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Biomarkers offer the possibility to speed up diagnosis of ventilator-associated pneumonia (VAP) and differentiate it from nonpulmonary infection. One such marker, the triggering receptor expressed on myeloid cells-1 (TREM-1), exists as a soluble protein and a surface receptor expressed on monocytes and neutrophils [1]. The purpose of the study was to determine the diagnostic utility of surface TREM-1 levels in VAP.

Background Measures of oxygenation are traditionally used to monitor the progress of patients on positive pressure ventilation. Although CO2 elimination depends on fewer variables, measures of CO2 elimination are comparatively overlooked except when monitoring patients who are difficult to ventilate. CO2 elimination is dependent upon CO2 production and alveolar ventilation, which together determine Pa co 2. Alveolar ventilation is the efficient portion of minute ventilation (‘E’). In the clinical setting, problems with CO2 elimination are observed as increasing Pa co 2, increasing minute ventilation, or both. In conventional tests of respiratory function, actual measurements are frequently compared with predicted measurements. However, this approach has rarely been applied to the measurement of ventilatory efficiency. Methods We have developed a ratio, called the ventilatory ratio (VR), which compares actual measurements and predicted values of minute ventilation and Pa co 2. VR = V ˙ E measured × P a CO 2 m e a s u r e d V ˙ E predicted × P a CO 2 p r e d i c t e d V ˙ E predicted is taken to be 100 (ml kg−1 min−1) based on predicted body weight, and Pa co 2predicted is taken to be 5 kPa. Results Inspection shows VR to be a unitless ratio that can be easily calculated at the bedside. VR is governed by carbon dioxide production and ventilatory efficiency in a logically intuitive way. We suggest that VR provides a simple guide to changes in ventilatory efficiency. A value close to 1 is predicted for normal individuals and an increasing value would correspond with worsening ventilation, increased CO2 production, or both. Conclusions VR is a new tool providing additional information for clinicians managing ventilated patients.

To determine whether clinicians' prognoses in patients with severe acute exacerbations of obstructive lung disease admitted to intensive care match observed outcomes in terms of survival.Prospective cohort study.92 intensive care units and three respiratory high dependency units in the United Kingdom.832 patients aged 45 years and older with breathlessness, respiratory failure, or change in mental status because of an exacerbation of COPD, asthma, or a combination of the two.Outcome predicted by clinicians. Observed survival at 180 days.517 patients (62%) survived to 180 days. Clinicians' prognoses were pessimistic, with a mean predicted survival of 49% at 180 days. For the fifth of patients with the poorest prognosis according to the clinician, the predicted survival rate was 10% and the actual rate was 40%. Information from a database covering 74% of intensive care units in the UK suggested no material difference between units that participated and those that did not. Patients recruited were similar to those not recruited in the same units.Because decisions on whether to admit patients with COPD or asthma to intensive care for intubation depend on clinicians' prognoses, some patients who might otherwise survive are probably being denied admission because of unwarranted prognostic pessimism.

Background: Multiple organ dysfunction syndrome is the commonest reason for sepsis-associated mortality. Discussion: In the 40 years since it was first described understanding of its pathophysiology has improved, and novel methodologies for monitoring and severity of illness scoring have emerged. These, together with the development of systematic strategies for managing organ dysfunction in sepsis, and potentially effective new therapeutic interventions, should assist in reducing sepsis-associated mortality. Conclusion: These historical developments are discussed, and the reader is directed to these references for further guidance.

This new guideline covers the rapidly advancing field of interventional bronchoscopy using flexible bronchoscopy. It includes the use of more complex diagnostic procedures such as endobronchial ultrasound, interventions for the relief of central airway obstruction due to malignancy and the recent development of endobronchial therapies for chronic obstructive pulmonary disease and asthma. The guideline aims to help all those who undertake flexible bronchoscopy to understand more about this important area. It also aims to inform respiratory physicians and other specialists dealing with lung cancer of the procedures possible in the management and palliation of central airway obstruction. The guideline covers transbronchial needle aspiration and endobronchial ultrasound-guided transbronchial needle aspiration, electrocautery/diathermy, argon plasma coagulation and thermal laser, cryotherapy, cryoextraction, photodynamic therapy, brachytherapy, tracheobronchial stenting, electromagnetic navigation bronchoscopy, endobronchial valves for emphysema and bronchial thermoplasty for asthma.

