To provide a comprehensive description of the histologic and bacteriologic characteristics of human nosocomial bronchopneumonia (BPN), the lungs of 83 critically ill patients decreased after a period of mechanical ventilation were examined in the immediate postmortem period. In addition, the accuracy of the protected minibronchoalveolar lavage (BAL) technique in the diagnosis of nosocomial BPN was evaluated. In each patient, a surgical pneumonectomy was performed at the bedside within 30 min following death. Each pulmonary lobe was sampled and bacteriologically analyzed using semiquantitative cultures in 50 patients and quantitative cultures in 33 patients. The entire lung was histologically analyzed using 5 to 10 slices per lung segment. In 69 patients, the bacteriologic result of a protected mini-BAL performed within 48 h preceding death was compared with histologic and bacteriologic results of study of the lung tissue itself. Histologic lesions of BPN were found in 43 of the 83 lungs examined. These lesions were (1) severe in the majority of patients (confluent BPN, n = 23; lung abscess, n = 6), (2) preferentially found in dependent lung segments, (3) often associated with nonspecific alveolar damage, (4) associated with positive lung cultures in 65% of patients (53% with gram-negative bacteria), (5) polymicrobial in 28% of patients, (6) characterized by a lobar bacterial burden greater than 10(3) cfu/g in 32% of cases. Using semiquantitative bacteriologic analysis, the sensitivity and the specificity of the protected mini-BAL in the diagnosis of nosocomial BPN were found to be 70 and 69%, respectively. Protected mini-BAL identified 77% of causative microorganisms of BPN.(ABSTRACT TRUNCATED AT 250 WORDS)

The incidence of infectious maxillary sinusitis (IMS) and its clinical relevance was prospectively studied in 162 consecutive critically ill patients who were mechanically ventilated for a period longer than 7 d. All had a paranasal computed tomographic (CT) scan within 48 h of admission and were divided into three groups according to the radiologic aspect of their maxillary sinuses: Group 1 = normal maxillary sinuses (n = 40), Group 2 = maxillary mucosal thickening (n = 26), Group 3 = radiologic maxillary sinusitis (RMS) defined as the presence of an air fluid level and/or opacification of maxillary sinuses (n = 96). Group 1 patients were randomized between nasal and oral endotracheal intubation with a gastric intubation performed via the same route and had a second paranasal CT scan 7 d later. Endotracheal and gastric tubes were left in their original position in Group 2 patients and a second paranasal CT scan was performed 7 d later. All patients of Group 3 underwent a transnasal puncture for bacteriologic analysis of maxillary sinus content. Forty-five spontaneously breathing patients served as a control group. In all patients with RMS, the occurrence of bronchopneumonia (BPN) was prospectively assessed for 7 d following the initial CT scan. Upon inclusion, only 25% of the patients had normal maxillary sinuses whereas all patients in the control group had normal paranasal CT scans. After 7 d, 46% of Group 2 patients had evidence of RMS. Risk factors for RMS were nasal placement and duration of endotracheal and gastric intubation.(ABSTRACT TRUNCATED AT 250 WORDS)

Nebulization of high-dose colistin was effective to treat VAP caused by multidrug-resistant P. aeruginosa or A. baumannii. Its therapeutic effect was noninferior to intravenous β-lactams associated with aminoglycosides or quinolones for treating VAP caused by susceptible P. aeruginosa and A. baumannii.

In hypoxemic patients with pulmonary hypertension and severe acute respiratory failure, therapeutic inhaled NO concentrations are in the range 100-2000 ppb. The risk of toxicity related to NO inhalation is therefore markedly reduced. Continuous SVO2 monitoring appears useful at the bedside for determining optimum therapeutic inhaled NO concentrations in a given patient.

Underlying histologic lesions responsible for clinical lung barotrauma consist of pleural cysts, bronchiolar dilatation, alveolar overdistension and intraprenchymal pseudocysts. Mechanical ventilation appears to be an aggravating factor, particularly when high peak airway pressures and large tidal volumes are delivered by the ventilator.

systemic diffusion. After colistin nebulization, the high lung deposition was associated with rapid and efficient bacterial killing, although systemic exposure was reduced. After IV colistin, the lack of lung deposition was associated with a lack of bacterial killing. A combination of IV and nebulized colistin might increase colistin tissue concentrations, but this is not necessarily the case and rationale for using the combination as a treatment of VAP is weak. However, for treating bacteremic VAP caused by resistant Pseudomonas aeruginosa and Acinetobacter baumannii, a combination of nebulized and IV colistin remains the only therapeutic option.Few complications have been reported in experimental animals given aerosolized antibiotics. Bronchoconstriction and hypoxemia can occur from the aerosol nebulization of any drug. A potential complication is the emergence of multiresistant pathogens. Therefore, the administration of nebulized antibiotics should be limited to isolated and nonbacteremic VAP.Several factors are important to the use of aerosolized antibiotics. Adequate nebulizers and appropriate circuit connections along with modification of ventilator settings during the nebulization period are required for providing laminar inspiratory flow. The dose of antibiotic should be determined based on extrapulmonary deposition and the interval between 2 aerosols. Lack of coordination with the ventilator should be avoided to prevent inspiratory turbulence and impact of the aerosolized particles on circuit walls and upper airways. Then, high lung tissue deposition and rapid and efficient bactericidal activity can be anticipated.V entilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa and Acinetobacter baumannii has a high rate of recurrence and resistance to antibiotics despite adequate initial antimicrobial therapy. Few drugs are available to treat gram-negative multidrug-resistant (MDR) VAP; colistin remains the only active agent. However, it has poor penetration into lung tissue, and the effectiveness of its intravenous (IV) administration is uncertain. This prospective, observational study was performed to evaluate the efficacy of high-dose nebulized colistin for treating VAP caused by MDR P. aeruginosa and A. baumannii and to determine the risk of developing colistin resistance in patients with recurrent VAP.Inclusion criteria for the patients were age older than 18 years, mechanical ventilation for more than 48 hours, and VAP caused by P. aeruginosa and A. baumannii. The patients were separated into 2 groups. The sensitive strain group had 122 patients with VAP caused by P. aeruginosa and A. baumannii susceptible to A-lactams, and the second, the MDR strain group, included 43 patients with VAP caused by P. aeruginosa and A. baumannii resistant to all A-lactams and susceptible to colistin. Patients in the sensitive strain group were treated with IV A-lactam for 14 days combined with a 3-day IV course of aminoglycoside or quinolone. This regimen was used to avoid a high pulmonary infection recurren...

This study suggests that the administration of intratracheal colistin during a 2-week period significantly reduces the incidence of Gram-negative BPN without creating an increasing number of BPN due to colistin-resistant micro-organisms.

Hypothesis: Under standard conditions following aortic reconstruction, nonocclusive ischemic colitis (IC) type 1 (mucosal ischemia) and type 2 (mucosal and muscularis ischemia) can be managed nonoperatively, whereas type 3 (transmural ischemia) requires emergency surgery. Our objective was to standardize the surgical approach for IC complicating aortic reconstruction.