Diagnosis and treatment of nosocomial pneumonia in ALI/ARDS patients

Abstract

Diagnosis and treatment of nosocomial pneumonia in ALI/ARDS patients. J-Y. Fagon, J. Chastre. #ERS Journals Ltd 2003. ABSTRACT: Ventilator-associated pneumonia (VAP) is a common complication of the acute respiratory distress syndrome (ARDS) or acute lung injury (ALI), often leading to the development of sepsis, multiple organ failure, and death. However, the diagnosis of pulmonary infection in patients with ARDS/ALI is often difficult: the systemic signs of infection, such as fever, tachycardia, leukocytosis are nonspecific findings in such patients; a variety of causes other than pneumonia can explain asymmetric consolidation in patients with ARDS and marked asymmetry of radiographic abnormalities has also been reported in patients with uncomplicated ARDS.In 2003, physicians in charge of these patients have to identify patients with true bacterial lung infection, to select appropriate initial antibiotic therapy, to adjust therapy as soon as possible, and to withhold antibiotics in patients without VAP. To do that, a bacteriological strategy based on the use of quantitative cultures of specimen obtained with fibreoptic bronchoscopy performed before initiation or modification of antibiotic treatment seems better than a strategy based on clinical evaluation alone, lowering antibiotic consumption and improving outcome. When bronchoscopy is not available or contraindicated, a nonbronchoscopic strategy or a clinical strategy with reevaluation 3 days after initiation of treatment may be used.Antimicrobial treatment of VAP is a complex issue. Some general principles can be helpful for the selection of initial treatment: knowledge of most frequently identified responsible pathogens and their susceptibility patterns in the unit; prior duration of hospitalisation; previously prescribed antibiotics; information obtained by direct examination of pulmonary secretions; antibacterial activity and pharmacodynamic characteristics of antibiotics that could be used to treat this infection.Appropriateness of initial antimicrobial therapy is probably a major prognostic factor for patients with ventilator-associated pneumonia. Thus, before new antiboitics are administered, reliable pulmonary specimens must be obtained for direct examination and cultures.

Prescribing Patterns of Drugs in Acute Respiratory Distress Syndrome (ARDS): An Observational Study

“…As for other infections, in these patients as well the choice of antimicrobial treatment is much easier when the specific aetiological agent is identified by a reliable diagnostic technique like pulmonary specimens obtained, for direct examination and cultures, from patients [22]. Also, the range of bacteria and their susceptibility patterns vary widely among hospitals and different countries, selection of initial antimicrobial therapy thus depends on the prevalent pattern of microbes and antimicrobial resistance.…”

Diagnosis of Acute Respiratory Distress Syndrome in Nosocomial Pneumonia

“…Проблема усложняется при сочетании ОРДС с Пн. Дифференцировать рентгенологически ОЛ, ателектаз, контузию легких, инфаркт и Пн у боль ного на ИВЛ крайне сложно [8]. Более достоверным ме тодом лучевой диагностики является КТ легких, кото рая позволяет выявить негомогенность повреждения легких, провести дифференциальную диагностику ОРДС и НПн, диагностировать стадии ОРДС, опреде лять степень воздушности легочной ткани [32].…”

“…Важным методом диагностики НПн является количественное микробиоло гическое исследование, которое позволяет подтвердить или исключить наличие НПн и отличить «чистое» ОРДС от ОРДС в сочетании с НПн [8], дает возможность полу чения положительных результатов посевов еще до появле ния рентгенологических признаков Пн. Количественная БАЛЖ имеет чувствительность 89% и специфичность 100%, а клинические данные -100 и 14%, соответственно [33].…”

“…Клиническая кар тина ОРДС и НПн сходна, специфичность критериев НПн для больных с ОРДС низка [8]. В материалах Американо Европейской Согласительной Конферен ции по ОРДС (АЕСК, 1994) оговорено, что если тяже лая инфекция легких начинает отвечать критериям ОРДС, то это можно считать моментом развития ОРДС [9].…”

Inflation lung mechanics deteriorates markedly after saline instillation and open endotracheal suctioning in mechanically ventilated healthy piglets

“…1 This procedure is usually performed via a bronchoscope. However, bronchoscopy in infants and small children is not always feasible due to the 1 small diameter of the endotracheal tube, and the fact that the smallest bronchoscopes do not have suction channels.…”