title: Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management.
abstract: BACKGROUND
  Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may, therefore, influence ventilator-associated pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation.
  
  
  METHODS
  We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization, using specific competing-risk methods (the Fine and Gray model).
  
  
  RESULTS
  Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual-care group vs 14 (9.2%) in the interventional group (P = .03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event (subhazard ratios [25th-75th percentiles], 0.44 [0.22-0.87], P = .02 and 0.50 [0.25-0.96], P = .03, respectively).
  
  
  CONCLUSIONS
  Using proper competing risk analyses, we found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP risk in patients who are mechanically ventilated.
  
  
  BACKGROUND
  ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov.
authors.affiliation: Service de Réanimation Médicale, AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Faculté de Médecine, Université Paris Est Créteil, Créteil, F-94010, France; INSERM, Unité U955, Créteil, F-94010, France. Electronic address: armand.dessap@hmn.aphp.fr.
authors.forename: Armand
authors.initials: A
authors.lastname: Mekontso Dessap
authors.affiliation: Unité de Recherche Clinique, AP-HP, CHU Henri Mondor, Créteil, F-94010, France.
authors.forename: Sandrine
authors.initials: S
authors.lastname: Katsahian
authors.affiliation: Service de Réanimation Médicale, AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain.
authors.forename: Ferran
authors.initials: F
authors.lastname: Roche-Campo
authors.affiliation: Unité de Recherche Clinique, AP-HP, CHU Henri Mondor, Créteil, F-94010, France.
authors.forename: Hugo
authors.initials: H
authors.lastname: Varet
authors.affiliation: Service de Réanimation Médicale, CHU d'Angers, Angers, France.
authors.forename: Achille
authors.initials: A
authors.lastname: Kouatchet
authors.affiliation: Departamento de Paciente Crítico, Clinica Alemana, Santiago de Chile, Chile.
authors.forename: Vinko
authors.initials: V
authors.lastname: Tomicic
authors.affiliation: Service de Réanimation Médicale and UPRES-EA 3830, CHU de Rouen, Rouen, France.
authors.forename: Gaetan
authors.initials: G
authors.lastname: Beduneau
authors.affiliation: Service de Réanimation Médicale et des Maladies Infectieuses, AP-HP, CHU Bichat-Claude Bernard, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France.
authors.forename: Romain
authors.initials: R
authors.lastname: Sonneville
authors.affiliation: Réanimation DAR B, CHU Saint Eloi, INSERM U1046, Montpellier, France.
authors.forename: Samir
authors.initials: S
authors.lastname: Jaber
authors.affiliation: Service de Réanimation Médicale, AP-HP, CHU Saint Louis, Paris, France.
authors.forename: Michael
authors.initials: M
authors.lastname: Darmon
authors.affiliation: Service de Soins Intensifs, Hôpital Universitaire Saint-Luc, Bruxelles, Belgium.
authors.forename: Diego
authors.initials: D
authors.lastname: Castanares-Zapatero
authors.affiliation: Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Laurent
authors.initials: L
authors.lastname: Brochard
authors.affiliation: Service de Réanimation Médicale, AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Faculté de Médecine, Université Paris Est Créteil, Créteil, F-94010, France; INSERM, Unité U955, Créteil, F-94010, France.
authors.forename: Christian
authors.initials: C
authors.lastname: Brun-Buisson
mesh_terms: D000368:Aged; D004232:Diuretics / Q000627:therapeutic use*; D005060:Europe / Q000453:epidemiology; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy; D012121:Respiration, Artificial / Q000009:adverse effects*; D013020:South America / Q000453:epidemiology; D016896:Treatment Outcome; D015300:Ventilator Weaning / Q000379:methods*
chemical_list: D004232:Diuretics