Incorporating Lung Ultrasound in Clinical Pulmonary Infection Score as an Added Tool for Diagnosing Ventilator-associated Pneumonia: A Prospective Observational Study from a Tertiary Care Center

Utility of chest ultrasound in the diagnosis of ventilator-associated pneumonia in the critical care unit of a tertiary care center: a prospective observational study

Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia developing in patients who are mechanically ventilated for ≥48 hours. Lung ultrasound (LUS) has been shown to be useful in evaluating various pathologic pulmonary conditions. We aimed to study the utility of chest ultrasound in the diagnosis of VAP in a critical care unit. This was a monocentric, prospective observational study carried out in the intensive care unit (ICU) of our institution. On clinical suspicion of VAP, patients were subjected to ultrasound chest (lung) examination, which was done in a supine position in six areas of each hemithorax on the same day, and endotracheal aspirate (ETA) for gram stain and aerobic culture was sent within 6 hours. The final diagnosis of VAP was made when ETA culture was positive (>105 CFU/mL). Days of mechanical ventilation, ICU stay, hospital stay, and mortality were separately recorded for monitoring outcomes. Diagnostic performance of risk factors for VAP was analyzed by parameters like sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio (positive and negative). Concerning LUS signs, subpleural consolidations >2 had a sensitivity of 96% and specificity of 63% with an odds ratio of 51.43 in predicting VAP. Dynamic air bronchogram within consolidation was seen in 45% of patients with a sensitivity and specificity of 29% and 73%, respectively. A clinical LUS score >2 had a sensitivity of 100% in predicting VAP. LUS is a robust diagnostic tool with high sensitivity for diagnosing VAP. Clinical trials are needed to study whether LUS can be used as a tool for early diagnosis of VAP, which will help in the timely introduction of antibiotics.

Effects of Zataria multiflora mouthwash and chlorhexidine compared to chlorhexidine alone on the incidence of ventilator-associated pneumonia in patients admitted to intensive care units

BACKGROUND AND PURPOSE

Ventilator-associated pneumonia (VAP) is the most prevalent nosocomial infection in intensive care units (ICUs). To prevent VAP, several strategies are employed, including oral care with mouthwashes. This study sought to compare the effects of Zataria multiflora essential oil mouthwash combined with chlorhexidine (ZM + CHG) against chlorhexidine (CHG) alone in reducing the incidence of VAP among ICU patients.

MATERIALS AND METHODS

This study is a single-blind clinical trial involving 120 mechanically ventilated ICU patients. They were randomly assigned into two groups. One group received Zataria multiflora 0.2 % mouthwash and chlorhexidine gluconate 0.2 % mouthwash (ZM + CHG group), while the control group received chlorhexidine gluconate 0.2 % mouthwash (CHG group), both administered twice daily for five days. Clinical pulmonary infection, oral health, and oral mucosal-plaque condition were assessed using the clinical pulmonary infection score (CPIS), Beck oral assessment scale (BOAS), and mucosal-plaque score (MPS), respectively.

RESULTS

Both ZM + CHG and CHG were effective in reducing the incidence of VAP, with ZM + CHG demonstrating superior effectiveness (p < 0.05). Moreover, ZM + CHG led to a significant improvement in oral and dental health scores and oral mucosal plaque condition compared to CHG (p < 0.05). This study found no significant complications from using either mouthwash, although the follow-up period was relatively short.

CONCLUSION

ZM + CHG reduced the incidence of VAP in ICU patients more effectively than CHG. It also improved oral health and mucosal-plaque condition in mechanically ventilated patients. Thus, ZM + CHG could serve as an alternative to CHG in ICU patients under mechanical ventilation. However, additional studies are needed to confirm its impact on VAP incidence.

Lung Ultrasound Score as a Predictor of Clinical Severity and Prognosis in Patients of Ventilator-associated Pneumonia

Background

To estimate a correlation between change in lung ultrasound aeration score (LUSS) and mortality in patients with ventilator-associated pneumonia.

Materials and methods

We conducted a prospective observational study in which lung ultrasound, the partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2 ratio), and static lung compliance were performed for five consecutive days since the diagnosis of ventilator-associated pneumonia (day 1-5) in a 20-bed multidisciplinary intensive care unit in at a tertiary care academic institute in Northern India. A hundred and seventeen ventilated patients were studied for the first 5 days after ventilator-associated pneumonia (VAP) development. Lung ultrasounds were performed with an ultrasonography machine using a round-tipped probe of 2-5 MHz at six different areas of each hemithorax, which includes superior and inferior in anterior, lateral, and posterior lung fields. Patients with a decreased LUSS of 2 were labeled as responders. A decrease of LUSS of less than 2 or an increase of LUSS were leveled as nonresponders.

