Evaluation of ICU Admission Criteria and

Diagnostic Methods for Patients With Severe

Community-Acquired Pneumonia : Current
Practice Survey
Marcos I. Restrepo, Thomas Bienen, Eric M. Mortensen, Antonio
Anzueto, Mark L. Metersky, Patricio Escalante, Richard G. Wunderink
and Bonita T. Mangura

Chest 2008;133;828-829
DOI 10.1378/chest.07-2887
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services can be found online on the World Wide Web at:
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advances in software will make the procedure used in our study
more popular. We appreciate the valuable comments by Dr.
Detterbeck.
Hiroaki Nomori, MD, PhD
Koei Ikeda, MD, PhD
Kazuo Awai, MD, PhD
Takeshi Mori, MD, PhD
Koichi Kawanaka, MD
Yasuyuki Yamashita, MD, PhD
Graduate School of Medical Sciences
Kumamoto University
Kumamoto, Japan
The authors have no conflicts of interest to disclose.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Hiroaki Nomori, MD, PhD, Department of
Thoracic Surgery, Kumamoto University, 1-1-1 Honjo, Kum-
amoto 860-8556, Japan; e-mail: hnomori@qk9.so-net.ne.jp
DOI: 10.1378/chest.07-2706
Reference
1 Ikeda K, Awai K, Mori T, et al. Differential diagnosis of
ground-glass opacity nodules: CT number analysis by three-
dimensional computerized quantification. Chest 2007; 132:
984 –990
Premature Atrial Contraction as an
Etiology for Cough
To the Editor:
Comprehensive contemporary reviews1 of cough do not in-
clude cardiac arrhythmia as a potential cause of unexplained
cough, although cough itself has been described as a cause for
tachyarrhythmia.2,3 I have encountered three patients recently
with a clinical history of cough immediately following a palpita-
tion. During echocardiography, these patients were seen to have
a single premature atrial contraction (PAC) prior to a cough,
which reproduced their symptoms. The patients’ histories all
include a description of the cough as reflexive after feeling a
“thump” in the chest, with an inability to stifle the cough. None
of the patients were receiving angiotensin-converting enzyme
inhibitors or had any other recognized etiology for cough. One of
these patients had complete resolution of cough when his PACs
resolved. I have not yet demonstrated the recurrence of the
cough through withholding treatment for PAC. A literature
review and an Internet search reveal no prior descriptions of
PACs in association with cough; there has been one recent case
report4 of chronic cough induced by premature ventricular
contractions.
In discussing this observation with colleagues, several physi-
cians have noticed a similar association between cough and PACs,
including two cardiologists who report experiencing it them-
selves. I suspect that if more clinicians look for this association
and query patients appropriately, the connection may be quite
frequent. The association of cough and asthma,5 as well as cough
and gastroesophageal reflux disease,6 were not commonly recog-
nized prior to landmark case reports on these phenomena.
The phrenic nerve is adjacent to the left atrium in close
proximity to the entry of the upper pulmonary veins. The nerve
has been documented in dog studies to be damaged in some
828
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© 2008 American College of Chest Physicians
instances of atrial fibrillation ablation.7 Patients sometimes cough
during atrial fibrillation ablation procedures as well. It is possible
that a PAC arising in the portion of the atrium near the phrenic
nerve triggers the cough reflex in susceptible patients. Extrapul-
monary vagal afferent C-fibers and rapidly adapting stretch
receptors8 may also be stimulated somehow by PACs. It is also
possible that this is a subtype of habit cough, triggered by
palpitations from PACs. The recent case report4 on premature
ventricular contraction-induced cough notes a transient increase
in pulmonary artery blood flow as another possible mechanism.
Sharing this observation may lead to further recognition of the
association, as well as to research on the prevalence, pathophys-
iology, and treatment of this potential PAC/cough syndrome. In
addition, there may be patients whose cough is due to otherwise
asymptomatic PACs.
