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Correspondence |

Could Fiberoptic Bronchoscopy and CT Lung Scan Differentiate Ventilator-Associated Tracheobronchitis From Ventilator-Associated Pneumonia? FREE TO VIEW

Saad Nseir, MD
Author and Funding Information

Affiliations: Dr. Nseir is affiliated with Hôpital A. Calmette.

Correspondence to: Saad Nseir, MD, Service de Réanimation Médicale, Hôpital A. Calmette, CHRU, Boulevard du Pr. Leclercq, 59037 Lille cedex, France; e-mail: s-nseir@chru-lille.fr


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(4):1187-1188. doi:10.1378/chest.08-2371
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Published online

I read with interest the article in CHEST (February 2009) by Dr. Craven and colleagues1 on ventilator-associated tracheobronchitis (VAT). In this general review, the authors elegantly discussed recent findings on the impact of targeted antibiotic therapy on patient outcomes.2,3 They outlined the difficulty in differentiating VAT from ventilator-associated pneumonia (VAP) and suggested fiberoptic bronchoscopy and CT lung scan to confirm the diagnosis of VAP. However, some clarification would be helpful for ICU physicians.

The authors stated that quantitative samples obtained from the distal airway using bronchoscopic or nonbronchoscopic lavage or specimen brush were used to confirm VAP. Do the authors suggest performing fiberoptic bronchoscopy in all patients with suspected VAT? According to the definition of VAT suggested by the authors, these patients do not have a new pulmonary infiltrate and might represent a large proportion of patients receiving mechanical ventilation because fever and purulent endotracheal aspirate are common in these patients. However, postmortem animal and human studies demonstrated an acceptable diagnostic accuracy of quantitative endotracheal aspirate in diagnosing VAP compared with bronchoscopic lavage or specimen brush.4 Fiberoptic bronchoscopy is considered to be a relatively safe procedure. Serious complications such as bleeding, bronchospasm, arrhythmia, pneumothorax, and pneumonia occur rarely. However, a recent study5 found fiberoptic bronchoscopy to be frequently associated with decreased mesenteric blood flow, which may place the patient at risk for mesenteric ischemia and GI bacterial translocation. Further, Baram et al6 demonstrated that stable patients receiving prolonged mechanical ventilation had a high alveolar burden of bacteria, exceeding the commonly accepted threshold for diagnosing VAP in most patients.

The authors also suggested that CT lung scan could differentiate VAT from VAP. However, recent guidelines require the presence of new pulmonary infiltrate to diagnose VAP. Therefore, to diagnose a new infiltrate on CT scan, a baseline examination is mandatory. One could wonder whether performing CT scan in all patients at ICU admission to differentiate potential subsequent VAT from VAP would be cost-effective. In addition, intrahospital transport is required because this diagnostic procedure is unrealizable inside the ICU. Intrahospital transport is associated with considerable potential for misadventure and can be a life-threatening endeavor. In addition, a recent case-control study identified intrahospital transport (odds ratio, 2.9; 95% confidence interval, 1.4 to 5.7) as an independent risk factor for VAP.7 The supine position during intrahospital transport, which increases the risk of aspiration of gastric content or of contaminated secretions, and the frequent manipulations of the ventilator circuits needed during intrahospital transport, are well known risk factors for VAP.

In fact, procalcitonin would be an interesting marker to differentiate VAT from airway tract colonization. In a recent, prospective observational study8 performed in COPD patients, procalcitonin was independently associated with community-acquired bacterial bronchitis. Future studies should determine whether these data are applicable to patients with VAT.

Financial/nonfinancial disclosures: The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Craven DE, Chroneou A, Zias N, et al. Ventilator-associated tracheobronchitis: the impact of targeted antibiotic therapy on patient outcomes. Chest. 2009;135:521-528. [PubMed] [CrossRef]
 
Nseir S, Favory R, Jozefowicz E, et al. Antimicrobial treatment for ventilator-associated tracheobronchitis: a randomized, controlled, multicenter study. Crit Care. 2008;12:R62. [PubMed]
 
Palmer LB, Smaldone GC, Chen JJ, et al. Aerosolized antibiotics and ventilator-associated tracheobronchitis in the intensive care unit. Crit Care Med. 2008;36:2008-2013. [PubMed]
 
Nseir S, Marquette CH. Diagnosis of hospital-acquired pneumonia: postmortem studies. Infect Dis Clin North Am. 2003;17:707-716. [PubMed]
 
Nayci A, Atis S, Duce MN, et al. Bronchoscopy is associated with decreased mesenteric arterial flow. Crit Care Med. 2008;36:2517-2522. [PubMed]
 
Baram D, Hulse G, Palmer LB. Stable patients receiving prolonged mechanical ventilation have a high alveolar burden of bacteria. Chest. 2005;127:1353-1357. [PubMed]
 
Bercault N, Wolf M, Runge I, et al. Intrahospital transport of critically ill ventilated patients: a risk factor for ventilator-associated pneumonia: a matched cohort study. Crit Care Med. 2005;33:2471-2478. [PubMed]
 
Nseir S, Cavestri B, Di Pompeo C, et al. Factors predicting bacterial involvement in severe acute exacerbations of chronic obstructive pulmonary disease. Respiration. 2008;76:253-260. [PubMed]
 

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References

Craven DE, Chroneou A, Zias N, et al. Ventilator-associated tracheobronchitis: the impact of targeted antibiotic therapy on patient outcomes. Chest. 2009;135:521-528. [PubMed] [CrossRef]
 
Nseir S, Favory R, Jozefowicz E, et al. Antimicrobial treatment for ventilator-associated tracheobronchitis: a randomized, controlled, multicenter study. Crit Care. 2008;12:R62. [PubMed]
 
Palmer LB, Smaldone GC, Chen JJ, et al. Aerosolized antibiotics and ventilator-associated tracheobronchitis in the intensive care unit. Crit Care Med. 2008;36:2008-2013. [PubMed]
 
Nseir S, Marquette CH. Diagnosis of hospital-acquired pneumonia: postmortem studies. Infect Dis Clin North Am. 2003;17:707-716. [PubMed]
 
Nayci A, Atis S, Duce MN, et al. Bronchoscopy is associated with decreased mesenteric arterial flow. Crit Care Med. 2008;36:2517-2522. [PubMed]
 
Baram D, Hulse G, Palmer LB. Stable patients receiving prolonged mechanical ventilation have a high alveolar burden of bacteria. Chest. 2005;127:1353-1357. [PubMed]
 
Bercault N, Wolf M, Runge I, et al. Intrahospital transport of critically ill ventilated patients: a risk factor for ventilator-associated pneumonia: a matched cohort study. Crit Care Med. 2005;33:2471-2478. [PubMed]
 
Nseir S, Cavestri B, Di Pompeo C, et al. Factors predicting bacterial involvement in severe acute exacerbations of chronic obstructive pulmonary disease. Respiration. 2008;76:253-260. [PubMed]
 
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