Results

The correlation between the change in LUSS between days 1 and 5 was significant with 28-day mortality (26.3% in responders vs 87.8% nonresponses with p < 0.001).

Conclusion

The responders to treatment for VAP described by LUSS had lower mortality than non-responders.

How to cite this article

Panda S, Agarwal A, Mishra SB, Jain G, Talawar P. Lung Ultrasound Score as a Predictor of Clinical Severity and Prognosis in Patients of Ventilator-associated Pneumonia. Indian J Crit Care Med 2024;28(11):1009-1014.

Critical insights from recent outbreaks of Mycoplasma pneumoniae: decoding the challenges and effective interventions strategies

OBJECTIVES

Mycoplasma pneumoniae (M. pneumoniae) continues to pose a significant disease burden on global public health as a respiratory pathogen. The antimicrobial resistance among M. pneumoniae strains has complicated the outbreak control efforts, emphasizing the need for robust surveillance systems and effective antimicrobial stewardship programs.

DESIGN

This review comprehensively investigates studies stemming from previous outbreaks to emphasize the multifaceted nature of M. pneumoniae infections, encompassing epidemiological dynamics, diagnostic innovations, antibiotic resistance, and therapeutic challenges.

RESULTS

We explored the spectrum of clinical manifestations associated with M. pneumoniae infections, emphasizing the continuum of disease severity and the challenges in gradating it accurately. Artificial intelligence and machine learning have emerged as promising tools in M. pneumoniae diagnostics, offering enhanced accuracy and efficiency in identifying infections. However, their integration into clinical practice presents hurdles that need to be addressed. Further, we elucidate the pivotal role of pharmacological interventions in controlling and treating M. pneumoniae infections as the efficacy of existing therapies is jeopardized by evolving resistance mechanisms.

CONCLUSION

Lessons learned from previous outbreaks underscore the importance of adaptive treatment strategies and proactive management approaches. Addressing these complexities demands a holistic approach integrating advanced technologies, genomic surveillance, and adaptive clinical strategies to effectively combat this pathogen.

The Clinical Pulmonary Infection Score Combined with Procalcitonin and Lung Ultrasound (CPIS-PLUS), a Good Tool for Ventilator Associated Pneumonia Early Diagnosis in Pediatrics

Ventilator-associated pneumonia (VAP) is common in Pediatric Intensive Care Units. Although early detection is crucial, current diagnostic methods are not definitive. This study aimed to identify lung ultrasound (LUS) findings and procalcitonin (PCT) values in pediatric patients with VAP to create a new early diagnosis score combined with the Clinical Pulmonary Infection Score (CPIS), the CPIS-PLUS score. Prospective longitudinal and interventional study. Pediatric patients with suspected VAP were included and classified into VAP or non-VAP groups, based on Centers of Disease Control (CDC) criteria for the final diagnosis. A chest-X-ray (CXR), LUS, and blood test were performed within the first 12 h of admission. CPIS score was calculated. A total of 108 patients with VAP suspicion were included, and VAP was finally diagnosed in 51 (47%) patients. CPIS-PLUS showed high accuracy in VAP diagnosis with a sensitivity (Sn) of 80% (95% CI 65-89%) and specificity (Sp) of 73% (95% CI 54-86%). The area under the curve (AUC) resulted in 0.86 for CPIS-PLUS vs. 0.61 for CPIS. In conclusion, this pilot study showed that CPIS-PLUS could be a potential and reliable tool for VAP early diagnosis in pediatric patients. Internal and external validations are needed to confirm the potential value of this score to facilitate VAP diagnosis in pediatric patients.

Prognostic Value of the Area of Lung Involved in Severe and Non-Severe Bronchiolitis: An Observational, Ultrasound-Based Study

BACKGROUND

Point of care lung ultrasound (LUS) has a definite role in viral bronchiolitis when combined with clinical data. Previous data showed a bigger involvement of the superior lung zones in more severe cases. The aim of the present study is to describe whether different lung areas are implicated to different degrees in patients admitted to a Pediatric Intensive Care Unit (PICU) and needing ventilation compared to those with less severe forms.

METHODS

observational, prospective study. LUS scores of single lung areas and clinical data were collected for all children aged 0-12 months presenting with bronchiolitis to the participating centers and used as covariates for logistic regression having "PICU admission" as outcome. A subsequent analysis was carried out to investigate factors concurring with different lung zones' involvement.

