LETTER
Does this Patient Have Ventilatorassociated Tracheobronchitis? To the Editor: I have read with interest the brief observation from Craven et al, and would like to raise 2 important issues.1 They reported that 29% of patients with ventilatorassociated tracheobronchitis progressed to ventilatorassociated pneumonia. This figure compares favorably with previous studies.2 However, 68% of their patients developed early-onset pneumonia, which could not be preceded by ventilator-associated tracheobronchitis in such a short span of time—4 days. Only 9 patients (32%) developed late-onset ventilator-associated pneumonia, and 6 of them had previous ventilator-associated tracheobronchitis, making two thirds of late-onset ventilator-associated pneumonia patients with past ventilator-associated tracheobronchitis. This is far more than previously published in a study with clinical trigger to take tracheal samples: only 9 of 42 (21%) patients with late-onset ventilator-associated pneumonia had previous ventilatorassociated tracheobronchitis.2 This deserves an attempt at an explanation. First, they may be right. Late-onset ventilator-associated pneumonia could be screened by routine sampling (daily, when clinically indicated), as the proposed natural history of heavy colonization, ventilator-associated tracheobronchitis, and then ventilator-associated pneumonia is a continuum. This is a widely accepted concept. However, several data do not support this concept, including some guidelines.2-4 Ventilator-associated tracheobronchitis and ventilatorassociated pneumonia being 2 distinct entities, depending on equilibrium between offender and host’s response, is still a matter of debate. On the other hand, major overlap between ventilatorassociated pneumonia and ventilator-associated tracheobronchitis has been commonly acknowledged, as the main difference relies on nonaccurate chest radiograph. Accordingly, in this study, misdiagnosed ventilator-associated Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for writing this manuscript.
0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
tracheobronchitis may have been correctly classified ventilator-associated pneumonia, as infection develops a few days later. Clearly, diagnosis of ventilator-associated tracheobronchitis hesitates between heavy colonization with subtle clinical signs and ventilator-associated pneumonia, but with delayed apparition of new chest radiograph infiltrate or invisible alveolar damage. Finally, it is very intriguing that most patients with ventilator-associated pneumonia (and ventilator-associated tracheobronchitis) had a Clinical Pulmonary Infection Score < 6. As acknowledged by the authors, this score has given conflicting results, but is considered sufficiently robust to be a surrogate of ventilator-associated pneumonia or to guide antimicrobial therapy. If calculated on the date of supposed infection, I wonder how they managed to obtain such minimal scores. Despite proof of accuracy, this score does not mean pneumonia, as there is no gold standard for ventilator-associated pneumonia.5 To conclude, after controversies about what clinical and bacteriological thresholds are best for diagnosis of ventilator-associated tracheobronchitis, one has to concede that ventilator-associated tracheobronchitis remains an obscure clinical entity, with no robust model to rely on. One question still remains: Does this patient have ventilatorassociated tracheobronchitis? Sébastien Champion, MD Réanimation Polyvalente CHU de la Réunion Saint Denis, France
http://dx.doi.org/10.1016/j.amjmed.2013.11.026
References 1. Craven DE, Lei Y, Ruthazer R, et al. Incidence and outcomes of ventilator-associated tracheobronchitis and pneumonia. Am J Med. 2013;126:542-549. 2. Dallas J, Skrupky L, Abebe N, et al. Ventilator-associated tracheobronchitis in a mixed surgical and medical ICU population. Chest. 2011;139:513-518. 3. Nseir S, Di Pompeo C, Pronnier P, et al. Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome. Eur Respir J. 2002;20:1483-1489. 4. Niederman MS, Craven DE. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388-416. 5. Klompas M. Does this patient have ventilator-associated pneumonia? JAMA. 2007;297:1583-1593.
Does this Patient Have Ventilatorassociated Tracheobronchitis? To the Editor: I have read with interest the brief observation from Craven et al, and would like to raise 2 important issues.1 They reported that 29% of patients with ventilatorassociated tracheobronchitis progressed to ventilatorassociated pneumonia. This figure compares favorably with previous studies.2 However, 68% of their patients developed early-onset pneumonia, which could not be preceded by ventilator-associated tracheobronchitis in such a short span of time—4 days. Only 9 patients (32%) developed late-onset ventilator-associated pneumonia, and 6 of them had previous ventilator-associated tracheobronchitis, making two thirds of late-onset ventilator-associated pneumonia patients with past ventilator-associated tracheobronchitis. This is far more than previously published in a study with clinical trigger to take tracheal samples: only 9 of 42 (21%) patients with late-onset ventilator-associated pneumonia had previous ventilatorassociated tracheobronchitis.2 This deserves an attempt at an explanation. First, they may be right. Late-onset ventilator-associated pneumonia could be screened by routine sampling (daily, when clinically indicated), as the proposed natural history of heavy colonization, ventilator-associated tracheobronchitis, and then ventilator-associated pneumonia is a continuum. This is a widely accepted concept. However, several data do not support this concept, including some guidelines.2-4 Ventilator-associated tracheobronchitis and ventilatorassociated pneumonia being 2 distinct entities, depending on equilibrium between offender and host’s response, is still a matter of debate. On the other hand, major overlap between ventilatorassociated pneumonia and ventilator-associated tracheobronchitis has been commonly acknowledged, as the main difference relies on nonaccurate chest radiograph. Accordingly, in this study, misdiagnosed ventilator-associated Funding: None. Conflict of Interest: None. Authorship: The author is solely responsible for writing this manuscript.
0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
tracheobronchitis may have been correctly classified ventilator-associated pneumonia, as infection develops a few days later. Clearly, diagnosis of ventilator-associated tracheobronchitis hesitates between heavy colonization with subtle clinical signs and ventilator-associated pneumonia, but with delayed apparition of new chest radiograph infiltrate or invisible alveolar damage. Finally, it is very intriguing that most patients with ventilator-associated pneumonia (and ventilator-associated tracheobronchitis) had a Clinical Pulmonary Infection Score < 6. As acknowledged by the authors, this score has given conflicting results, but is considered sufficiently robust to be a surrogate of ventilator-associated pneumonia or to guide antimicrobial therapy. If calculated on the date of supposed infection, I wonder how they managed to obtain such minimal scores. Despite proof of accuracy, this score does not mean pneumonia, as there is no gold standard for ventilator-associated pneumonia.5 To conclude, after controversies about what clinical and bacteriological thresholds are best for diagnosis of ventilator-associated tracheobronchitis, one has to concede that ventilator-associated tracheobronchitis remains an obscure clinical entity, with no robust model to rely on. One question still remains: Does this patient have ventilatorassociated tracheobronchitis? Sébastien Champion, MD Réanimation Polyvalente CHU de la Réunion Saint Denis, France
http://dx.doi.org/10.1016/j.amjmed.2013.11.026
References 1. Craven DE, Lei Y, Ruthazer R, et al. Incidence and outcomes of ventilator-associated tracheobronchitis and pneumonia. Am J Med. 2013;126:542-549. 2. Dallas J, Skrupky L, Abebe N, et al. Ventilator-associated tracheobronchitis in a mixed surgical and medical ICU population. Chest. 2011;139:513-518. 3. Nseir S, Di Pompeo C, Pronnier P, et al. Nosocomial tracheobronchitis in mechanically ventilated patients: incidence, aetiology and outcome. Eur Respir J. 2002;20:1483-1489. 4. Niederman MS, Craven DE. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388-416. 5. Klompas M. Does this patient have ventilator-associated pneumonia? JAMA. 2007;297:1583-1593.
