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      Assessing predictive accuracy for outcomes of ventilator-associated events in an international cohort: the EUVAE study

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          Abstract

          Purpose

          To analyze the impact on patient outcome of ventilator-associated events (VAEs) as defined by the Centers for Disease Control and Prevention (CDC) in 2008, 2013, and the correlation with ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT).

          Methods

          This was a prospective, observational, multicenter, international study conducted at 13 intensive care units (ICUs); thirty consecutive adults mechanically ventilated for ≥ 48 h per site were eligible, with daily follow-up being recorded in a collaborative web database; VAEs were assessed using the 2013 CDC classification and its 2015 update.

          Results

          A total of 2856 ventilator days in 244 patients were analyzed, identifying 33 VAP and 51 VAT episodes; 30-day ICU mortality was significantly higher (42.8 vs. 19.6%, p < 0.007) in patients with VAP than in those with VAT. According to the 2013 CDC definitions, 117 VAEs were identified: 113 (96%) were infection-related ventilator-associated complication-plus (IVAC-plus), while possible ventilator-associated pneumonia (PVAP) was found in 64 (56.6%) of them. VAE increased the number of ventilator days and prolonged ICU and hospital LOS (by 5, 11, and 12 days, respectively), with a trend towards increased 30-day mortality (43 vs 28%, p = 0.06). Most episodes (26, 55%) classified as IVAC-plus without PVAP criteria were due to atelectasis. PVAP significantly increased (p < 0.05) ventilator days as well as ICU and hospital LOS (by 10.5, 14, and 13 days, respectively). Only 24 (72.7%) of VAP and 15 (29.4%) of VAT episodes met IVAC-plus criteria.

          Conclusions

          Respiratory infections (mainly VAT) were the most common complication. VAE algorithms only identified events with surrogates of severe oxygenation deterioration. As a consequence, IVAC definitions missed one fourth of the episodes of VAP and three fourths of the episodes of VAT. Identifying VAT (often missed by IVAC-plus criteria) is important, as VAP and VAT have different impacts on mortality.

          Electronic supplementary material

          The online version of this article (10.1007/s00134-018-5269-7) contains supplementary material, which is available to authorized users.

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          Most cited references28

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          Lung ultrasound in the critically ill

          Daniel Lichtenstein (2014)
          Lung ultrasound is a basic application of critical ultrasound, defined as a loop associating urgent diagnoses with immediate therapeutic decisions. It requires the mastery of ten signs: the bat sign (pleural line), lung sliding (yielding seashore sign), the A-line (horizontal artifact), the quad sign, and sinusoid sign indicating pleural effusion, the fractal, and tissue-like sign indicating lung consolidation, the B-line, and lung rockets indicating interstitial syndrome, abolished lung sliding with the stratosphere sign suggesting pneumothorax, and the lung point indicating pneumothorax. Two more signs, the lung pulse and the dynamic air bronchogram, are used to distinguish atelectasis from pneumonia. All of these disorders were assessed using CT as the “gold standard” with sensitivity and specificity ranging from 90% to 100%, allowing ultrasound to be considered as a reasonable bedside “gold standard” in the critically ill. The BLUE-protocol is a fast protocol (<3 minutes), which allows diagnosis of acute respiratory failure. It includes a venous analysis done in appropriate cases. Pulmonary edema, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease, asthma, and pneumothorax yield specific profiles. Pulmonary edema, e.g., yields anterior lung rockets associated with lung sliding, making the “B-profile.” The FALLS-protocol adapts the BLUE-protocol to acute circulatory failure. It makes sequential search for obstructive, cardiogenic, hypovolemic, and distributive shock using simple real-time echocardiography (right ventricle dilatation, pericardial effusion), then lung ultrasound for assessing a direct parameter of clinical volemia: the apparition of B-lines, schematically, is considered as the endpoint for fluid therapy. Other aims of lung ultrasound are decreasing medical irradiation: the LUCIFLR program (most CTs in ARDS or trauma can be postponed), a use in traumatology, intensive care unit, neonates (the signs are the same than in adults), many disciplines (pulmonology, cardiology…), austere countries, and a help in any procedure (thoracentesis). A 1992, cost-effective gray-scale unit, without Doppler, and a microconvex probe are efficient. Lung ultrasound is a holistic discipline for many reasons (e.g., one probe, perfect for the lung, is able to scan the whole-body). Its integration can provide a new definition of priorities. The BLUE-protocol and FALLS-protocol allow simplification of expert echocardiography, a clear advantage when correct cardiac windows are missing.
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            Resolution of ventilator-associated pneumonia: prospective evaluation of the clinical pulmonary infection score as an early clinical predictor of outcome.

