L Papazian, P Thomas, L Garbe, I Guignon, X Thirion, J Charrel, C Bollet, P Fuentes and F Gouin
Department of Anesthesia and Intensive Care, Hopital Sainte-Marguerite, Marseilles, France.

The purpose of this prospective postmortem study was to assess the diagnostic accuracy of bronchoscopic techniques (bronchoalveolar lavage [BAL] and protected specimen brush [PSB]) and nonbronchoscopic techniques (blind bronchial sampling [BBS] and mini-BAL) in the diagnosis of ventilator-associated pneumonia (VAP). The results of each technique were compared with histology and culture of lung tissue specimens obtained by surgical pneumonectomies in 38 patients who died after at least 72 h of mechanical ventilation. Histology was positive for VAP in 18 patients and negative in 20 patients. There were 12 definite VAP (positive histology and positive lung cultures) and 6 histologic VAP (positive histology and negative cultures). Clinical pulmonary infection score (CPIS) at a threshold of 6 achieved a sensitivity of 72% and a specificity of 85%. When the CPIS was combined with the logarithmic concentration of the predominant microorganism obtained from the BBS sample culture, specificity was increased to 95%, for a threshold of 10. Using 10(3) cfu/ml as the threshold of positivity for cultures obtained with PSB and mini-BAL samples and 10(4) cfu/ml for cultures obtained with BBS and BAL, the respective sensitivities of these techniques for definite VAP were 42, 67, 83, and 58%. The sensitivity of BBS was significantly higher than that of PSB (p < 0.05). The area under the receiver operator characteristic curve was significantly greater for BBS than PSB (p < 0.05). Given that it is more sensitive and noninvasive, BBS is preferable to PSB for the diagnosis of VAP.

This article has been cited by other articles:

				C. L. Munro, M. J. Grap, D. J. Jones, D. K. McClish, and C. N. Sessler Chlorhexidine, Toothbrushing, and Preventing Ventilator-Associated Pneumonia in Critically Ill Adults Am. J. Crit. Care., September 1, 2009; 18(5): 428 - 437. [Abstract] [Full Text] [PDF]

				M. Klompas Unintended consequences in the drive for zero Thorax, June 1, 2009; 64(6): 463 - 465. [Full Text] [PDF]

				M. B. Rosbolt, E. S. Sterling, and B. G. Fahy The Utility of the Clinical Pulmonary Infection Score J Intensive Care Med, January 1, 2009; 24(1): 26 - 34. [Abstract] [PDF]

				M. Klompas Silver-Coated Endotracheal Tubes and Patient Outcomes in Ventilator-Associated Pneumonia JAMA, December 10, 2008; 300(22): 2605 - 2605. [Full Text] [PDF]

				E. Kipnis, K. Hansen, T. Sawa, K. Moriyama, A. Zurawel, A. Ishizaka, and J. Wiener-Kronish Proteomic Analysis of Undiluted Lung Epithelial Lining Fluid Chest, August 1, 2008; 134(2): 338 - 345. [Abstract] [Full Text] [PDF]

				G. Horonenko, J. C. Hoyt, R. A. Robbins, C. U. Singarajah, A. Umar, J. Pattengill, and J. M. Hayden Soluble Triggering Receptor Expressed on Myeloid Cell-1 Is Increased in Patients With Ventilator-Associated Pneumonia: A Preliminary Report Chest, July 1, 2007; 132(1): 58 - 63. [Abstract] [Full Text] [PDF]

				M. Klompas Does This Patient Have Ventilator-Associated Pneumonia? JAMA, April 11, 2007; 297(14): 1583 - 1593. [Abstract] [Full Text] [PDF]

				S. M. Koenig and J. D. Truwit Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention Clin. Microbiol. Rev., October 1, 2006; 19(4): 637 - 657. [Abstract] [Full Text] [PDF]

				C. L. Munro, M. J. Grap, R.K. Elswick Jr, J. McKinney, C. N. Sessler, and R. S. Hummel III Oral health status and development of ventilator-associated pneumonia: a descriptive study. Am. J. Crit. Care., September 1, 2006; 15(5): 453 - 460. [Abstract] [Full Text] [PDF]

