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Communications to the Editor |

ARDS and Nosocomial Pneumonia : Scientific Value of Parenteral Fluids Data FREE TO VIEW

William S. Lyons, MD
Author and Funding Information

Affiliations: Falls Church, VA,  Klinikum der Ruhr-Universiteit Bochum, Germany

Correspondence to: William S. Lyons, MD, Skyline Towers, 5601 Seminary Rd, Apt 2214N, Falls Church, VA 22041; e-mail: lyonsmd@msn.com



Chest. 2005;127(2):682-683. doi:10.1378/chest.127.2.682
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Published online

To the Editor:

It is unfortunate that Dr. Bauer took my letter to be an argument ad hominem. It was not. It was consistent with his own observation on the generally confused posture of the profession on treatment for nosocomial pneumonia.

Recognized authorities had previously noted the unsatisfactory status not only of our treatment but of our fundamental understanding of the problem.16 Dr. Bauer makes the assertion that there are no studies in the literature supporting my view that excessive parenteral salt and water is a basic problem in the development of ARDS/nosocomial pneumonia, “to his knowledge.” In fact, there is quite a lot of information on acute substantial weight gain in ARDS,79 fluid overload,1014 benefit of parenteral fluid volume reduction,10,15 and the value of off-loading (edema) fluid in ARDS patients.11 I see this as basic information that is of value to the scientific community.

Bone, RC (1996) Why sepsis trials fail.JAMA276,565-566. [CrossRef] [PubMed]
 
Bone, RC Sepsis and controlled clinical trials: the odyssey.Crit Care Med1995;23,1313-1315. [CrossRef] [PubMed]
 
Chernow, B Back to the drawing board.Crit Care Med1996;24,1097-1098. [CrossRef] [PubMed]
 
Astiz, ME, Rackow, C Crystalloid—colloid controversy revisited.Crit Care Med1999;27,34-35. [CrossRef] [PubMed]
 
Abraham, E Toward new definitions of acute respiratory distress syndrome.Crit Care Med1999;27,237-238. [CrossRef] [PubMed]
 
Fuhrman, BP, Abraham, E, Dellinger, RP Futility of randomized, controlled ARDS trials: a new approach is needed.Crit Care Med1999;27,431-433. [CrossRef] [PubMed]
 
Eberhard, LW, Morabito, DJ, Matthay, MA, et al Initial severity of metabolic acidosis predicts development of acute lung injury in severely traumatized patients.Crit Care Med2000;28,125-131. [CrossRef] [PubMed]
 
Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome: The ARDS Network.N Engl J Med2000;342,1301-1308. [CrossRef] [PubMed]
 
Mangialardi, RJ, Martin, GS, Bernard, GR, et al Hypoproteinemia predicts acute respiratory distress syndrome development, weight gain and death in patients with sepsis.Crit Care Med2000;28,3137-3145. [CrossRef] [PubMed]
 
Mitchell, JP, Schuller, D, Calandrino, FS, et al Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization.Am Rev Respir Dis1992;145,990-998. [CrossRef] [PubMed]
 
Stegmayr, BG, Banga, R, Berggren, L, et al Plasma exchange as rescue therapy in multiple organ failure including renal failure.Crit Care Med2003;31,1730-1736. [CrossRef] [PubMed]
 
Bishop, MA, Jorgens, J, Shoemaker, WC, et al The relationship between ARDS, pulmonary infiltration, fluid balance and hemodynamics in critically ill surgical patients.Am Surg1991;57,785-792. [PubMed]
 
Raeburn, CD, Moore, EE, Biffl, WL, et al The abdominal compartment syndrome is a morbid complication of post injury damage control surgery.Am J Surg2001;182,542-546. [CrossRef] [PubMed]
 
Biffl, WL, Moore, EE, Burch, JM, et al Secondary abdominal compartment syndrome is a highly lethal event.Am J Surg2001;182,645-648. [CrossRef] [PubMed]
 
Alsous, F, Khamiees, M, DeGirolamo, A, et al Negative fluid balance predicts survival of patients in septic shock.Chest2000;117,1749-1754. [CrossRef] [PubMed]
 

I read with interest the letter responding to my editorial in CHEST (November 2003).1The author argued that fluid overload is a basic problem in the development of nosocomial infections and/or ARDS. Although fluid overload is a consequence of ARDS and its management is probably crucial to the outcome in these patients, to my knowledge, there is no study in the literature supporting fluid overload as an etiology of ARDS apart from near-drowning. Regarding the issue of infection, Rivers et al2proved the opposite, namely, that fluid management is pivotal to the survival of patients presenting with severe sepsis and septic shock. Though conducted in non-critically ill patients, a small review of the literature3 tried to address the issue raised in our correspondence. Guppy and coworkers3 could not, however, identify any serious adverse effects of drinking large quantities of fluid during an acute respiratory infection. Nevertheless, in terms of citable evidence this issue remains unsolved. From my clinical perspective, there is no good reason to assume that parenteral fluid overload induces ARDS or facilitates nosocomial infections. It does, as we are all aware of, often induce problems in patients with left heart failure, and fluid supplementation needs to be closely monitored in all our patients.