Introduction Biomarkers have been investigated in order to speed up diagnosis of VAP, a common condition in ICU patients. TREM-1 is a protein involved in amplification of immune responses to bacterial and fungal infection and exists as soluble and surface forms.1 2 The diagnostic value of soluble TREM-1 in broncho-alveolar lavage fluid (BALF) in VAP is controversial.[3][1] Therefore the utility of surface TREM-1 for diagnosing VAP in a two-compartment model (BALF and blood) was investigated. Methodology Paired blood and BALF were obtained in consenting patients in the following groups: (1) Ventilated patients with VAP diagnosed on semi-quantitative microbiology and Clinical Pulmonary Infection Score (CPIS); (2) Ventilated patients without sepsis; (3) Day-case bronchoscopy patients without evidence of infection. Flow cytometry was performed on cell pellets derived from simultaneous BALF and blood samples. Surface TREM-1, CD11b (immune cell activation marker) and L-selectin (immune cell migration marker) levels were measured on monocytes and neutrophils. At the same time an inflammatory cytokine panel (comprising IL-1β, IL-6, IL-8 and soluble TREM-1) was measured by ELISA in the paired blood and BALF samples. Results Expression of TREM-1 and CD11b on monocytes were significantly elevated in BALF samples obtained from the VAP patient group. There was no change in blood surface TREM-1 and CD11b levels between the different patient groups. The BALF/blood ratio of monocytic TREM-1 increased the discrimination between the VAP and non-VAP groups ([Abstract S77 Figure 1][2]). Soluble TREM-1 levels were not significantly different between the groups. There was no difference in peripheral blood white cell count, CRP, expression of CD11b, L-selectin and inflammatory cytokines between VAP and disease controls. ![Abstract S77 Figure 1][3] Abstract S77 Figure 1 The ratio monocytic surface TREM-1 between BALF and blood (flow cytometry). 16 patients with VAP are compared with 8 ventilated non-septic control (VC) and 17 non-ventilated non-infected control patients (NVC). The median levels and IQRs are: VAP (0.92, 0.66–1.77), VC (0.21, 0.12–0.28) and NVC (0.36, 0.22–0.41). * and # p=0.0001. Conclusion The BALF/blood ratio of monocytic surface TREM-1 discriminates between the VAP and non-VAP groups. Measurement of surface TREM-1 using a two-compartment index may have utility in diagnosing VAP. [1]: #ref-3 [2]: #F1 [3]: pending:yes

Sampling from blood has been performed for over 200 years. However clinically useful arterial blood gas sampling became a reality after the development of robust methods for measuring oxygen tension from humans in the 1940s. Thus the development of the Clark electrode and subsequent safe tools for sampling plasma, heralded an era of blood sampling, and analysis from which we have not looked back. [1] As with many new medical technologies of their time, it was borne out of a combination of the need for investigational improvements, inventive spirit and serendipity. Arterial Blood gas sampling has been the standard of care for monitoring acid-base disturbance for decades - a testimony to its value in diverse settings. Despite this, concerns remain regarding its risks to the patient from repeated same site sampling. [2] This in part led to the alternative approach of arterialized blood samples (AzB), using either an earlobe or Þ nger pulp skin prick. [3] In theory AzB are more easily obtained than ABG, repeatable with better patient tolerance, and accurate. Thus it was surprising to know of the relatively poor uptake of this technique in the ambulatory setting. [4] Despite better utilisation in the UK, ongoing concerns regarding equipment, reliability and accuracy hamper its wider use. [5]

The acute respiratory distress syndrome (ARDS) is characterized by refractory hypoxemia in the presence of bilateral pulmonary infiltrates on chest radiography1. It was recognised that ARDS probably represents only the extreme manifestation of a range of pulmonary insults. Hence, acute lung injury (ALI) was similarly defined but with less severe indices of hypoxemia (Table 1). A wide variety of serious medical and surgical conditions can precipitate the syndrome, only some of which involve the lung (Table 2). Although the mortality associated with ARDS has fallen in recent years (from approximately 70% to 50%) in a number of large centres, it is undoubtedly influenced by the underlying pathology. Furthermore, epidemiological studies have suggested for many years that the majority of patients succumb not to refractory hypoxemia, but rather to sepsis and associated multiple organ failure (MOF). MOF is defined by a constellation of symptoms and clinical signs of which multiple organs (e,g, kidney, heart, GIT, etc) are in a state of dysfunction or failure. Indeed, given that respiratory failure accounts for only 16% of ARDS deaths, improvements in outcome of ARDS may depend more on treatment of sepsis and further understandingJprevention of MOF than on improvements in oxygenation and pulmonary haemodynamics2,3.