				I. Porzecanski and D. L. Bowton Diagnosis and treatment of ventilator-associated pneumonia. Chest, August 1, 2006; 130(2): 597 - 604. [Abstract] [Full Text] [PDF]

				S. Fujitani and V. L. Yu Diagnosis of Ventilator-Associated Pneumonia: Focus on Nonbronchoscopic Techniques (Nonbronchoscopic Bronchoalveolar Lavage, Including Mini-BAL, Blinded Protected Specimen Brush, and Blinded Bronchial Sampling) and Endotracheal Aspirates J Intensive Care Med, January 1, 2006; 21(1): 17 - 21. [Abstract] [PDF]

				C. Brun-Buisson, M. Fartoukh, E. Lechapt, S. Honore, J.-R. Zahar, C. Cerf, and B. Maitre Contribution of Blinded, Protected Quantitative Specimens to the Diagnostic and Therapeutic Management of Ventilator-Associated Pneumonia Chest, August 1, 2005; 128(2): 533 - 544. [Abstract] [Full Text] [PDF]

				M. J. Grap, C. L. Munro, R. S. Hummel III, R.K. Elswick Jr, J. L. McKinney, and C. N. Sessler Effect of Backrest Elevation on the Development of Ventilator-Associated Pneumonia Am. J. Crit. Care., July 1, 2005; 14(4): 325 - 332. [Abstract] [Full Text] [PDF]

				S. A. Voils, K. S. Kim, and E. T. Wittbrodt Recent Trends in the Management of Ventilator-Associated Pneumonia Journal of Pharmacy Practice, February 1, 2005; 18(1): 53 - 62. [Abstract] [PDF]

				F. Michel, B. Franceschini, P. Berger, J.-M. Arnal, M. Gainnier, J.-M. Sainty, and L. Papazian Early Antibiotic Treatment for BAL-Confirmed Ventilator-Associated Pneumonia: A Role for Routine Endotracheal Aspirate Cultures Chest, February 1, 2005; 127(2): 589 - 597. [Abstract] [Full Text] [PDF]

				S. Gibot and A. Cravoisy Soluble Form of the Triggering Receptor Expressed on Myeloid Cells-1 as a Marker of Microbial Infection Clin. Med. Res., August 1, 2004; 2(3): 181 - 187. [Abstract] [Full Text] [PDF]

				S. Gibot, A. Cravoisy, B. Levy, M.-C. Bene, G. Faure, and P.-E. Bollaert Soluble Triggering Receptor Expressed on Myeloid Cells and the Diagnosis of Pneumonia N. Engl. J. Med., January 29, 2004; 350(5): 451 - 458. [Abstract] [Full Text] [PDF]

				J-Y. Fagon and J. Chastre Diagnosis and treatment of nosocomial pneumonia in ALI/ARDS patients Eur. Respir. J., August 1, 2003; 22(42_suppl): 77s - 83s. [Abstract] [Full Text] [PDF]

				M. Fartoukh, B. Maitre, S. Honore, C. Cerf, J.-R. Zahar, and C. Brun-Buisson Diagnosing Pneumonia during Mechanical Ventilation: The Clinical Pulmonary Infection Score Revisited Am. J. Respir. Crit. Care Med., July 15, 2003; 168(2): 173 - 179. [Abstract] [Full Text] [PDF]

				L. Papazian and M. Gainnier Indications of BAL, lung biopsy, or both in mechanically ventilated patients with unexplained infiltrations Eur. Respir. J., March 1, 2003; 21(3): 383 - 384. [Full Text] [PDF]

				C. M. Hartog, J. A. Wermelt, C. O. Sommerfeld, W. Eichler, K. Dalhoff, and J. Braun Pulmonary Matrix Metalloproteinase Excess in Hospital-acquired Pneumonia Am. J. Respir. Crit. Care Med., February 15, 2003; 167(4): 593 - 598. [Abstract] [Full Text] [PDF]

				J.-M. Sirvent, L. Vidaur, S. Gonzalez, P. Castro, J. de Batlle, A. Castro, and A. Bonet Microscopic Examination of Intracellular Organisms in Protected Bronchoalveolar Mini-Lavage Fluid for the Diagnosis of Ventilator-Associated Pneumonia Chest, February 1, 2003; 123(2): 518 - 523. [Abstract] [Full Text] [PDF]

