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The aim of this study was to determine the incidence, the organisms responsible for and the impact on outcome of nosocomial tracheobronchitis (NTB) in the intensive care unit (ICU).This prospective observational cohort study was conducted in a 30-bed medical/ surgical ICU over a period of 6.5 yrs. All patients ventilated for w48 h were eligible. Patients with nosocomial pneumonia (NP) without prior NTB were excluded. Patients with first episodes of NTB were compared with those without NTB by univariate analysis.The study diagnosed 201 (10.6%) cases of NTB. Pseudomonas aeruginosa was the most common bacteria. NP rates were similar in patients with NTB compared with patients without NTB. Even in the absence of subsequent NP, NTB was associated with a significantly higher length of ICU stay and duration of mechanical ventilation in both surgical and medical populations. Mortality rates were similar in NTB patients without subsequent NP compared with patients without NTB. Antimicrobial treatment in NTB patients was associated with a trend to a better outcome.Nosocomial tracheobronchitis is common in mechanically ventilated intensive care unit patients. In this population, nosocomial tracheobronchitis was associated with longer durations of intensive care unit stay and mechanical ventilation. Further studies are needed to determine the impact of antibiotics on outcomes of patients with nosocomial tracheobronchitis.

Cellular events that occur in status asthmaticus (SA) remain poorly investigated. Autopsy studies frequently emphasized about the presence of eosinophils in bronchial airway wall, whereas recent studies reported increased number of neutrophils in patients dying of sudden-onset fatal asthma. Mucus plugs occluding the bronchial lumen are almost constant features during SA. Bronchial lavage (BL) may be useful to remove mucus plugs in cases of atelectasis and/or refractory SA. We investigated the contribution of different cell types and cellular mediators (neutrophil elastase, eosinophil cationic protein [ECP], histamine, interleukin-8 [IL-8]) to the pathogenesis of SA. We studied 16 BL from eight patients undergoing mechanical ventilation (MV) for SA (time interval from onset of MV = Day 0 to Day 11), four BL from patients undergoing MV without preexisting respiratory disease (V), 11 BL from patients with stable asthma (A) and eight BL from healthy controls (C). SA exhibited higher number and percentage of neutrophils (81.5 +/- 4.5%) than V (44.3 +/- 12.2) (p < 0.05), A (6.9 +/- 2.7) and C (9.5 +/- 3.8) (p < 0.0001), and higher number of eosinophils than V, A, and C (p < 0.01). Neutrophil elastase, ECP, and IL-8 levels were dramatically increased in SA. Histamine was higher in SA than in C and V (p < 0.05). Bronchial neutrophilia was not related to concomitant bacterial infection as bacteriological cultures were positive in only three BL. Eosinophils, mast cells and histamine were higher in BL performed within the first 48 h of MV (p < 0.05) than in BL performed later on. Our results indicate that bronchial inflammation in SA differs from bronchial inflammation in mild asthma. Persistent bronchial neutrophilia is associated with increased eosinophils and mast cells in the early phase of SA. Neutrophils may result in tissue damage and participate to the shedding of the epithelium in SA.

The diagnostic accuracy of protected-specimen brush (PSB), bronchoalveolar lavage (BAL), and endotracheal aspirates (EA) was prospectively evaluated in a series of 28 mechanically ventilated patients (MV patients) who died within 3 d of the bronchoscopic procedure, using postmortem lung examination as the gold standard for establishing the diagnosis of pneumonia. The entire fixed lungs were carefully dissected along the bronchovascular axes and each segment was cut into 5- to 10-mm thick sections, enabling gross examination of the lung parenchyma. Two tissue blocks were taken from each segment, including grossly abnormal areas whenever present. In several cases, two peripheral (subpleural) lung-tissue blocks were also taken from each lobe prior to systematic dissection of the lungs. Quantitative cultures (QC) and direct cytologic and microbiologic examination (DE) was performed on respiratory samples obtained within 72 h before death. Values of 10(3) cfu/ml of Ringer's solution, 10(4) cfu/ml of retrieved fluid, and 10(6) cfu/ml of respiratory secretions were used as cutoff points for quantitative PSB, BAL, and EA cultures, respectively. The main findings in this study were that: (1) Pneumonia was present in 67% of the patients. (2) Histologic lesions of pneumonia were mainly bilateral and predominated in the dependent lung segments. (3) Coexistence of a variety of noninfectious processes was a common finding in patients with pneumonia. (4) In several cases pneumonia was absent from peripheral lung samples while more central areas of the same segment displayed typical foci of pneumonia. (5) The sensitivity of quantitative cultures was 55%, 57%, and 47% for EA, PSB, and BAL, respectively, and the specificity was 85%, 88%, and 100%, respectively. Reducing the diagnostic threshold of EA to 10(5) cfu/ml of respiratory secretions instead of 10(6) cfu/ml resulted in a sensitivity of 63.1% and a specificity of 75% for EA. The sensitivity of direct examination (DE) was 50%, 47%, and 47%, respectively, and the specificity was 75%, 88%, and 87%. (6) The presence of intracellular organisms (ICO) in BAL had a 36.8% sensitivity and 100% specificity in establishing the diagnosis of pneumonia regardless of their percentage. (7) Although 15 patients (53%) were not on antibiotics or were off antibiotics for more than 48 h before testing, no relationship could be established between the patients' antibiotic status and the result of any diagnostic test. By using a recommended methodology for respiratory sampling techniques together with complete postmortem lung examination as a diagnostic "gold standard," this study provides a realistic insight into the diagnostic values of EA, PSB, and BAL in MV patients with suspected pneumonia.

Changes in stroke volume, radial pulse pressure, and peak velocity of femoral artery flow induced by passive leg raising are accurate and interchangeable indices for predicting fluid responsiveness in nonintubated patients with severe sepsis or acute pancreatitis.

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Due to their lack of sensitivity and their dependence to respiratory status, DeltaPP and DeltaSP are clearly less reliable to predict fluid responsiveness during SB than in mechanically ventilated patients. However, when their baseline value is high without acute right ventricular dysfunction in a participating patient, a positive response to fluid is likely.