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
Arvind K Baronia, Banani Poddar, Zafar Neyaz
Citation Information :
Baronia AK, Poddar B, Neyaz Z. 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. Indian J Crit Care Med 2021; 25 (3):284-291.
Background: Clinical pulmonary infection score (CPIS) is an established diagnostic parameter for ventilator-associated pneumonia (VAP). Lung ultrasound (LUS) is an evolving tool for diagnosing VAP. Various scores have been proposed for the diagnosis of VAP, taking LUS as a parameter. We proposed whether replacing LUS with chest radiograph in CPIS criteria will add to the diagnosis of VAP. The current study was done to evaluate the diagnostic accuracy of LUS alone and in combination with clinical and microbiological criteria for VAP by replacing chest radiograph with LUS in CPIS. Materials and methods: We conducted a prospective single-center observational study including 110 patients with suspected VAP to investigate the diagnostic accuracy of LUS. Quantitative mini-bronchoalveolar lavage (mini-BAL) culture was considered the gold standard for diagnosis of VAP. Here, the authors have explored the combination of LUS, clinical, and microbiology parameters for diagnosing VAP. On replacing chest radiograph with LUS, sono-pulmonary infection score (SPIS) and modified SPIS (SPIS-mic, SPIS-cult) was formulated as a substitute for CPIS. Results: Overall LUS performance for VAP diagnosis was good with sensitivity, specificity, positive or negative predictive value, and positive or negative likelihood ratios of 91.3%, 70%, 89%, 75%, 3, and 0.1, respectively. Adding microbiology culture to LUS increased diagnostic accuracy. The areas under the curve for SPIS and modified SPIS were 0.808, 0.815, and 0.913, respectively. Conclusion: The diagnosis of VAP requires agreement between clinical, microbiological, and radiological criteria. Replacing chest radiograph with LUS in CPIS criteria (SPIS) increases diagnostic accuracy for VAP. Adding clinical and culture data to SPIS provided the highest diagnostic accuracy. Clinical parameters along with lung ultrasound increase diagnostic accuracy for VAP.
Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA 1995;274(8):639–644.
Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med 1999;159(4 Pt 1):1249–1256. DOI: 10.1164/ajrccm.159.4.9807050.
Fartoukh M, Maitre B, Honoré S, Cerf C, Zahar JR, Brun-Buisson C. Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med 2003;168(2):173–179. DOI: 10.1164/rccm.200212-1449OC.
Sperandeo M, Carnevale V, Muscarella S, Sperandeo G, Varriale A, Filabozzi P, et al. Clinical application of transthoracic ultrasonography in inpatients with pneumonia. Eur J Clin Invest. 2011;41(1):1–7. DOI: 10.1111/j.1365-2362.2010.02367.x.
Lichtenstein D, Lascols N, Mezière G, Gepner A. Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med 2004;30(2):276–281. DOI: 10.1007/s00134-003-2075-6.
Zagli G, Cozzolino M, TerreniA, Biagioli T, Caldini AL, Peris A. Diagnosis of ventilator-associated pneumonia: a pilot, exploratory analysis of a new core based on procalcitonin and chest echography. Chest 2014;146(6):1578–1585. DOI: 10.1378/chest.13-2922.
Mongodi S, Via G, Girard M, Rouquette I, Misset B, Braschi A, et al. Lung ultrasound for early diagnosis of ventilator-associated pneumonia. Chest 2016;149(4):969–980. DOI: 10.1016/j.chest.2015.12.012.
Pugin J, Auckenthaler R, Milli N, Janssens JP, Lew PD, Suter PM. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis 1991;143(5 Pt 1):1121–1129. DOI: 10.1164/ajrccm/143.5_Pt_1.1121.
Croce MA, Swanson JM, Magnotti LJ, Claridge JA, Weinberg JA, Wood GC, et al. The futility of the clinical pulmonary infection scores in trauma patients. J Trauma 2006;60(3):523–528. DOI: 10.1097/01.ta.0000204033.78125.1b.
Schurink CAM, Van Nieuwenhoven CA, Jacobs JA, Rozenberg-Arska M, Joore HCA, Buskens E, et al. Clinical pulmonary infection score for ventilator-associated pneumonia: accuracy and inter-observer variability. Intensive Care Med 2004;30(2):217–224. DOI: 10.1007/s00134-003-2018-2.
Fàbregas N, Ewig S, Torres A, El-Ebiary M, Ramirez J, de La Bellacasa JP, et al. Clinical diagnosis of ventilator associated pneumonia revisited: comparative validation using immediate post-mortem lung biopsies. Thorax 1999;54(10):867–873. DOI: 10.1136/thx.54.10.867.
Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for an indiscriminate antibiotic prescription. Am J Respir Crit Care Med 2000;162(2):505–511. DOI: 10.1164/ajrccm.162.2.9909095.
Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: bedside lung ultrasound in critical care practice. Crit Care 2007;11(1):205. DOI: doi: 10.1186/cc5668.
Winer-Muram HT, Steiner RM, Gurney JW, Shah R, Jennings SG, Arheart KL, et al. Ventilator-associated pneumonia in patients with adult respiratory distress syndrome: CT evaluation. Radiology 1998;208(1):193–199. DOI: 10.1148/radiology.208.1.9646813.
Bourcier JE, Paquet J, Seinger M, Gallard E, Redonnet JP, Cheddadi F, et al. Performance comparison of lung ultrasound and chest x-ray for the diagnosis of pneumonia in the ED. Am J Emerg Med 2014;32(2):115–118. DOI: 10.1016/j.ajem.2013.10.003.
Hu QJ, Shen YC, Jia LQ, Guo SJ, Long HY, Pang CS, et al. Diagnostic performance of lung ultrasound in the diagnosis of pneumonia: a bivariate meta-analysis. Int J Clin Exp Med 2014;7(1):115–121.
Inglis AJ, Nalos M, Sue KH, Hruby J, Campbell DM, Braham RM, et al. Bedside lung ultrasound, mobile radiography, and physical examination: a comparative analysis of diagnostic tools in the critically ill. Crit Care Resusc 2016;18(2):124.
Parlamento S, Copetti R, Di Bartolomeo S. Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emerg Med 2009;27(4):379–384. DOI: 10.1016/j.ajem.2008.03.009.
Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest 2011;139(5):1140–1147. DOI: 10.1378/chest.10-0435.
Reissig A, Copetti R, Mathis G, Mempel C, Schuler A, Zechner P, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest 2012;142(4):965–972. DOI: 10.1378/chest.12-0364.
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171(4):388–416. DOI: 10.1164/rccm.200405-644ST.
Hindler JF, Stelling J. Analysis and presentation of cumulative antibiograms: a new consensus guideline from the Clinical and Laboratory Standards Institute. Clin Infect Dis 2007;44(6): 867–873. DOI: 10.1086/511864.
Becher RD, Hoth JJ, Rebo JJ, Kendall JL, Miller PR. Locally derived versus guideline-based approach to treatment of hospital-acquired pneumonia in the trauma intensive care unit. Surg Infect (Larchmt) 2012;13(6):352–359. DOI: 10.1089/sur.2011.056.