Intensive Care Management in the Immunocompromised Patients with Severe Pulmonary Infection = Intensive Care Management in the Immunocompromised Patients with Severe Pulmonary Infection
저자
발행기관
대한결핵 및 호흡기학회(The Korean Academy of Tuberculosis and Respiratory Diseases)
학술지명
권호사항
발행연도
2021
작성언어
-주제어
KDC
500
자료형태
학술저널
수록면
238-239(2쪽)
제공처
The proportion of critically ill patients with immune deficiency has risen in recent years to about a third of patients admitted to medical intensive care unit (ICU). Severe pulmonary infection is the leading cause for ICU admission in immunocompromised patients, are often life threatening and associated with hypoxemic acute respiratory failure (ARF), resulting in mortality. Therefore, rapid and accurate diagnosis with extensive investigations and proper respiratory support for hypoxemia caused by pulmonary infection is a major cornerstone for the intensive care of immunocompromised patients with severe pulmonary infection. In this symposium, diagnostic strategy and respiratory management in immunocompromised patients with severe pulmonary infection will be discussed.
Existing guidelines for managing pulmonary infections in critically ill immunocompromised patients emphasize the importance of obtaining valid samples for the diagnosis of infection. However, antimicrobial therapy is often started immediately, before adequate samples are collected. As a result, causative microorganisms are identified in only about half the patients even with bacterial pneumonia. Therefore, a detailed analysis of the clinical, laboratory, and radiologic findings would be needed, which can provide valuable diagnostic orientation in these cases. Nevertheless, the frequency of pulmonary infection is probably underestimated as signs and symptoms of infection may be subtle as a result of blunted immune response. On the other hand, non-infectious pulmonary abnormalities may be mistakenly diagnosed as clinically presumed infections. Therefore, the etiological diagnosis can be extremely challenging especially in critically ill immunocompromised patients, as the effects of pulmonary infection can be combined with those of the underlying disease and treatments, creating extraordinarily complicated clinical features. In addition, some patients have more than one concurrent infection, and others have non-infectious causes of ARF that mimic infection.
Chest radiography is the preferred initial diagnostic imaging examination in the ICU for evaluation of suspected pulmonary infection in immunocompromised patients. Due to the blunted host immune response, however, radiographic findings may be subtle or occult until more widespread infection has developed. Computed tomography (CT) using thin-section provides superior resolution and can better characterize and localize radiographic abnormalities. In addition, CT scan is helpful in differentiating infectious from non-infectious cause. Furthermore, bronchoalveolar lavage and transbronchial lung biopsy are commonly used for diagnosis even in the ICU, but may cause further respiratory deterioration in patients with mechanical ventilation (MV) support. However, first-line bronchoalveolar lavage should be considered in which patients have a possible diagnosis of atypical pulmonary infections, such as CMV or Pneumocystis pneumonia. Non-invasive diagnostic tests offer an alternative to bronchoalveolar lavage, however, these tests are more sensitive than specific, and the clinical relevance of a positive PCR is sometimes uncertain.
Over the past two decades, studies have consistently shown higher mortality in immunocompromised patients who required invasive MV. Therefore, priority has been given to avoidance of invasive MV by use of non-invasive devices. However, a recent multicenter RCT showed that failure of non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) was associated with higher mortality, and previous studies even suggested that early invasive MV was associated with improved survival. These data raise concerns about the use of NIV or HFNC in immunocompromised patients with hypoxemic acute respiratory failure. Therefore, response of patients to HFNC or NIV should be carefully assessed in immunocompromised patients with respiratory failure caused by severe pulmonary infection.
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