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Byline: E. Roupie (1), E. Lepage (2), M. Wysocki (3), J.-Y. Fagon (4), J. Chastre (5), D. Dreyfuss (6), H. Mentec (7), J. Carlet (8), C. Brun-Buisson (1), F. Lemaire (1), L. Brochard (1) Keywords: Key words Acute lung injury; Acute respiratory distress syndrome; Mechanical ventilation Abstract: Objective: To evaluate the prevalence and outcome of the acute respiratory distress syndrome (ARDS) among patients requiring mechanical ventilation. Design: A prospective, multi-institutional, initial cohort study including 28-day follow-up. Settings: Thirty-six French intensive care units (ICUs) from a working group of the French Intensive Care Society (SRLF). Patients: All the patients entering the ICUs during a 14-day period were screened prospectively. Hypoxemic patients, defined as having a PaO.sub.2/FIO.sub.2 ratio (P/F) of 300 mmHg or less and receiving mechanical ventilation, were classified into three groups, according to the Consensus Conference on ARDS: group 1 refers to ARDS (P/F: 200 mmHg or less and bilateral infiltrates on the chest X-ray) group 2 to acute lung injury (ALI) without having criteria for ARDS (200 < P/F a$? 300 mmHg and bilateral infiltrates) and group 3 to patients with P/F of 300 mmHg or less but having exclusion criteria from the previous groups. Results: Nine hundred seventy-six patients entered the ICUs during the study period, 43 % of them being mechanically ventilated and 213 (22 %) meeting the criteria for one of the three groups. Among all the ICU admissions, ARDS, ALI and group 3 patients amounted, respectively, to 6.9 % (67), 1.8 % (17) and 13.3 % (129) of the patients, and represented 31.5 %, 8.1 % and 60.2 % of the hypoxemic, ventilated patients. The overall mortality rate was 41 % and was significantly higher in ARDS patients than in the others (60 % vs 31 % p < 0.01). In group 3, 42 patients had P/F less than 200 mmHg associated with unilateral lung injury mortality was significantly lower (40.5 %) than in the ARDS group. In the whole group of hypoxemic, ventilated patients, septic shock and severity indices but not oxygenation indices were significantly associated with mortality, while the association with immunosuppression revealed only a trend (p = 0.06). Conclusions: In this survey we found that very few patients fulfilled the ALI non-ARDS criteria and that the mortality of the group with ARDS was high. Author Affiliation: (1) Medical Intensive Care Unit, INSERM U492, Hopital Henri Mondor, AP-HP, Paris XII University, F-94 010 Creteil, France e-mail: laurent.brochard@hmn. ap-hop-paris.fr, Tel. + 33-1-49812545 Fax: + 33-1-42 079943, FR (2) Medical Information Unit, Hopital Henri Mondor, AP-HP, Paris XII University, F-94 010 Creteil, France, FR (3) Medical Intensive Care Unit, Institut Mutualiste Montsouris Jourdan, Paris (4) Medical Intensive Care Unit, Hopital Broussais, Paris (5) Medical Intensive Care Unit, Hopital Bichat-Claude Bernard, Paris (6) Medical Intensive Care Unit, Hopital, A. Beclere, Clamart (7) Medical Intensive Care Unit, Hopital V. Dupouy, Argenteuil (8) Medical Intensive Care Unit, Hopital Saint-Joseph, Paris Article note: Received: 21 September 1998 Final revision received: 3 February 1999 Accepted: 3 May 1999

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Background Patients aged >80 years represent a growing population admitted to intensive care units (ICUs). However, little is known about ICU-acquired infection (IAI) in this population, and the rate of invasive procedures is increasing. Aim To evaluate the frequency and effects of IAI in elderly (≥80 years) and younger patients. Methods Retrospective evaluation of consecutive patients hospitalized for three days or more over a three-year period in an 18-bed ICU in an academic medical centre. Findings Elderly patients represented 18.9% of the study population. At admission, the mean number of organ dysfunctions was similar in elderly and younger patients. The use of invasive procedures was also similar in elderly and younger patients, as follows: invasive mechanical ventilation for more than two days, 67.4% vs 55%; central venous catheterization, 56.9% vs 51.4%; and renal replacement therapy, 17.6% vs 17.8%, respectively. The frequency of IAI was 16.5% in elderly patients and 13.9% in younger patients (P = 0.28), with 20.5 vs 18.9 IAI episodes per 1000 ICU-days, respectively (P = 0.2). A Cox model identified central venous catheterization and invasive mechanical ventilation for more than two days as independent risk factors for IAI. The associations between IAI and prolonged ICU stay, increased nursing workload, and ICU and hospital mortality rates were similar in elderly and younger patients. Conclusions The frequency of IAI was similar in elderly and younger patients, as were the associations between IAI and length of ICU stay, nursing workload and ICU mortality in an ICU with a high rate of invasive procedures. [ABSTRACT FROM AUTHOR]

