BAL Fabrice Michel, MD; Bruno Franceschini, MD; Pierre Berger, MD; Jean-Michel Arnal, MD; Marc Gainnier, MD; Jean-Marie Sainty, MD; and Laurent Papazian, MD (VAP) BAL ICU 48 h 299 2 (EA) VAP BAL VAP EA (EA-pre) (EA-pre ) (ATS) Trouillet (Am J Respir Crit Care Med 1998;157:531-539) 75 BAL 41 ( BAL ) VAP 41 BAL EA-pre ( ) 34 (83%) 1 VAP BAL EA-pre BAL 4 EA-pre 2 40 38 (95%) Trouillet 41 VAP 34 [83% P = 0.15 ( EApre )] ATS 41 VAP 28 [68% P = 0.005 ( EA-pre )] BAL 2 EA 95% BAL VAP (BAL); (empiric antibiotic therapy); (endotracheal aspirate); (mechanical ventilation); (pneumonia) www.chestjournal.org.cn CHEST 2005 6 2 6 351
(ventilator-associated pneumonia, VAP) ICU 9% ~ 20% [1,2] ICUs [3,4] VAP [5~7] [8,9] ICU BAL VAP [10] 50% ICU VAP ( 2 ) [11~19] BAL VAP Luna [12] VAP BAL VAP BAL [12] VAP Marseille Sainte-Marguerite ICU 21 mo (2001 (BAL ) BAL 5 1 2002 1 31 ) 24 ~ 48 h VAP [13,14,20~23] BAL BAL 24 ~ 48 h 48 h VAP ( 18 ) (< 0.5 10 9 cells / L) AIDS [11] [24] (American Thoracic Society ATS) Trouillet [25] 2 From the Service de Réanimation Médicale (Drs. Michel, Franceschini, Arnal, Gainnier, Sainty, and Papazian), Hôpital Sainte-Marguerite, Unité Propre de Recherche de L Enseignment Superior Equire D Accueil, 2201, and the Service de Microbiologie (Dr. Berger), Hôpital de La Timone, Université de la Méditerranée, Marseille, France. Correspondence to: Laurent Papazian, MD, Réanimation Médicale,Hôpital Sainte-Marguerite, 13274 Marseille Cedex 9, France; e-mail: laurent. papazian@ap-hm. fr (model 534-16; Vygon; Ecouen, France) (endotracheal aspiration, EA) [26,27] 10 3 cfu / ml EA VAP VAP (EA-pre) EAs ( 1) 352
BAL WBC PaO 2 / (fraction of EA EA EA EA EA-pre EA EA EA-pre BAL 1 inspired oxygen FIO 2 ) (clinical pulmonary infection score CPIS) [30] PaCO 2 EA-pre 24 h BAL BAL VAP ICU ICU VAP EA-pre BAL (L.P.) BAL 10 4 cfu / ml EA-pre VAP BAL > 48 h EA-pre 4 2 VAP ( > 38 ) ( < 36 ); ( > 10 10 9 cells / L < 5 10 9 cells / L); VAP 24 h EA-pre (EA-pre ) BAL ATS [24] Trouillet [25] Trouillet 50 ml 3 [25] (< 7 7 d) 1 VAP 15 d BAL 1 10 4 cfu / β ml VAP ( ICU 5 VAP VAP d) (> 5 d) EA ICU ICU VAP 60 x ± s ICU ICU (interquartile range IQR) (simplified Student t [28] acute physiology score SAPS) Wilcoxon (sequential organ failure assessment [29] SOFA) ; BAL SOFA Weinberg χ 2 Fisher ICU SAPS www.chestjournal.org.cn CHEST 2005 6 2 6 353
2 BAL EA-pre EA-pre 21 mo 299 48 h 1 211 EA VAP 75 BAL 2 (18) 4 (14) 8 2 VAP 2 (%) 3 4 VAP 1 VAP MV 75 BAL 41 (55%) VAP ( BAL ) 48 h VAP 13.7% (10.4 / 1 000 ) (95%CI 9.8% ~ 17.6%) 4 EA-pre BAL EApre 2 41 VAP 12 (29%) 3 ~ 5 VAP ( VAP) 29 (71%) 5 ( VAP) BAL 12 (29%) EA-pre BAL BAL EA-pre 22 VAP EA-pre 41 BAL EA-pre BAL ( ) 34 (83%; 95%CI 70% ~ 96%) VAP EA-pre 25 29 BAL 86% ( 2) 3 10 4 cfu / ml BAL EA-pre 1 ( VAP) BAL BAL MV 5 d (11 ) 9 (82) 25 (86) MV > 5 d (29 ) EA-pre 40 38 (95% 95% CI 88% ~ 100%) 5% (95% CI 0% ~ 12%) EA-pre Trouillet 41 34 [83% 95% CI 72% ~ 94% P = 0.15 ( 1 62 VAP ICU ICU / y 65 14 ICU 9 (15) ( ) 16 18 (29) 46 8 (13) ICU NYHA 4 7 (11) 55 (89) 4 (6) 4 (6) 3 (5) 2 (3) 1 (2) 1 (2) 1 (2) SAFA 7.1 3.5 35 (56) SAPS 44 17 x ± s (%) NYHA EA-pre )] ATS 41 28 [68% 95% CI 54% ~ 82% P = 0.005 ( EA-pre )] BAL 34 EA-pre 12 (35% 95% CI 19% ~ 51%) Trouillet ATS 34 [P = 0.001 ( EA-pre )] (24%) ( 4) 12 7 VAP 12 VAP 1 29 11 (38%) 12 3 (25%) 354