            Daniel Blanzaco, Fernando Rios, Ana Mercedes S C Luna … (2003)
            To prospectively evaluate the performance of the Clinical Pulmonary Infection Score (CPIS) and its components to identify early in the hospital course of ventilator-associated pneumonia (VAP) which patients are responding to therapy. Prospective, multicenter, in a cohort of mechanically ventilated patients. The intensive care unit of six hospitals located in the metropolitan area of Buenos Aires, Argentina. Sixty-three patients, from a cohort of 472 mechanically ventilated patients hospitalized for >72 hrs, had clinical evidence of VAP and bacteriologic confirmation by bronchoalveolar lavage (BAL) or blood cultures. Bronchoscopy with BAL fluid culture and blood cultures after establishing a clinical diagnosis of VAP. All patients received antibiotics, 46 before bronchoscopy and 17 immediately after bronchoscopy. CPIS was measured at 3 days before VAP (VAP-3); at the onset of VAP (VAP); and at 3 (VAP+3), 5 (VAP+5), and 7 (VAP+7) days after onset. CPIS rose from VAP-3 to VAP and then fell progressively in the population as a whole (p <.001), and the fall in CPIS was significant in 31 survivors, but not in 32 nonsurvivors. From the individual components of the CPIS, only the Pao /Fio ratio distinguished survivors from nonsurvivors, beginning at VAP+3. When CPIS was <6 at 3 or 5 days after VAP onset, mortality was lower than in the remaining patients (p =.018). These differences also related to the finding that those receiving adequate therapy had a slight fall in CPIS and a significant increase of Pao /Fio at VAP+3, whereas those getting inadequate therapy did not. Serial measurements of CPIS can define the clinical course of VAP resolution, identifying those with good outcome as early as day 3, and could possibly be of help to define strategies to shorten the duration of therapy.
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              Does this patient have ventilator-associated pneumonia?

              Michael Klompas (2007)
              Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection. Accurate, timely diagnosis enables affected patients to receive appropriate therapy and avoids mistreatment of patients having other conditions. To review the published medical literature describing the precision and accuracy of clinical, radiographic, and laboratory data to diagnose bacterial VAP relative to a histological gold standard. English-language articles identified by a structured search strategy using MEDLINE (January 1966-October 31, 2006) and Google Scholar. Additional articles were identified through the reference lists of studies and review papers identified by the search strategy. Included studies described clinical findings associated with VAP in 25 or more patients receiving mechanical ventilation who subsequently underwent pulmonary biopsy or autopsy. Fourteen studies describing clinical findings in 655 patients met inclusion criteria. Data were abstracted onto a structured form, allowing calculation of the likelihood ratios (LRs) for each sign or combination of findings. The presence or absence of fever, abnormal white blood cell count, or purulent pulmonary secretions do not substantively alter the probability of VAP. However, the combination of a new radiographic infiltrate with at least 2 of fever, leukocytosis, or purulent sputum increases the likelihood of VAP (summary LR, 2.8; 95% confidence interval, 0.97-7.9). The absence of a new infiltrate on a plain chest radiograph lowers the likelihood of VAP (summary LR, 0.35; 95% confidence interval, 0.14-0.87). Fewer than 50% neutrophils on cell count analysis of lower pulmonary secretions makes VAP unlikely (LR range, 0.05-0.10). Routine bedside evaluation coupled with radiographic information provides suggestive but not definitive evidence that VAP is present or absent. Given the severity of VAP and the frequency of serious conditions that can mimic VAP, clinicians should be ready to consider additional tests that provide further evidence for VAP or that establish another diagnosis.
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                Author and article information

