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Can Procalcitonin and Chest Echography Be Used to Diagnose Ventilator-Associated Pneumonia?Diagnosis of Ventilator-Associated Pneumonia FREE TO VIEW

Xia Feng, BM; Jian-yong Zhang, MD
Author and Funding Information

From the Second Department of Respiration, Affiliated Hospital of Zunyi Medical College.

CORRESPONDENCE TO: Jian-yong Zhang, MD, Second Department of Respiration, Affiliated Hospital of Zunyi Medical College, 149 Dalian Rd, Zunyi, Guizhou, China 563000; e-mail: 18788608686@163.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(3):e107. doi:10.1378/chest.14-2735
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To the Editor:

We read with great interest the article by Zagli et al1 in a recent issue of CHEST (December 2014). The authors reported that the Chest Echography and Procalcitonin Pulmonary Infection Score (CEPPIS) had an acceptable and promising level of prediction effectiveness in diagnosing ventilator-associated pneumonia (VAP). Although we strongly agree that ultrasonography is very helpful and a readily available tool with acceptable sensitivity and specificity to detect pneumonia, we have some concerns.

First, the incidence of VAP varies widely depending on the criteria used to diagnose VAP. Ego et al2 compared the incidence of VAP diagnosed based on six different sets of criteria and reported it to range from 4% to 42%; the range was 0% to 44% when using 89 different combinations of criteria. These findings are no fluke; other studies have come to similar conclusions.2 Even studies using microbiologic criteria to diagnose VAP have shown different incidences of VAP because the technique used to collect samples was different between studies.2 Therefore, we wonder how the authors chose their diagnostic criteria and evaluated their effectiveness.

Second, chest radiography was replaced by chest echography in Zagli et al.1 However, the training required for detecting the sonographic features of VAP is extensive, just as the training required for detecting the sonographic features of pneumothorax, localized atelectasis, and pulmonary fibrosis probably requires at least level 2 Royal College of Radiology training in chest ultrasonography in the United Kingdom.3 In addition, identification and interpretation of ultrasound images is not so easy and notoriously operator dependent. Therefore, we wonder who performed the chest ultrasound in the present study. If it was performed by an intensivist, then he or she must be competent in chest ultrasonography. However, very few intensivists have definitive skill in chest ultrasonography, not only in North America but also in Europe and the Asia-Pacific region.4

Third, we are interested in why the authors used plasma procalcitonin concentration not soluble triggering receptor expressed on myeloid cells-1 in BAL fluid or other indicators to replace leukocyte count. As we all know, procalcitonin has a limited predictive value in the diagnosis of VAP; in addition, some noninfective factors, such as severe trauma, invasive surgical procedure, and critical burn injuries, could increase procalcitonin levels and result in false-positive results.5 In the Zagli et al1 study, trauma patients were predominant in the VAP group, and this would confound the results.

References

Zagli G, Cozzolino M, Terreni A, Biagioli T, Caldini AL, Peris A. Diagnosis of ventilator-associated pneumonia: a pilot, exploratory analysis of a new score based on procalcitonin and chest echography. Chest. 2014;146(6):1578-1585. [CrossRef] [PubMed]
 
Ego A, Preiser JC, Vincent JL. Impact of diagnostic criteria on the incidence of ventilator-associated pneumonia [published online ahead of print October 23, 2014]. Chest. doi:10.1378/chest.14-0610.
 
The Royal College of Radiologists. Ultrasound training recommendations for medical and surgical specialties, 2005. Ref No.: BFCR(05)2. The Royal College of Radiologists website. http://www.rcr.ac.uk/publications.aspx. Accessed November 4, 2014.
 
Mayo PH, Maury E. Echography is mandatory for the initial management of critically ill patients: we are not sure. Intensive Care Med. 2014;40(11):1760-1762. [CrossRef] [PubMed]
 
Christ-Crain M, Müller B. Procalcitonin in bacterial infections—hype, hope, more or less? Swiss Med Wkly. 2005;135(31-32):451-460. [PubMed]
 

Figures

Tables

References

Zagli G, Cozzolino M, Terreni A, Biagioli T, Caldini AL, Peris A. Diagnosis of ventilator-associated pneumonia: a pilot, exploratory analysis of a new score based on procalcitonin and chest echography. Chest. 2014;146(6):1578-1585. [CrossRef] [PubMed]
 
Ego A, Preiser JC, Vincent JL. Impact of diagnostic criteria on the incidence of ventilator-associated pneumonia [published online ahead of print October 23, 2014]. Chest. doi:10.1378/chest.14-0610.
 
The Royal College of Radiologists. Ultrasound training recommendations for medical and surgical specialties, 2005. Ref No.: BFCR(05)2. The Royal College of Radiologists website. http://www.rcr.ac.uk/publications.aspx. Accessed November 4, 2014.
 
Mayo PH, Maury E. Echography is mandatory for the initial management of critically ill patients: we are not sure. Intensive Care Med. 2014;40(11):1760-1762. [CrossRef] [PubMed]
 
Christ-Crain M, Müller B. Procalcitonin in bacterial infections—hype, hope, more or less? Swiss Med Wkly. 2005;135(31-32):451-460. [PubMed]
 
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