In adults, lung injury may complicate a wide range of serious medical and surgi-cal conditions, only some of which involve a direct pulmonary insult (Table 1).

Sepsis and spontaneous bacterial peritonitis (SBP) are common sequelae in patients with cirrhosis. Cirrhotics admitted to the ICU have an in-hospital mortality of up to 50% [1]. Microbial translocation (MT) is the pathogenic mechanism implicated in SBP. The triggering receptor expressed by myelocytes-1 (TREM-1) modulates the immune response with resultant production of proinflammatory cytokines and has been used as a biomarker in the diagnosis of bacterial infection. We wish to evaluate the role of TREM-1 as a biomarker in cirrhosis.

Background The predominant pathophysiology in severe emphysema with gas trapping and hyperinflation is that of dynamic airway collapse on minimal expiratory effort. This limits the benefit from drug therapy. Safer and cheaper alternatives to lung volume reduction surgery (LVRS), which has success in selected patients with low exercise capacity and upper lobe-predominant emphysema, are being developed. Endobronchial valve treatment has been shown to be beneficial to patients with heterogenous disease in the absence of collateral ventilation. RePneu Lung Volume Reduction Coils (LVRCs) are self-actuating implantable devices composed of nitinol. They are implanted bronchoscopically using conscious sedation. The LVRC is delivered into targeted airways using fluoroscopic guidance, and when its sheath is removed recoils to it original pre-determined shape. Methods In a prospective randomised study of LVRCs on patients with severe emphysema and hyperinflation, 63 patients were screened at 3 centres in the United Kingdom with 23 randomised to treatment with LVRCs and 24 to best medical care (control). LVRC patients were initially treated in one lung, with the contralateral lung treated after one month if appropriate. The primary end point was the difference between treatment and control groups in the St. George’s Respiratory Questionnaire (SGRQ) 90 days post-final treatment. The trial is registered with ClinicalTrials.gov (NCT01334307). Results Significant improvements in the treatment group compared to control group were observed for the primary end point mean SGRQ (Δ-10.54 points, p=0.004), as well as secondary end points mean six-minute walk distance (Δ+70.39 metres, p Conclusions Treatment with endobronchial coils in patients with severe emphysema and hyperinflation significantly improves quality of life, exercise capacity and pulmonary function with a good safety profile. LVRCs present a novel, safe, and minimally invasive treatment option for patients with both homogenous and heterogenous emphysema, with benefits unaffected by collateral ventilation. A larger randomised controlled pivotal trial with longer follow-up is now needed. Funding shared by PneumRx and study sites.

A 12-bed ICU experienced an outbreak of multiresistant Acinetobacter baumannii (MRA) from October 2009 to May 2010. A multifaceted strategy involving segregation, enhanced infection control procedures, and microbiological surveillance was implemented. We evaluated its impact on antibiotic stewardship.

Summary Ulcerative colitis has a number of associated skin lesions. We report the case of a patient with active ulcerative disease presenting with rapidly progressive necrotic skin lesions, identified as thrombotic and requiring skin grafting. Thrombotic cutaneous gangrene is a rare but potentially serious manifestation of uncontrolled ulcerative colitis.

The pathogenesis of cryptogenic fibrosing alveolitis (CFA) involves injury, an immune/inflammatory response and fibrosis. The cause of the injury is unknown, but the identification of serum autoantibodies makes an autoimmune aetiology attractive. The core study on which this commentary is based used novel cloning and serum screening technologies in order to identify new public and private autoantibodies in sera from 12 patients with CFA. Largely negative conclusions were drawn from that study. However, we suggest that the prevalence of autoantibodies may have been underestimated, that the study was timely and that this approach is worth pursuing further.

Additional file 4. Survey Report 2.

Additional file 5. Survey Report 3.

Additional file 3. Survey Report 1.

Additional file 5. Survey Report 3.

Additional file 4. Survey Report 2.

Additional file 1. Search Strategy and Selection Criteria.

Additional file 2. Details and Results of the Delphi process.

Additional file 6. Survey Report 4.

Additional file 1. Search Strategy and Selection Criteria.

Additional file 3. Survey Report 1.

Additional file 6. Survey Report 4.

Additional file 2. Details and Results of the Delphi process.