3 EA-pre BAL EA BAL BAL BAL MSSA +MSSA + MSSA MSSA MSSA VAP VAP ( VAP (76%; 95% CI 63% ~ 89%) [P = 0.01 ( EA-pre )]; ) ATS 33 (80% 95% CI 68% ~ 92%) [P = 0.002 ( EA-pre )] ( 5) 8 VAP BAL EA-pre 23 Trouillet BAL EA-pre 18 Trouillet ATS 34 31 EA-pre (91%; 95% CI 81% ~ 100%) ATS ( ) EA-pre 7 Trouillet BAL 13 EA-pre 6 CPIS BAL ATS 8 7 BAL EA-pre ICU Trouillet ATS Trouillet 1 VAP BAL ATS EA-pre VAP ICU ( ) 41 30 31 [(35 23) (25 13) d 41 2 P = 0.062] 60 d EA-pre (P < 0.001 1 VAP ( 0 d IQR ATS Trouillet EA-pre ) Trouillet [25] 31 0 19 d) BAL ( 23 d IQR 2 43 d) (P = 0.01) 1 VAP ICU β (38.5% 73.9% P < 0.05) EA-pre β 3 ICU 18 (45%; 95% CI 30% ~ 60%); SAPS II 36 50 (29% 80% P = 0.03) www.chestjournal.org.cn CHEST 2005 6 2 6 355
4 41 BAL ( 10 4 cfu / ml) ( / (%)VAP (%) ) (24 ~ 48 h BAL ) 2 EA 95% 36 (6 / 30) 72 88 5 (1 / 4) 10 12 7 (0 / 7) 14 17 2 (1 / 1) 4 5 2 (0 / 2) 4 5 ESBL 3 (0 / 3) 6 7 3 (2 / 1) 6 7 ESBL 3 (1 / 2) 6 7 5 (1 / 4) 10 12 14 (6 / 8) 28 32 11 (5 / 6) 22 27 1 (1 / 0) 2 2.5 2 (0 / 2) 4 5 50 (12 / 38) 100 EOP LOP ESBL β ICU SAPS < 36 (20% 30%) > 50 (33% 57%) 48 h BAL ( EA-pre ) 2 11 718 VAP β ( BAL ) β 7 773 VAP VAP [24,25] EA EA BAL VAP [24,31] BAL EA Hayon [32] ICU BAL ( BAL EA) 125 VAP 102 (82%) [32] 37 35% [32] BAL 5 41 VAP Trouillet ATS EA-pre Trouillet ATS ( ) ( ) ( ) + AG + 0 11 0 + AG 10 0 0 + AG 2 20 33 + AG 5 0 0 + AG 5 0 0 0 10 8 /β + AG 1 0 0 /β 3 0 0 1 0 0 + 11 0 0 2 0 0 1 0 0 AG 356
6 BAL 10 4 cfu / ml (41 ) < 10 4 cfu / ml (34 ) P / 38.3 0.9 38.5 0.7 NS 37.0 0.8 37.0 0.9 NS WBC / 10 3 cells ml -1 14.7 (10.6 ~ 18.4) 13.4 (10.7 ~ 16.9) NS SOFA 8.2 3.8 7.4 3.6 NS Weinberg 6.7 2.6 6.1 2.3 NS PaO 2 / FIO 2 180 (139 ~ 248) 163 (137 ~ 234) NS PaCO 2 / mm Hg 39 (33 ~ 46) 40 (34 ~ 44) NS CPIS 6.6 2.2 5.0 1.5 0.001 BAL 24 h (PEEP, FIO 2, ) (2) 20 (49) 14 (41) NS VAP / d 11 (5 ~ 22) 11.5 (7 ~ 24) NS (3) 15 (37) 14 (41) NS x (2) ± s (IQR) (%) NS PEEP FIO 2 (3) 72 h VAP VAP OR 6.81 Rello [14] [ (8 9) d] VAP 37% VAP Hayon 15.4% Kollef [11] [32] 72 h BAL 33 VAP 17 (52%) 3 Iregui [39] VAP 85% 84% Dennesen [33] [40] 27 ICU 2 EA Rello [41] EA 3 ICUs Delclaux [34] ATS [24] Trouillet [25] ARDS 48 ~ 72 h 67% VAP 24 h 30% VAP Kollef [11] BAL [12,13,35,36] 61% VAP VAP 33% [11~14] VAP VAP [9,31] Celis [37] Torres [38] BAL www.chestjournal.org.cn CHEST 2005 6 2 6 357
