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Brain Natriuretic Peptide and Fluid Restrictive Approaches to Prevent Ventilator-Associated PneumoniaVentilator-Associated Pneumonia Fluid Restriction: Let’s Look at Small Details FREE TO VIEW

Guniz M. Koksal, MD, PhD; Yalım Dikmen, MD, PhD; Antonio M. Esquinas, MD, PhD
Author and Funding Information

From the Department of Anesthesiology and Reanimation (Dr Koksal), Istanbul University, Cerrahpasa Medical Faculty; Anesthesiology Department (Dr Dikmen), Cerrahpaşa Medical Faculty; and ICU (Dr Esquinas), Hospital Morales Meseguer.

CORRESPONDENCE TO: Guniz M. Koksal, MD, PhD, Cerrahpasa Medical Faculty Anesthesiology and Reanimation Department, Istanbul, Fatih, Turkey 34400; e-mail: gunizkoksal@hotmail.com


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


Chest. 2015;147(2):e63. doi:10.1378/chest.14-1792
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Published online
To the Editor:

Biomarkers such as brain natriuretic peptide (BNP) and fluid-management protocols are emerging to improve weaning from mechanical ventilation and prevent complications such as ventilator-associated pneumonia (VAP).1,2 However, there is scarce solid evidence to add both processes as real tools to make decisions.

We read with great interest the study published in CHEST (July 2014) by Mekontso Dessap et al3 reporting on decreased incidence of VAP in patients on depletive fluid management. However, there are some questions that should be addressed for proper clinical extrapolations.

First, patients with “chronic heart diseases” were included in the study. BNP was used as a follow-up parameter for ventilator-associated conditions and VAP, but we can state that BNP has a low specificity as a biochemical parameter.2 It is known that BNP is secreted from ventricles (mainly the left ventricle).2,4 BNP is also affected by physiologic factors and noncardiac situations.2,4 In addition, as β-blockers and antihypertensive drugs affect BNP levels, patients using these drugs should be excluded.3,4 Although the study is based on BNP levels, normal values of BNP were not addressed, and no data are observed in the results about BNP nor were these parameters discussed.3

Second, some definitions need clarification, such as the following: (1) Fluid management was mentioned superficially and routine clinical parameters that we use in our daily practice such as central venous pressure, echocardiogram, and pleth variability index have not been used; (2) the dosage of furosemide 10 to 30 mg every 3 h should be explained in the study (as we know, furosemide creates hyponatremia and that is an important factor affecting BNP levels2,4); and (3) the authors used BNP levels as an indication of “lung edema.” This concept could be affected by ventricular performance and objective measurements were not described.

Third, interindividual autonomic activity response during different modes of ventilatory weaning could be related to different sympathetic activation. This would affect the measurements of BNP levels.5

Fourth, there is not a statistically significant difference between the two groups in terms of the Simplified Acute Physiology Score (SAPS) II, Pao2/Fio2, Sequential Organ Failure Assessment (SOFA) score, and ICU and hospital stay. Additionally, although a higher infection rate was observed in the fluid-restricted group, no difference was observed in terms of body temperature values. Further prospective clinical trials are needed to consolidate a solid association between BNP measurement, fluid management, and VAP.

References

Bouadma L, Wolff M, Lucet JC. Ventilator-associated pneumonia and its prevention. Curr Opin Infect Dis. 2012;25(4):395-404. [CrossRef] [PubMed]
 
Christenson RH. What is the value of B-type natriuretic peptide testing for diagnosis, prognosis or monitoring of critically ill adult patients in intensive care? Clin Chem Lab Med. 2008;46(11):1524-1532. [CrossRef] [PubMed]
 
Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65. [CrossRef] [PubMed]
 
Mair J, Gerda F, Renate H, Ulmer H, Andrea G, Pachinger O. Head-to-head comparison of B-type natriuretic peptide (BNP) and NT-proBNP in daily clinical practice. Int J Cardiol. 2008 29;124(2):244-246.
 
Perini R, Veicsteinas A. Heart rate variability and autonomic activity at rest and during exercise in various physiological conditions. Eur J Appl Physiol. 2003;90(3-4):317-325. [CrossRef] [PubMed]
 

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References

Bouadma L, Wolff M, Lucet JC. Ventilator-associated pneumonia and its prevention. Curr Opin Infect Dis. 2012;25(4):395-404. [CrossRef] [PubMed]
 
Christenson RH. What is the value of B-type natriuretic peptide testing for diagnosis, prognosis or monitoring of critically ill adult patients in intensive care? Clin Chem Lab Med. 2008;46(11):1524-1532. [CrossRef] [PubMed]
 
Mekontso Dessap A, Katsahian S, Roche-Campo F, et al. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest. 2014;146(1):58-65. [CrossRef] [PubMed]
 
Mair J, Gerda F, Renate H, Ulmer H, Andrea G, Pachinger O. Head-to-head comparison of B-type natriuretic peptide (BNP) and NT-proBNP in daily clinical practice. Int J Cardiol. 2008 29;124(2):244-246.
 
Perini R, Veicsteinas A. Heart rate variability and autonomic activity at rest and during exercise in various physiological conditions. Eur J Appl Physiol. 2003;90(3-4):317-325. [CrossRef] [PubMed]
 
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