				S. Michaud, S. Suzuki, and S. Harbarth Effect of Design-related Bias in Studies of Diagnostic Tests for Ventilator-associated Pneumonia Am. J. Respir. Crit. Care Med., November 15, 2002; 166(10): 1320 - 1325. [Full Text] [PDF]

				O. Lambotte, J.-F. Timsit, M. Garrouste-Orgeas, B. Misset, A. Benali, and J. Carlet The Significance of Distal Bronchial Samples With Commensals in Ventilator-Associated Pneumonia: Colonizer or Pathogen? Chest, October 1, 2002; 122(4): 1389 - 1399. [Abstract] [Full Text] [PDF]

				J. Chastre and J.-Y. Fagon Ventilator-associated Pneumonia Am. J. Respir. Crit. Care Med., April 1, 2002; 165(7): 867 - 903. [Abstract] [Full Text] [PDF]

				S Ewig, T Bauer, and A Torres The pulmonary physician in critical care * 4: Nosocomial pneumonia Thorax, April 1, 2002; 57(4): 366 - 371. [Abstract] [Full Text] [PDF]

				J Dakin and M Griffiths The pulmonary physician in critical care 1: Pulmonary investigations for acute respiratory failure Thorax, January 1, 2002; 57(1): 79 - 85. [Abstract] [Full Text] [PDF]

				P. E. Marik and J. Varon Ventilator-Associated Pneumonia : Science and Hocus-Pocus Chest, September 1, 2001; 120(3): 702 - 704. [Full Text] [PDF]

				J. Rello, J. A. Paiva, J. Baraibar, F. Barcenilla, M. Bodi, D. Castander, H. Correa, E. Diaz, J. Garnacho, M. Llorio, et al. International Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-Associated Pneumonia Chest, September 1, 2001; 120(3): 955 - 970. [Abstract] [Full Text] [PDF]

				Members of the Task Force:, E. Bouza, C. Brun-Buisson, J. Chastre, S. Ewig, J-Y. Fagon, C.H. Marquette, P. Munoz, M.S. Niederman, L. Papazian, et al. Ventilator-associated pneumonia: European Task Force on ventilator-associated pneumonia Chairmen of the Task Force: A. Torres and J. Carlet Eur. Respir. J., May 1, 2001; 17(5): 1034 - 1045. [Full Text] [PDF]

				A Rañó, C Agustí, P Jimenez, J Angrill, N Benito, C Danés, J González, M Rovira, T Pumarola, A Moreno, et al. Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures Thorax, May 1, 2001; 56(5): 379 - 387. [Abstract] [Full Text]

				G. San Pedro Are Quantitative Cultures Useful in the Diagnosis of Hospital-Acquired Pneumonia? Chest, February 1, 2001; 119 (2009): 385S - 390S. [Abstract] [Full Text] [PDF]

				S. Fiel Guidelines and Critical Pathways for Severe Hospital-Acquired Pneumonia Chest, February 1, 2001; 119 (2009): 412S - 418S. [Abstract] [Full Text] [PDF]

				R. S. Morehead and S. J. Pinto Ventilator-Associated Pneumonia Arch Intern Med, July 10, 2000; 160(13): 1926 - 1936. [Abstract] [Full Text] [PDF]

				M. RUIZ, A. TORRES, S. EWIG, M. A. MARCOS, A. ALCÓN, R. LLEDÓ, M. A. ASENJO, and A. MALDONALDO Noninvasive Versus Invasive Microbial Investigation in Ventilator-associated Pneumonia . Evaluation of Outcome Am. J. Respir. Crit. Care Med., July 1, 2000; 162(1): 119 - 125. [Abstract] [Full Text]

				P. E. Marik Fever in the ICU Chest, March 1, 2000; 117(3): 855 - 869. [Abstract] [Full Text] [PDF]

				T. T Bauer and A. Torres Acute respiratory distress syndrome and nosocomial pneumonia Thorax, November 1, 1999; 54(11): 1036 - 1040. [Full Text]

				N. Fàbregas, S. Ewig, A. Torres, M. El-Ebiary, J. Ramirez, J. P. de la Bellacasa, T. Bauer, and H. Cabello Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies Thorax, October 1, 1999; 54(10): 867 - 873. [Abstract] [Full Text]

