Clinical features of invasive bronchial-pulmonary aspergillosis in critically ill patients with chronic obstructive respiratory diseases: a prospective study

He Hangyong, Ding Lin, Li Fang, Zhan, Zhan Qingyuan

Description

Critically ill patients with chronic obstructive respiratory diseases (CORD) who require intensive care unit (ICU) admission are at particular risk for invasive bronchial-pulmonary aspergillosis (IBPA). The purpose of this study is to investigate clinical features for rapid recognition of IBPA in critically ill patients with CORD. Methods We included 55 consecutive CORD patients in a respiratory ICU in a prospective, single-center, cohort study. In this study, IBPA combined two entities: ATB and IPA. Results Thirteen of 55 patients were diagnosed with IBPA. Before ICU admission, three variables were independent predictors of IBPA with statistical significance: more than three kinds of antibiotics used before the ICU admission, accumulated doses of corticosteroids (>350 mg) received before the ICU admission, and APACHE II scores >18 (OR, 1.208; P = 0.022; OR, 8.661; P = 0.038; and OR, 19.488; P = 0.008, respectively). After ICU admission, more IBPA patients had a high fever (>38.5°C) (46.2% versus 11.9%; P = 0.021), wheeze without exertion (84.6% versus 50.0%; P = 0.027), dry rales (84.6% versus 40.4%; P = 0.005), higher white blood cell counts (21 × 10 9 /L versus 9.4 × 10 9 /L; P = 0.012), lower mean arterial pressures (77.9 mm Hg versus 90.5 mm Hg; P = 0.019), and serum creatinine clearances (36.2 ml/min versus 68.8 ml/min; P < 0.001), and liver-function and coagulation abnormalities. Bronchospasm, sputum ropiness, and plaque formation were more common for IBPA patients during bronchoscopy (66.7% versus 14.3%; P = 0.082; 18% versus 0; P = 0.169; and 73% versus 13%; P = 0.003, respectively). More IBPA patients had nodules and patchiness on chest radiograph on day 1 of admission, which rapidly progressed to consolidation on day 7. IBPA mortality was higher than that of non-IBPA patients (69.2% versus 16.7%; P = 0.001). Conclusions IBPA may be suspected in critically ill CORD patients with respiratory failure and clinical and bronchoscopic manifestations of severe infection, bronchospasm, and rapid progression of radiologic lesions that are irresponsive to steroids and antibiotics. To avoid misdiagnosis and establish the microbiologic etiology, early bronchoscopy and tight radiologic follow-up should be performed.

Informations

• Publié par: biomed
• Publié le: 01 janvier 2011
• Nombre de lectures: 12
• Langue: English

Extrait

Heet al.Critical Care2011,15:R5 http://ccforum.com/content/15/1/R5

R E S E A R C HOpen Access Clinical features of invasive bronchialpulmonary aspergillosis in critically ill patients with chronic obstructive respiratory diseases: a prospective study 1†1†2 1* Hangyong He, Lin Ding, Fang Li , Qingyuan Zhan

Abstract Introduction:Critically ill patients with chronic obstructive respiratory diseases (CORD) who require intensive care unit (ICU) admission are at particular risk for invasive bronchialpulmonary aspergillosis (IBPA). The purpose of this study is to investigate clinical features for rapid recognition of IBPA in critically ill patients with CORD. Methods:We included 55 consecutive CORD patients in a respiratory ICU in a prospective, singlecenter, cohort study. In this study, IBPA combined two entities: ATB and IPA. Results:Thirteen of 55 patients were diagnosed with IBPA. Before ICU admission, three variables were independent predictors of IBPA with statistical significance: more than three kinds of antibiotics used before the ICU admission, accumulated doses of corticosteroids (>350 mg) received before the ICU admission, and APACHE II scores >18 (OR, 1.208;P= 0.022; OR, 8.661;P= 0.038; and OR, 19.488;P= 0.008, respectively). After ICU admission, more IBPA patients had a high fever (>38.5°C) (46.2% versus 11.9%;P= 0.021), wheeze without exertion (84.6% versus 50.0%;P= 0.027), 9 9 dry rales (84.6% versus 40.4%;P = 0.005), higher white blood cell counts (21 × 10 /L versus 9.4 × 10 /L;P= 0.012), lower mean arterial pressures (77.9 mm Hg versus 90.5 mm Hg;P= 0.019), and serum creatinine clearances (36.2 ml/ min versus 68.8 ml/min;P< 0.001), and liverfunction and coagulation abnormalities. Bronchospasm, sputum ropiness, and plaque formation were more common for IBPA patients during bronchoscopy (66.7% versus 14.3%;P= 0.082; 18% versus 0;P= 0.169; and 73% versus 13%;P= 0.003, respectively). More IBPA patients had nodules and patchiness on chest radiograph on day 1 of admission, which rapidly progressed to consolidation on day 7. IBPA mortality was higher than that of nonIBPA patients (69.2% versus 16.7%;P= 0.001). Conclusions:IBPA may be suspected in critically ill CORD patients with respiratory failure and clinical and bronchoscopic manifestations of severe infection, bronchospasm, and rapid progression of radiologic lesions that are irresponsive to steroids and antibiotics. To avoid misdiagnosis and establish the microbiologic etiology, early bronchoscopy and tight radiologic followup should be performed.

Introduction Aspergillustracheobronchitis (ATB) and invasive pulmon ary aspergillosis (IPA) are two clinical presentations of invasive aspergillosis (IA) [1]. The predisposing factors for ATB and IPA are similar [1,2]. Neutropenic and

* Correspondence: [e-mail] †Contributed equally 1 Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing ChaoYang Hospital, Capital Medical University, 8 Gongren Tiyuchang South Road, Beijing, 100020, PR China Full list of author information is available at the end of the article

immunocompromised patients are particularly at risk. Chronic obstructive respiratory disease (CORD) is defined as chronic obstructive diseases of the airways and pulmon ary tissues. CORD includes a wide array of serious dis eases, and chronic obstructive pulmonary disease (COPD), bronchial asthma, and bronchiectasis are common CORDs [3]. Patients with CORD frequently experience acute exacerbations of their underlying illnesses that require hospitalization or intensive care unit (ICU) admission. Recent reports suggest that the incidence of IA appears to

© 2011 Zhan et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.