Neil Brandon, MD
South County Cardiology Associates
Wakefield, RI
The author has no conflict of interest to disclose.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Neil Brandon, MD, South County Cardiology
Associates, 70 Kenyon Ave, Suite 103, Wakefield, RI 02879;
e-mail: brandon@southcountycardiology.com
DOI: 10.1378/chest.07-2059
References
1 Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and
management of cough: ACCP evidence-based clinical prac-
tice guidelines. Chest 2006; 129:1S–292S
2 Omori I, Yamada C, Inoue D, et al. Tachyarrhythmia
provoked by coughing and other stimuli. Chest 1984;
86:797–799
3 Irwin RS. Complications of cough. Chest 2006; 129:54S–58S
4 Stec S, Dabrowski M, Zaborska B, et al. Premature ventric-
ular complex-induced chronic cough and cough syncope. Eur
Respir J 2007; 30:391–394
5 Corrao WM, Braman SS, Irwin RS. Chronic cough as the sole
presenting manifestation of bronchial asthma. N Engl J Med
1979; 300:633– 637
6 Irwin RS, Zawacki JK, Curley FJ, et al. Chronic cough as the
sole presenting manifestation of gastroesophageal reflux. Am
Rev Respir Dis 1989; 140:1294 –1300
7 Bunch TJ, Bruce GK, Mahapatra S, et al. Mechanisms of
phrenic nerve injury during radiofrequency ablation of the
pulmonary vein orifice. Cardiovasc Electrophysiol 2005; 16:
1318 –1325
8 Canning BJ, Mori N, Mazzone SB. Vagal afferent nerves
regulating the cough reflex. Respir Physiol Neurobiol 2006;
152:223–242
Evaluation of ICU Admission Criteria
and Diagnostic Methods for Patients
With Severe Community-Acquired
Pneumonia
Current Practice Survey
To the Editor:
Community-acquired pneumonia (CAP) is a common disease
seen in clinical practice. Various professional societies have
released guidelines1,2 regarding criteria for ICU admission and
appropriate diagnostic testing after admission.
Correspondence
 We e-mailed self-administered surveys to American College of
Chest Physicians members (in the Chest Infections and Critical
Care Network) in 2004 to elucidate which of these admission
guidelines and diagnostic criteria are utilized in practice.
The first questionnaire asked physicians which of the following
ICU admission criteria they use: American Thoracic Society
(ATS) 1993 and 2001,1 British Thoracic Society (BTS) CURB or
CURB-65,1 pneumonia severity index (PSI) class IV and V,3
APACHE (acute physiology and chronic health evaluation) II or
III, and simplified acute physiology score (SAPS) of 1 or 2.4 We
compared academic vs nonacademic practitioners.
The second questionnaire involved diagnostic testing.1,2 We
compared academic vs nonacademic clinicians and whether they
work in closed vs open ICUs.
Three hundred ninety-three questionnaires (19%) were re-
turned. The most commonly stated admission criteria used were
as follows: ATS 2001, 50%; APACHE II or III, 28%; and PSI
class V, 27%. Responders were aware of SAPS (74%), ATS 1993
(68%), and APACHE (67%) but did not use them in clinical
practice; 77% and 72% of responders were not aware or did not
use the CURB and CURB-65 criteria, respectively. Differences
were found when comparing academicians (n ⫽ 182) vs nonaca-
demicians (n ⫽ 203). Academicians preferred the BTS guidelines
(63% vs 51%, p ⫽ 0.04), PSI class IV (69% vs 56%, p ⫽ 0.02),
and SAPS (87% vs 71%, p ⬍ 0.01).
The most common diagnostic tests selected for ICU patients
with pneumonia were blood cultures (97%), sputum Gram stain
(83%), Legionella urinary antigen (77%), and endotracheal aspi-
rate (76%). Academic physicians ordered more endotracheal
aspirates (79% vs 68%, p ⫽ 0.03) and Legionella cultures (37% vs
27%, p ⫽ 0.05) but fewer serologic tests for atypical pathogens
(34% vs 46%, p ⫽ 0.03). Physicians working in closed ICUs
(n ⫽ 159) ordered more blood cultures (99% vs 93%, p ⫽ 0.01)
and Legionella sputum cultures (39% vs 26%, p ⫽ 0.01) than
those working in open ICUs (n ⫽ 224).
It is evident that practice environment (academia vs private
practice) has an effect on which ICU admission guidelines are
followed.1,2 In addition, different diagnostic tests were ordered
in open vs closed ICUs. This suggests that additional educa-
tion and research are needed for severely ill CAP patients
admitted to the ICU.
