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Approach to Pneumonia in Patients with ARDS

Approach to Pneumonia in Patients with ARDS. Richard G. Wunderink MD Northwestern University Chicago IL USA. Pneumonia and ARDS. Community-acquired pneumonia is the most common infectious cause of ARDS Viral pneumonia very significant mortality Aspiration pneumonitis is often confused

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Approach to Pneumonia in Patients with ARDS

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  1. Approach to Pneumonia in Patients with ARDS Richard G. Wunderink MD Northwestern University Chicago IL USA

  2. Pneumonia and ARDS • Community-acquired pneumonia is the most common infectious cause of ARDS • Viral pneumonia very significant mortality • Aspiration pneumonitis is often confused • VAP as a cause of ARDS is uncommon • ARDS secondary to pneumonia has the highest associated mortality

  3. BAL Neutrophilia * BAL > 106, PSB > 105 cfu/ml

  4. BAL Amylase N= 136 consecutive BALs • Visual inspection of data – clear separation >80 IU/L • 14 patients with 20 BALs >80 IU/L • 5/14 BALs diagnostic colony counts as well (2 oral flora only) • 3/14 known esophogeal disease • 6/14 severe neurologic disease • 9/14 suspected aspiration • 10/14 subsequently diagnosed swallowing dysfunction • No significant pancreas-specific amylase (N=78) 13

  5. ARDS and VAP • VAP occurs frequently in ARDS

  6. ARDS and VAP: Incidence

  7. ARDS and VAP: Mortality

  8. ARDS and VAP: Diagnosis • VAP occurs frequently in ARDS • VAP hard to diagnose in ARDS • Frequent empirical antibiotic use • Multiple other potential causes of signs • Pre-existing CXR abnormalities

  9. ARDS and VAP: Diagnosis • VAP occurs frequently in ARDS • VAP hard to diagnose in ARDS • Frequent empirical antibiotic use • Multiple other potential causes of signs • Pre-existing CXR abnormalities Quantitative culture techniques (bronchoscopic or nonbronchoscopic) are more likely to define true VAP in ARDS

  10. Invasive versus Clinical Diagnosis of VAP * 14 Day: 28-Day severity-adjusted mortality significantly higher also ( RR 1.25, 95% CI 1.05-1.47)

  11. ARDS and VAP: Response to Treatment • VAP occurs frequently in ARDS • VAP hard to diagnose in ARDS • Ineffective antibiotic therapy for VAP is difficult to detect in ARDS • High frequency of MDR pathogens like Pseudomonas and MRSA • Compromises ability to use “therapeutic response” to assess presence of pneumonia

  12. Treatment Failure in VAP

  13. Resolution of VAP Dennesen, AJRCCM, 2001

  14. Original Temperature Leukocytosis Secretions PaO2/Fio2 ratio CXR pattern (0 points for ARDS) Modifications Leukocytosis definition Secretion definition CXR definitions Clinical Pulmonary Infection Score (CPIS)

  15. Resolution of VAP Nonsurvivors Allpatients Survivors Luna, Crit Care Med, 2003

  16. Resolution of VAP

  17. Procalcitonin Response to VAP Procalcitonin Response in VAP

  18. 104 cfu/ml Quantitative Culture (cfu/ml)

  19. p < 0.05 MRSA VAP:Microbiologic Response to Vancomycin Repeat PSB after 72 hours Baughman, J Intensive Care Med, 2003

  20. Follow-up Bronchoscopy in Nonfermenter VAP P = 0.008 Mortality

  21. Pneumonia and ARDS • Pneumonia common cause of ARDS • VAP common complication of ARDS • VAP difficult to diagnosis • May need more aggressive approach to both initial diagnosis and subsequent evaluation

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