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Armand Mekontso Dessap, MD, PhD; Laurent Brochard, MD; Christian Brun-Buisson, MD
Author and Funding Information

From Service de Réanimation Médicale, Hôpital Henri Mondor (Drs Mekontso Dessap and Brun-Buisson); St. Michael’s Hospital (Dr Brochard); and Interdepartmental Division of Critical Care Medicine (Dr Brochard), University of Toronto.

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


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts of interest: Dr Brochard’s clinical research laboratory has received research grants from the following companies: Dräger (SmartCare), Covidien (proportional assist ventilation), GE (lung volume), Vygon (CPAP), and Fisher and Paykel (high-flow oxygen). He has been a consultant for Covidien (proportional assist ventilation) and Dräger (SmartCare). Drs Mekontso Dessap and Brun-Buisson have reported 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):e64. doi:10.1378/chest.14-2573
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To the Editor:

We thank Dr Koksal and colleagues for their interest in our recent article in CHEST1 on fluid management and ventilator-associated pneumonia (VAP). Although Dr Koskal and colleagues discussed several possible mechanisms interfering with brain natriuretic peptide (BNP) measurements, our goal was not to report a proof-of-concept study linking BNP concentration to VAP, but merely to describe a strong observed association between fluid management and VAP, which may have clinical relevance. As stated in our article, this is an ancillary study of a published randomized controlled trial (BNP for the Fluid Management of Weaning [BMW] study), and we refer Dr Koksal and colleagues to our earlier publication of the primary results of the BMW trial, in which all details about BNP measurements and results are reported and discussed.2 Fluid management strategy in the two arms of the BMW study is also described extensively in that report,2 and detailed methods of the trial have been published in an accompanying online supplement.

The aim of the BMW study was to use BNP as a screening tool for a fluid depletive strategy, a situation in which the sensitivity is more relevant than the specificity. We agree that BNP levels are influenced by many factors in patients in the ICU; this is one reason for the exclusion criteria used in the BMW study.2 The randomization was stratified on left ventricle systolic dysfunction because we hypothesized that the benefit of a BNP-driven fluid depletive strategy may be enhanced in this patient subgroup, which is relatively prevalent in general ICUs.2 For the same reason, we did not exclude patients receiving cardiotropic drugs. Both cardiac function and volemia influence natriuretic peptide concentrations, which have been used to detect weaning failure3 and weaning-induced pulmonary edema.4,5

Regarding the possible influence of hyponatremia on BNP concentrations, this is an avoidable consequence of furosemide when closely monitored in the ICU (hyponatremia was absent during the course of weaning in 71% and 78% of patients in the control and intervention group, respectively), and a causal relationship between hyponatremia and BNP levels is not supported by the current literature.6 The ventilator mode used for weaning was similar in all patients (closed loop pressure support ventilation). Finally, the temperature values reported in our article1 should not be interpreted as associated with VAP or ventilator-associated complications, because these are values recorded at randomization, and not at time of occurrence of subsequent VAP during weaning.

References

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]
 
Mekontso Dessap A, Roche-Campo F, Kouatchet A, et al. Natriuretic peptide-driven fluid management during ventilator weaning: a randomized controlled trial. Am J Respir Crit Care Med. 2012;186(12):1256-1263. [CrossRef] [PubMed]
 
Mekontso-Dessap A, de Prost N, Girou E, et al. B-type natriuretic peptide and weaning from mechanical ventilation. Intensive Care Med. 2006;32(10):1529-1536. [CrossRef] [PubMed]
 
Grasso S, Leone A, De Michele M, et al. Use of N-terminal pro-brain natriuretic peptide to detect acute cardiac dysfunction during weaning failure in difficult-to-wean patients with chronic obstructive pulmonary disease. Crit Care Med. 2007;35(1):96-105. [CrossRef] [PubMed]
 
Zapata L, Vera P, Roglan A, Gich I, Ordonez-Llanos J, Betbesé AJ. B-type natriuretic peptides for prediction and diagnosis of weaning failure from cardiac origin. Intensive Care Med. 2011;37(3):477-485. [CrossRef] [PubMed]
 
Mohammed AA, van Kimmenade RR, Richards M, et al. Hyponatremia, natriuretic peptides, and outcomes in acutely decompensated heart failure: results from the International Collaborative of NT-proBNP Study. Circ Heart Fail. 2010;3(3):354-361. [CrossRef] [PubMed]
 

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References

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]
 
Mekontso Dessap A, Roche-Campo F, Kouatchet A, et al. Natriuretic peptide-driven fluid management during ventilator weaning: a randomized controlled trial. Am J Respir Crit Care Med. 2012;186(12):1256-1263. [CrossRef] [PubMed]
 
Mekontso-Dessap A, de Prost N, Girou E, et al. B-type natriuretic peptide and weaning from mechanical ventilation. Intensive Care Med. 2006;32(10):1529-1536. [CrossRef] [PubMed]
 
Grasso S, Leone A, De Michele M, et al. Use of N-terminal pro-brain natriuretic peptide to detect acute cardiac dysfunction during weaning failure in difficult-to-wean patients with chronic obstructive pulmonary disease. Crit Care Med. 2007;35(1):96-105. [CrossRef] [PubMed]
 
Zapata L, Vera P, Roglan A, Gich I, Ordonez-Llanos J, Betbesé AJ. B-type natriuretic peptides for prediction and diagnosis of weaning failure from cardiac origin. Intensive Care Med. 2011;37(3):477-485. [CrossRef] [PubMed]
 
Mohammed AA, van Kimmenade RR, Richards M, et al. Hyponatremia, natriuretic peptides, and outcomes in acutely decompensated heart failure: results from the International Collaborative of NT-proBNP Study. Circ Heart Fail. 2010;3(3):354-361. [CrossRef] [PubMed]
 
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