References
Bauer, TT Nosocomial pneumonia: therapy is just not good enough.Chest2003;124,1632-1634. [CrossRef] [PubMed]
 
Rivers, E, Nguyen, B, Havstad, S, et al Early goal-directed therapy in the treatment of.N Engl J Med2001;345,1368-1377. [CrossRef] [PubMed]
 
Guppy, MPB, Mickan, SM, Del Mar, CB “Drink plenty of fluids”: a systematic review of evidence for this recommendation in acute respiratory infections.BMJ2004;328,499-500. [CrossRef] [PubMed]
 

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References

Bone, RC (1996) Why sepsis trials fail.JAMA276,565-566. [CrossRef] [PubMed]
 
Bone, RC Sepsis and controlled clinical trials: the odyssey.Crit Care Med1995;23,1313-1315. [CrossRef] [PubMed]
 
Chernow, B Back to the drawing board.Crit Care Med1996;24,1097-1098. [CrossRef] [PubMed]
 
Astiz, ME, Rackow, C Crystalloid—colloid controversy revisited.Crit Care Med1999;27,34-35. [CrossRef] [PubMed]
 
Abraham, E Toward new definitions of acute respiratory distress syndrome.Crit Care Med1999;27,237-238. [CrossRef] [PubMed]
 
Fuhrman, BP, Abraham, E, Dellinger, RP Futility of randomized, controlled ARDS trials: a new approach is needed.Crit Care Med1999;27,431-433. [CrossRef] [PubMed]
 
Eberhard, LW, Morabito, DJ, Matthay, MA, et al Initial severity of metabolic acidosis predicts development of acute lung injury in severely traumatized patients.Crit Care Med2000;28,125-131. [CrossRef] [PubMed]
 
Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome: The ARDS Network.N Engl J Med2000;342,1301-1308. [CrossRef] [PubMed]
 
Mangialardi, RJ, Martin, GS, Bernard, GR, et al Hypoproteinemia predicts acute respiratory distress syndrome development, weight gain and death in patients with sepsis.Crit Care Med2000;28,3137-3145. [CrossRef] [PubMed]
 
Mitchell, JP, Schuller, D, Calandrino, FS, et al Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization.Am Rev Respir Dis1992;145,990-998. [CrossRef] [PubMed]
 
Stegmayr, BG, Banga, R, Berggren, L, et al Plasma exchange as rescue therapy in multiple organ failure including renal failure.Crit Care Med2003;31,1730-1736. [CrossRef] [PubMed]
 
Bishop, MA, Jorgens, J, Shoemaker, WC, et al The relationship between ARDS, pulmonary infiltration, fluid balance and hemodynamics in critically ill surgical patients.Am Surg1991;57,785-792. [PubMed]
 
Raeburn, CD, Moore, EE, Biffl, WL, et al The abdominal compartment syndrome is a morbid complication of post injury damage control surgery.Am J Surg2001;182,542-546. [CrossRef] [PubMed]
 
Biffl, WL, Moore, EE, Burch, JM, et al Secondary abdominal compartment syndrome is a highly lethal event.Am J Surg2001;182,645-648. [CrossRef] [PubMed]
 
Alsous, F, Khamiees, M, DeGirolamo, A, et al Negative fluid balance predicts survival of patients in septic shock.Chest2000;117,1749-1754. [CrossRef] [PubMed]
 
Bauer, TT Nosocomial pneumonia: therapy is just not good enough.Chest2003;124,1632-1634. [CrossRef] [PubMed]
 
Rivers, E, Nguyen, B, Havstad, S, et al Early goal-directed therapy in the treatment of.N Engl J Med2001;345,1368-1377. [CrossRef] [PubMed]
 
Guppy, MPB, Mickan, SM, Del Mar, CB “Drink plenty of fluids”: a systematic review of evidence for this recommendation in acute respiratory infections.BMJ2004;328,499-500. [CrossRef] [PubMed]
 
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