                Contributors
                Jordi Rello:
                ORCID: http://orcid.org/0000-0003-0676-6210
                34 932746209 , jrello@crips.es
                Journal
                Journal ID (nlm-ta): Intensive Care Med
                Journal ID (iso-abbrev): Intensive Care Med
                Title: Intensive Care Medicine
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Print): 0342-4642
                ISSN (Electronic): 1432-1238
                Publication date (Electronic): 12 July 2018
                Publication date (Print): 2018
                Volume: 44
                Issue: 8
                Pages: 1212-1220
                Affiliations
                [1 ]ISNI 0000 0004 1763 0287, GRID grid.430994.3, Vall d’Hebron Institute of Research, ; Pg Vall d’Hebron 119-129, AMI-14, 08035 Barcelona, Spain
                [2 ]GRID grid.7080.f, Medicine Department, , Universitat Autónoma de Barcelona, ; Barcelona, Spain
                [3 ]ISNI 0000 0004 1763 0287, GRID grid.430994.3, Clinical Research in Pneumonia and Sepsis, , Vall d´Hebron Research Institute, ; Barcelona, Spain
                [4 ]GRID grid.453512.4, European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Study Group for Infections in Critically Ill Patients (ESGCIP), ; Basel, Switzerland
                [5 ]ISNI 0000 0000 9975 294X, GRID grid.411521.2, Trauma Research Center, Nursing Faculty, , Baqiyatallah University of Medical Sciences, ; Tehran, Iran
                [6 ]ISNI 0000 0004 0471 8845, GRID grid.410463.4, Critical Care Center, , Centre Hospitalier Universitaire Lille, ; Lille, France
                [7 ]ISNI 0000 0001 2186 1211, GRID grid.4461.7, Inflammation Research International Center, , Université Lille, ; Lille, France
                [8 ]GRID grid.417144.3, Papageorgiou General Hospital, ; Thessaloníki, Greece
                [9 ]ISNI 0000 0004 0642 7670, GRID grid.413791.9, Infectious Diseases and Clinical Microbiology Department, , Ankara Numune Training and Research Hospital, ; Ankara, Turkey
                [10 ]GRID grid.414651.3, Intensive Care Department, , Donostia University Hospital, ; Donostia, Spain
                [11 ]ISNI 0000 0004 0471 9397, GRID grid.413819.6, Antalya Education and Research Hospital, ; Antalya, Turkey
                [12 ]ISNI 0000 0000 8588 831X, GRID grid.411119.d, Hôpital Bichat-Claude-Bernard, ; Diderot, Paris, France
                [13 ]ISNI 0000 0000 9320 7537, GRID grid.1003.2, Burns, Trauma and Critical Care Research Centre-UQCCR, Faculty of Medicine, , University of Queensland, ; Brisbane, Australia
                [14 ]ISNI 0000 0004 0622 4662, GRID grid.411449.d, Critical Care Department, , Attikon University Hospital, ; Athens, Greece
                [15 ]ISNI 0000 0000 9314 1427, GRID grid.413448.e, Centro de Investigación Biomédica en Red, Enfermedades Respiratorias, CIBERES, ; Madrid, Spain
                Author information
                http://orcid.org/0000-0003-0676-6210
                Article
                Publisher ID: 5269
                DOI: 10.1007/s00134-018-5269-7
                PMC ID: 7095084
                PubMed ID: 30003304
                SO-VID: 2d4516da-3782-4215-9de7-33a9419b8809
                Copyright © © Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2018
                License:

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                Date received : 22 March 2018
                Date accepted : 5 June 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100001704, European Society of Clinical Microbiology and Infectious Diseases;
                Funded by: Centro de Investigación Biomédica en Red
                Award ID: 06/06/036
                Award Recipient :
                Categories
                Subject: Original
                Custom metadata
                issue-copyright-statement © Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2018

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: ventilator-associated pneumonia,ventilator-associated tracheobronchitis,ventilator-associated events,surveillance,hypoxemia
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: ventilator-associated pneumonia, ventilator-associated tracheobronchitis, ventilator-associated events, surveillance, hypoxemia

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