24 ~ 48 h [31] VAP [24] VAP VAP VAP [9,31] Trouillet [25] VAP (OR 13.5) (OR 4.1) EA-pre EA VAP BAL VAP VAP VAP 17% VAP VAP VAP 1847 3 Bercault N, et al. Crit Care Med 2001;29:2303 2309 [42,43] 4 Bregeon F, et al. Anesthesiology 2001;94:554 560 6 Rello J, et al. Chest 1991;100:439 444 Sirvent [44] BAL ( ) VAP 508 9 Fagon JY, et al. Am J Med 1993;94:281 288 BAL EA 15 Montravers P, et al. Clin Infect Dis 1996;23:486 494 Rello [41] VAP 16 Chow JW, et al. Ann Intern Med 1991;115:585 590 17 Chang YC, et al. Pediatr Neurol 1997;17:144 149 ATS Trouillet EA 371 376 1 Vincent JL, et al. JAMA 1995;274:639 644 2 George DL, et al. Am J Respir Crit Care Med 1998;158:1839 5 Papazian L, et al. Am J Respir Crit Care Med 1996;154:91 97 7 Dreyfuss D, et al. Am Rev Respir Dis 1993;147:946 951 8 Kappstein I, et al. Eur J Clin Microbiol Infect Dis 1992;11:504 10 Bergmans D, et al. J Antimicrob Chemother 1997;39:527 535 11 Kollef MH, et al. Chest 1998;113:412 420 12 Luna CM, et al. Chest 1997;111:676 685 13 Alvarez-Lerma F. Intensive Care Med 1996;22:387 394 14 Rello J, et al. Am J Respir Crit Care Med 1997;156:196 200 18 Romero-Vivas J, et al. Clin Infect Dis 1995;21:1417 1423 19 Heath CH, et al. Eur J Clin Microbiol Infect Dis 1996;15:286 290 20 Bonten MJ, et al. Am J Respir Crit Care Med 1997;156:1820 1824 21 Sanchez-Nieto JM, et al. Am J Respir Crit Care Med 1998;157: 22 Ruiz M, et al. Am J Respir Crit Care Med 2000;162:119 125 358
23 Fagon JY, et al. Chest 1993;103:547 553 24 Campbell GD, et al. Am J Respir Crit Care Med 1996;153:1711 1725 25 Trouillet JL, et al. Am J Respir Crit Care Med 1998;157:531 539 26 Papazian L, et al. Chest 1993;103:236 242 27 Papazian L, et al. Am J Respir Crit Care Med 1995;152:1982 1991 28 Le Gall JR, et al. JAMA 1993;270:2957 2963 29 Vincent JL, et al. Crit Care Med 1998;26:1793 1800 30 Pugin J, et al. Am Rev Respir Dis 1991;143:1121 1129 31 Rello J, et al. Chest 1993;104:1230 1235 32 Hayon J, et al. Am J Respir Crit Care Med 2002;165:41 46 33 Dennesen PJ, et al. Am J Respir Crit Care Med 2001;163:1371 1375 34 Delclaux C, et al. Am J Respir Crit Care Med 1997;156:1092 1098 35 Heyland DK, et al. Am J Respir Crit Care Med 1999;159:1249 1256 36 Dupont H, et al. Intensive Care Med 2001;27:355 362 37 Celis R, et al. Chest 1988;93:318 324 38 Torres A, et al. Am Rev Respir Dis 1990;142:523 528 39 Iregui M, et al. Chest 2002;122:262 268 40 Ioanas M, et al. Eur Respir J 2001;17:791 801 41 Rello J, et al. Am J Respir Crit Care Med 1999;160:608 613 42 Timsit JF, et al. Intensive Care Med 2001;27:640 647 43 Papazian L, et al. Anesthesiology 1997;87:268 276 44 Sirvent JM, et al. Chest 2003;123:518 523 CHEST 2005;127:589-597 CHEST No.21 Which one of the following statements concerning the effects of late pregnancy (third trimester) on lung function testing in healthy subjects is correct? A. Vital capacity is reduced. B. Functional residual capacity is unchanged. C. Tidal volume is reduced. D. Arterial PCO 2 is reduced. E. Arterial PO 2 is reduced. 375 CHEST www.chestjournal.org.cn CHEST 2005 6 2 6 359