al. Intensive Care Med 2004;30:1384 1389 17 Knaus WA, et al. Crit Care Med 1981;9:591 597 www.chestjournal.org.cn CHEST 2006 6 3 6 355
18 Le Gall JR, et al. JAMA 1996;276:802 810 19 Le Gall JR, et al. JAMA 1993;270:2957 2963 20 Azoulay E, et al. Candida in lung specimens from non-neutropenic ICU patients: infection or colonisation? In:Vincent JL. Yearbook of intensive care and emergency medicine. Berlin, Germany: Springer-Verlag, 2003;301 307 21 Masur H, et al. Am J Med 1977;63:914 925 22 Rose HD, et al. Arch Intern Med 1978;138:964 965 23 Kerr JR, et al. J Clin Pathol 1999;52:385 387 24 Kerr JR. J Clin Microbiol 1994;32:525 527 25 Hockey LJ, et al. J Clin Microbiol 1982;16:1080 1085 26 Rex JH, et al. Clin Infect Dis 2001;32:1191 1200 27 Ibanez-Nolla J, et al. J Infect 2004;48:181 192 28 Nolla-Salas J, et al. Intensive Care Med 1997;23:23 30 29 Jacobs S, et al. Crit Care Med 2003;31:1938 1946 30 Eggimann P, et al. Lancet Infect Dis 2003;3:772 785 31 British Society for Antimicrobial Chemotherapy Working Party. Intensive Care Med 1994;20:522 528 32 Piarroux R, et al. Crit Care Med 2004;32:2443 2449 CHEST 2006;129:110 117 CHEST The use of inhaled corticosteroids over 6 months to 3 years in patients with moderate to severe COPD (FEV 1 /FVC< 70%, FEV 1 < 80%) has improved all of the following outcomes EXCEPT: A. Respiratory symptoms. B. Rate of exacerbations. C. 6 minute walking distance. D. Rate of decline of lung function. E. Rate of decline of health-related quality of life. 366 CHEST 356