RESULTS

173 patients were enrolled. Difficulty in feeding, presence of wheezing, SpO2 were all risk factors for PICU admission. Superior lung areas' LUS scores presented higher Odds Ratios for PICU admission and need for ventilation than inferior ones. Age and prematurity concurred in determining their higher LUS scores.

CONCLUSIONS

Superior lobes' greater involvement could be favored by the geometrical distribution of relative bronchi, exiting with an acute angle from mainstem bronchi in small children where airway caliber is small and only small volumes of secretions can be occlusive.

Teaching Bundle Care Approach to Intensive Care Nurses to Prevent Ventilator Associated Pneumonia with a Stratified Validated Module

BACKGROUND

Module-based teaching of ventilator-associated pneumonia (VAP) with a systematic, stratified approach is expected to have a promising role in teaching. We hypothesized it to improve the skill and knowledge of intensive care unit nurses.

OBJECTIVES

The aim of this study was to determine the efficacy of the teaching module with debriefing sessions on the VAP bundle care approach, and the secondary objective was to estimate the improvement in individual components of the VAP bundle.

METHODS

A total of 200 paramedical staff were exposed to a teaching module consisting of pretest didactic lectures, debriefing sessions, reflection by participants, and feedback. Posttest analysis was done to assess knowledge. Skill assessment was done with directly observed procedural skills (DOPS) assessment, and feedback was taken from participants. Follow-up was done at 6 months to assess decay in knowledge and skills.

RESULTS

Preworkshop and postworkshop DOPS scores were analyzed using the Mann-Whitney U test. Subgroup analysis was performed using the paired t test. Median pretest and posttest scores were 6 (interquartile range, 4-8) and 13 (interquartile range, 11-15), respectively (P < .001). Comparing DOPS scores before and after exposure to the teaching module, the number of subjects with scores that were below expectations was 24 and 4; meeting expectations was 94 and 24; borderline expectations were 36 and 104; and above expectations was 46 and 58, respectively, between the groups (P < .001). A decay in knowledge and skills was noted in the follow-up.

CONCLUSION

A validated teaching module with debriefing sessions is useful in training bundle care approaches to intensive care unit nurses.

Examining the Definition of Ventilator-Associated Pneumonia in the Trauma Setting: A Single-Center Analysis

Background: Ventilator associated pneumonia (VAP) is defined by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) using laboratory findings, pathophysiologic signs/symptoms, and imaging criteria. However, many critically ill trauma patients meet the non-specific laboratory and sign/symptom thresholds for VAP, so the TQIP designation of VAP depends heavily upon imaging evidence. We hypothesized that physician opinions widely vary regarding chest radiograph findings significant for VAP. Patients and Methods: The TQIP Spring 2021 Benchmark Report (BR) was used to identify 14 patients with VAP at an academic Level 1 Trauma Center. Critically ill trauma patients (n = 7) who spent at least four days intubated and met TQIP's laboratory and sign/symptom thresholds for VAP but did not appear as VAPs on the BR comprised the control group. For each deidentified patient, four successive chest radiographic images were compiled and arranged chronologically. Cases and controls were randomly arranged in digital format. Blinded physicians (n = 27) were asked to identify patients with VAP based solely on imaging evidence. Results: Radiographic evidence of VAP was highly subjective (Krippendorff α = 0.134). Among physicians of the same job description, inter-rater reliability remained low (α = 0.137 for trauma attending physicians; α = 0.141 for trauma fellows; α = 0.271 for radiologists). When majority judgment was compared to the TQIP BR, there was disagreement between the two tests (Cohen κ = ^-0.071; sensitivity, 64.3%; specificity, 28.6%). Conclusions: Current definitions of VAP rely on subjective imaging interpretation and ignore the reality that there are numerous explanations for opacities on CXR. The inconsistency of physicians' imaging interpretation and protean physiologic findings for VAP in trauma patients should preclude the current definition of VAP from being used as a quality improvement metric in TQIP.

Ventilator -associated Pneumonia and Lung Ultrasound: Finally, What is between the Ears Matters

How to cite this article: Gopaldas JA, Kumar AKA. Ventilator-associatedPneumonia and Lung Ultrasound: Finally, What is between the EarsMatters. Indian J Crit Care Med 2021;25(9):1075-1076.

CPIS Lung Ultrasound and the Erratic March toward Diagnostic Certainty in VAP

How to cite this article: Rajagopalan RE. CPIS Lung Ultrasound and the Erratic March toward Diagnostic Certainty in VAP. Indian J Crit Care Med 2021;25(3):255-257.