Background: Optimal management of patients who are clinically suspected of having ventilator-associated pneumonia remains open to debate.Objective: To evaluate the effect on clinical outcome and antibiotic use of two strategies to diagnose ventilator-associated pneumonia and select initial treatment for this condition.Design: Multicenter, randomized, uncontrolled trial.Setting: 31 intensive care units in France.Patients: 413 patients suspected of having ventilator-associated pneumonia.Intervention: The invasive management strategy was based on direct examination of bronchoscopic protected specimen brush samples or bronchoalveolar lavage samples and their quantitative cultures. The noninvasive ("clinical") management strategy was based on clinical criteria, isolation of microorganisms by nonquantitative analysis of endotracheal aspirates, and clinical practice guidelines.Measurements: Death from any cause, quantification of organ failure, and antibiotic use at 14 and 28 days.Results: Compared with patients who received clinical management, patients who received invasive management had reduced mortality at day 14 (16.2% and 25.8%; difference, -9.6 percentage points [95% CI, -17.4 to -1.8 percentage points]; P = 0.022), decreased mean Sepsis-related Organ Failure Assessment scores at day 3 (6.1+/-4.0 and 7.0+/-4.3; P = 0.033) and day 7 (4.9+/-4.0 and 5.8+/-4.4; P = 0.043), and decreased antibiotic use (mean number of antibiotic-free days, 5.0+/-5.1 and 2.2+/-3.5; P < 0.001). At 28 days, the invasive management group had significantly more antibiotic-free days (11.5+/-9.0 compared with 7.5+/-7.6; P < 0.001), and only multivariate analysis showed a significant difference in mortality (hazard ratio, 1.54 [CI, 1.10 to 2.16]; P = 0.01).Conclusions: Compared with a noninvasive management strategy, an invasive management strategy was significantly associated with fewer deaths at 14 days, earlier attenuation of organ dysfunction, and less antibiotic use in patients suspected of having ventilator-associated pneumonia. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the role that nosocomial pneumonia plays in the outcome of intensive care unit (ICU) patients.Design: Cohort study.Setting: Medical ICU, Hôpital Bichat, Paris, France, an academic tertiary care center.Patients: A total of 1978 consecutive patients admitted to the ICU for at least 48 hours.Main Outcome Measures: Various parameters known to be strongly associated with death of ICU patients were recorded: age, location before admission to the ICU, diagnostic categories, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiologic Score, McCabe score, number and type of dysfunctional organs, and the development of nosocomial bacteremia and nosocomial urinary tract infection. These variables and the presence or absence of nosocomial pneumonia were compared between survivors and nonsurvivors and entered into a stepwise logistic regression model to evaluate their independent prognostic roles.Results: Nosocomial pneumonia developed in 328 patients (16.6%) whose mortality was 52.4% compared with 22.4% for patients without ICU-acquired pneumonia (P < .001), APACHE II score (odds ratio [OR] = 1.08; 95% confidence interval [CI], 1.06 to 1.10; P < .001), number of dysfunctional organs (OR = 1.54; 95% CI, 1.36 to 1.74; P < .001), nosocomial pneumonia (OR = 2.08; 95% CI, 1.55 to 2.80; P < .001), nosocomial bacteremia (OR = 2.51; 95% CI, 1.78 to 3.55; P < .001), ultimately or rapidly fatal underlying disease (OR = 1.76; 95% CI, 1.38 to 2.25; P < .001), and admission from another ICU (OR = 1.30; 95% CI, 1.01 to 1.68; P =.04) were significantly associated with mortality.Conclusion: These data suggest that, in addition to the severity of underlying medical conditions and nosocomial bacteremia, nosocomial pneumonia independently contributes to ICU patient mortality. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the usefulness of bronchoalveolar lavage in establishing the diagnosis of the fat embolism syndrome in trauma patients with long-bone fractures.Design: Case series.Setting: Referral hospital.Patients: Eighteen trauma patients with long-bone fractures, including 5 with definite fat embolism syndrome, 5 in whom the diagnosis had been clinically suspected but was impossible to confirm or exclude before bronchoscopy, and 8 with no clinical evidence of the syndrome. Control groups included 9 patients without previous trauma who developed the adult respiratory distress syndrome for various reasons and 15 normal volunteers.Measurements and Main Results: Each patient had fiber-optic bronchoscopy with bronchoalveolar lavage, and the percentage of lavage cells containing intracellular fat droplets stained with oil red 0 were determined. In the five patients with definite fat embolism syndrome, light microscopic study of bronchoalveolar cells stained with oil red 0 showed many large intracellular fat droplets (mean percentage of cells containing fat droplets, 63%; range, 31% to 82%), whereas less than 2% of cells recovered by lavage from trauma patients with no clinical evidence of the syndrome, from patients with the adult respiratory distress syndrome, or from normal volunteers contained such inclusions. Use of the same technique in the five patients with possible fat embolism syndrome permitted the immediate identification of three patients in whom this diagnosis was later confirmed by subsequent autopsy or clinical follow-up.Conclusions: The identification of fat droplets within cells recovered by bronchoalveolar lavage in trauma patients may be a rapid and specific method for establishing the diagnosis of the fat embolism syndrome. [ABSTRACT FROM AUTHOR]

Although epidemiologic investigations of hospital-acquired pneumonia have certain intrinsic limitations because of the heterogeneity of the study populations, the difficulties in making a clinical diagnosis of nosocomial pneumonia, and the need for better microbiologic assays, recent studies have provided new and important data concerning the role of Staphylococcus aureus in this disease. This pathogen has now been identified as the most frequent cause of nosocomial pneumonia in hospitals in both Europe and the United States among patients in general hospital units as well as in the intensive care unit (ICU). Patients who have been treated with mechanical ventilation are at especially high risk for S. aureus pneumonia. The incidence of nosocomial pneumonia related to methicillin-resistant S. aureus (MRSA) has increased in recent years in many countries, especially among patients in the ICU. Because hospitalized patients with suspected nosocomial pneumonia often have many risk factors for MRSA infection, it seems advisable to include coverage of MRSA in the initial therapeutic regimen for these patients until MRSA infection is excluded. INSET: Table 2. Expected pathogens in hospital-acquired pneumonia.... [ABSTRACT FROM AUTHOR]