				J. HALL Assessment of Fever in the Intensive Care Unit . Is the Answer Just Beyond The Tip of Our Nose? Am. J. Respir. Crit. Care Med., March 1, 1999; 159(3): 693 - 694. [Full Text]

				L. HOLZAPFEL, C. CHASTANG, G. DEMINGEON, J. BOHE, B. PIRALLA, and A. COUPRY A Randomized Study Assessing the Systematic Search for Maxillary Sinusitis in Nasotracheally Mechanically Ventilated Patients . Influence of Nosocomial Maxillary Sinusitis on the Occurrence of Ventilator-associated Pneumonia Am. J. Respir. Crit. Care Med., March 1, 1999; 159(3): 695 - 701. [Abstract] [Full Text]

				D. L. Bowton Nosocomial Pneumonia in the ICUYear 2000 and Beyond Chest, March 1, 1999; 115 (2009): 28S - 33S. [Abstract] [Full Text] [PDF]

				P. E. Marik and P. Careau The Role of Anaerobes in Patients With Ventilator-associated Pneumonia and Aspiration Pneumonia: A Prospective Study Chest, January 1, 1999; 115(1): 178 - 183. [Abstract] [Full Text] [PDF]

				P J Sanderson, B Allaouchiche, H Jaumain, D Chassard, D. Leung, R. D'Amico, S. Pifferi, and A. Liberati Effectiveness of antibiotic prophylaxis in critically ill patients BMJ, November 28, 1998; 317(7171): 1526a - 1526. [Full Text]

				D. WERMERT, C.-H. MARQUETTE, M.-C. COPIN, F. WALLET, A. FRATICELLI, P. RAMON, and A.-B. TONNEL Influence of Pulmonary Bacteriology and Histology on the Yield of Diagnostic Procedures in Ventilator-Acquired Pneumonia Am. J. Respir. Crit. Care Med., July 1, 1998; 158(1): 139 - 147. [Abstract] [Full Text] [PDF]

				M. H. KOLLEF, J. VLASNIK, L. SHARPLESS, C. PASQUE, D. MURPHY, and V. FRASER Scheduled Change of Antibiotic Classes . A Strategy to Decrease the Incidence of Ventilator-associated Pneumonia Am. J. Respir. Crit. Care Med., October 1, 1997; 156(4): 1040 - 1048. [Abstract] [Full Text] [PDF]

				M. J. M. BONTEN, A. H. M. FROON, C. A. GAILLARD, J. W. M. GREVE, P. W. de LEEUW, M. DRENT, E. E. STOBBERINGH, and W. A. BUURMAN The Systemic Inflammatory Response in the Development of Ventilator-Associated Pneumonia Am. J. Respir. Crit. Care Med., October 1, 1997; 156(4): 1105 - 1113. [Abstract] [Full Text] [PDF]

				M. EL-EBIARY, A. TORRES, N. FÁBREGAS, J. P. de la BELLACASA, J. GONZÁLEZ, J. RAMIREZ, D. del BAÑO, C. HERNÁNDEZ, and M. T. JIMÉNEZ de ANTA Significance of the Isolation of Candida Species from Respiratory Samples in Critically Ill, Non-neutropenic Patients . An Immediate Postmortem Histologic Study Am. J. Respir. Crit. Care Med., July 1, 1997; 156(2): 583 - 590. [Abstract] [Full Text]

				F. Bregeon, L. Papazian, A. Visconti, R. Gregoire, X. Thirion, and F. Gouin Relationship of Microbiologic Diagnostic Criteria to Morbidity and Mortality in Patients With Ventilator-Associated Pneumonia JAMA, February 26, 1997; 277(8): 655 - 662. [Abstract] [PDF]

				J. M. SANCHEZ-NIETO, A. TORRES, F. GARCIA-CORDOBA, M. EL-EBIARY, A. CARRILLO, J. RUIZ, M. L. NUÑEZ, and M. NIEDERMAN Impact of Invasive and Noninvasive Quantitative Culture Sampling on Outcome of Ventilator-Associated Pneumonia . A Pilot Study Am. J. Respir. Crit. Care Med., February 1, 1997; 157(2): 371 - 376. [Abstract] [Full Text]