Original Research: Critical Care |

Ventilator-Associated Pneumonia During Weaning From Mechanical VentilationVentilator-Associated Pneumonia and Fluids: Role of Fluid Management

Armand Mekontso Dessap, MD, PhD; Sandrine Katsahian, MD; Ferran Roche-Campo, MD, PhD; Hugo Varet, PhD; Achille Kouatchet, MD; Vinko Tomicic, MD; Gaetan Beduneau, MD; Romain Sonneville, MD, PhD; Samir Jaber, MD, PhD; Michael Darmon, MD, PhD; Diego Castanares-Zapatero, MD; Laurent Brochard, MD; Christian Brun-Buisson, MD
Author and Funding Information

From the Service de Réanimation Médicale (Drs Mekontso Dessap, Roche-Campo, and Brun-Buisson), and Unité de Recherche Clinique (Drs Katsahian and Varet), AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Faculté de Médecine (Drs Mekontso Dessap and Brun-Buisson), Université Paris Est Créteil, Créteil, F-94010, France; INSERM (Drs Mekontso Dessap and Brun-Buisson), Unité U955, Créteil, F-94010, France; Servei de Medicina Intensiva (Dr Roche-Campo), Hospital de Sant Pau, Barcelona, Spain; Service de Réanimation Médicale (Dr Kouatchet), CHU d’Angers, Angers, France; Departamento de Paciente Crítico (Dr Tomicic), Clinica Alemana, Santiago de Chile, Chile; Service de Réanimation Médicale and UPRES-EA 3830 (Dr Beduneau), CHU de Rouen, Rouen, France; Service de Réanimation Médicale et des Maladies Infectieuses (Dr Sonneville), AP-HP, CHU Bichat-Claude Bernard, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France; Réanimation DAR B (Dr Jaber), CHU Saint Eloi, INSERM U1046, Montpellier, France; Service de Réanimation Médicale (Dr Darmon), AP-HP, CHU Saint Louis, Paris, France; Service de Soins Intensifs (Dr Castanares-Zapatero), Hôpital Universitaire Saint-Luc, Bruxelles, Belgium; Critical Care Department (Dr Brochard), St. Michael’s Hospital, Toronto, ON, Canada; and Interdepartmental Division of Critical Care Medicine (Dr Brochard), University of Toronto, Toronto, ON, Canada.

CORRESPONDENCE TO: Armand Mekontso Dessap, MD, PhD, Service de Réanimation Médicale, Centre Hospitalo-Universitaire Henri Mondor; 51, avenue du Mal de Lattre de Tassigny 94 010 Créteil Cedex, France; e-mail: armand.dessap@hmn.aphp.fr

FUNDING/SUPPORT: This project was funded by the French Ministry of Health research program (Programme Hospitalier de Recherche Clinique) [contract 05104]. Biosite France supplied the BNP assay devices and kits (Triage MeterPlus) for the study. Dräger provided the AWS-equipped ventilators for the study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

Chest. 2014;146(1):58-65. doi:10.1378/chest.13-2564
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BACKGROUND:  Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may, therefore, influence ventilator-associated pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation.

METHODS:  We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization, using specific competing-risk methods (the Fine and Gray model).

RESULTS:  Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual-care group vs 14 (9.2%) in the interventional group (P = .03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event (subhazard ratios [25th-75th percentiles], 0.44 [0.22-0.87], P = .02 and 0.50 [0.25-0.96], P = .03, respectively).

CONCLUSIONS:  Using proper competing risk analyses, we found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP risk in patients who are mechanically ventilated.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov

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