outlines an approach to early isolation, testing, and involvement of institutional infection control, infectious diseases, and public health in patients with FRI and respiratory failure admitted to the ICU. All patients with FRI and respiratory failure should immediately be isolated on arrival to the health-care system, and subsequently undergo initial diagnostic testing, including pretreatment Gram stain, respiratory culture, and urine antigen testing for Legionella. If an etiologic agent is identified on initial screening and clinical findings (ie, Gram-positive diplococci with a lobar pneumonia on radiography), targeted treatment and ICU admission are performed. Further isolation of the patient can be discontinued at this point, depending on the identified organism. However, if an agent is not easily identified as often seen with viral causes of FRIs, the patients should remain in isolation and further diagnostic testing should be performed. Isolation should most likely be droplet, but based on specific epidemiologic clues airborne isolation may be instituted (Table 1).20 Many cases of viral pneumonia in the ICU are suspected based on certain at-risk groups, epidemiologic clues, and specific clinical findings. If these are present, testing should target these pathogens, but viral culture and isolation should be performed to rule out other agents as well. If a certain viral pathogen, such as avian influenza or SARS, is suspected based on these clues, hospital infection control, infectious diseases, microbiology, and the public health officials should be notified immediately. Although bronchoscopy generates aerosols and can increase transmission risk, it should not be avoided in these cases because viral isolation and etiology becomes important from a public health perspective and transmission risk is low when the appropriate PPE is used. Isolation of the virus from a nasopharyngeal swab or aspirate is highest early in disease course, but by the time the patient has disease developed in the lower respiratory tract with respiratory failure, a lower respiratory sample by bronchoscopy may provide the highest yield. In addition to more specific testing, a sample should be sent for viral culture, which provides a viral isolate for further testing, subtyping, and resistance analysis if ever indicated (unless avian influenza is suspected, since this requires a biosafety level 3 laboratory). Patient isolation should remain until a diagnosis is established or the patient improves, remaining afebrile for at least 48 h. Any change in isolation status should involve an infection control and infectious disease specialist.