Marcos I. Restrepo, MD, MSc, FCCP
Thomas Bienen, MD
Eric M. Mortensen, MD, MSc
Antonio Anzueto, MD, FCCP
Mark L. Metersky, MD, FCCP
Patricio Escalante, MD, MSc, FCCP
Richard G. Wunderink, MD, FCCP
Bonita T. Mangura, MD, FCCP
On Behalf of the Chest Infections Network
American College of Chest Physicians
The authors have no conflicts of interest to disclose.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Marcos I. Restrepo, MD, MSc, FCCP, South
Texas Veterans Health Care System, Audie L. Murphy Division,
7400 Merton Minton Blvd (11c6), San Antonio, TX; e-mail:
RESTREPOM@uthscsa.edu
DOI: 10.1378/chest.07-2887
References
1 Mandell LA, Wunderink RG, Anzueto A, et al. Infectious
Diseases Society of America/American Thoracic Society
consensus guidelines on the management of community-
acquired pneumonia in adults. Clin Infect Dis 2007; 44:S27–
S72
www.chestjournal.org
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© 2008 American College of Chest Physicians
2 Woodhead M, Blasi F, Ewig S, et al. Guidelines for the
management of adult lower respiratory tract infections. Eur
Respir J 2005; 26:1138 –1180
3 Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to
identify low-risk patients with community-acquired pneumo-
nia. N Engl J Med 1997; 336:243–250
4 Herridge MS. Prognostication and intensive care unit out-
come: the evolving role of scoring systems. Clin Chest Med
2003; 24:751–762
Electromagnetic Navigation
Diagnostic Bronchoscopy and
Transbronchial Biopsy
To the Editor:
We read the article by Eberhardt et al1 (June 2007) with a lot
of interest. The authors1 concluded that electromagnetic naviga-
tion diagnostic bronchoscopy (EMN) can be used as a stand-
alone bronchoscopic technique without compromising diagnostic
yield or increasing the risk of pneumothorax. In contrast to
fluoroscopic guidance, the technique is not associated with
radiation exposure, and the overall diagnostic yield reported for
EMN1,2 is superior to rates reported previously for small periph-
eral pulmonary nodules with bronchoscopy.3,4 Thus, EMN may
improve the diagnostic yield of transbronchial biopsy.
We seek the opinion of the authors on the following issues in
order to further refine this technique. First, it is not yet clear
whether the initial choice of registration points can improve
further the diagnostic yield of EMN. Although in the study by
Eberhardt et al1 the registration process did not affect diagnostic
accuracy, in a recent investigation2 diagnostic accuracy was
affected by registration error. We believe that there should be
some criteria regarding the number and characteristics of regis-
tration points, especially in cases where registration error is
important (as in the case of 34 patients in the study by Eberhardt
et al1). These criteria could be defined by scientific consensus
based on published evidence.
Second, in a study2 that assessed EMN without additional
guidance, there was no difference in terms of diagnostic accuracy
between bronchoscopists. Is this also the case in the study by
Eberhardt et al,1 especially considering that two centers partici-
pated in this investigation? In addition, was there a learning
curve? If yes, an active participation of pulmonologists in educa-
tional courses should be greatly encouraged. Third, we would
appreciate it if the authors could provide some additional data
regarding the mean distance between the center of the lesion and
the visceral pleura, so that we can have a better description of
lesion characteristics.
Demosthenes Makris, MD
University Hospital
Heraklion, Greece
Konstantinos I. Gourgoulianis, MD
University of Thessaly Medical School
Thessaly, Greece
Dr. Makris received 2,000 Euros for direction of a Super
Dimension (Europe) GmbH clinical course in Germany.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Demosthenes Makris, MD, University Hos-
pital, Voutes Heraklion, Heraklion, Greece 74110; e-mail:
appollon7@hotmail.com
DOI: 10.1378/chest.07-1754
CHEST / 133 / 3 / MARCH, 2008 829
 Evaluation of ICU Admission Criteria and Diagnostic Methods for
Patients With Severe Community-Acquired Pneumonia : Current
Practice Survey
Marcos I. Restrepo, Thomas Bienen, Eric M. Mortensen, Antonio Anzueto,
Mark L. Metersky, Patricio Escalante, Richard G. Wunderink and Bonita T.
Mangura
Chest 2008;133; 828-829
DOI 10.1378/chest.07-2887
This information is current as of March 21, 2011
Updated Information & Services
Updated Information and services can be found at:
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References
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