Abstract
Objective
To evaluate the diagnostic value of gallium-67 scintigraphy in febrile ventilated patents by correlating the findings of67Ga scintigraphy to sources of fever and pulmonary density, as determined by a comprehensive protocolized diagnostic evaluation.
Design
Prospective observational study.
Patients
Thirty-two intubated patients on mechanical ventilation for ≥3 days with fiver (≥38.3°C) and a new or progressive density on chest radiograph. Twenty patients (21 tests) had adult respiratory distress syndrome (ARDS).
Intevention
Diagnostic evaluation for fever included bronchoscopy with protected specimen brushing and (protected) bronchoalveolar lavage (BAL); computed tomography (CT) of sinuses; cultures of blood, urine, and central lines; and CT of the abdomen in high-risk patients.
Measurements and results
Uptake of67Ga was reported as either focal or diffused pulmonary uptake and extrapulmonary uptake. The combined causes of fever were pneumonia (9), fibroproliferation of late ARDS (7), abdominal process (4), sinusitis (4), urinary tract infection (3), and others (6). Causes of the pulmonary densities were pneumonia (9), ARDS (13), atelectasis (7), congestive heart failure (3), and empyema (1). Marked and diffused pulmonary uptake was found only in patients with ARDS; however, it was not useful in discriminating those patients with pulmonary fibroproliferation as the sole cause of fever (p=0.167) from those with infection.67Ga scintigraphy was inadequate for detecting pneumonia but valuable in identifying extrapulmonary sites of infection in patients with ARDS (p=0.021).
Conclusions
67Ga scintigraphy should be considered only as an adjunct diagnostic test in the febrile, ventilaged patients who has no obvious source of fever, despite a negative evaluation that includes testing for pneumonia, sinusitis, and urinary tract infection, conditions that are rarely detected by67Ga scintigraphy.
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References
Andrews CP, Coalson JJ, Smith JD, Johanson WG Jr (1981) Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury. Chest 80:254–258
Bell RC, Coalson JJ, Smith JD, Johanson WG Jr (1983) Multiple organ system failure and infection in adult respiratory distress syndrome. Ann Intern Med 99: 293–298
Ashbaugh DG, Petty TL (1972) Sepsis complicating the adult respiraotyr distress syndrome. Surg Gynecl Obstet 135: 865–868
Seidenfield JJ, Pohl DF, Bell RC, Harris GD, Johanson WG Jr (1986) Incidence, site, and outcome of infections in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 134:12–16
Johanson WG Jr, Higuchi JH, Woods DE, Gomez P, Coalson JJ (1985) Dissemination of Pneusdomonas aeruginosa during lung infection in hamsters: role of oxygeninduced infection in hamsters: role of oxygeninduced lung injury. Am Rev Respir Dis 132:358–361
Montgomery AB, Stager MA, Carrico CJ, Hudson LD (1985) Causes of mortality in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 132: 485–489
Chastre J, Viau F, Brun P, Pierre J, Dauge MC, Couchama A, Akesbi A, Gibert C (1984) Prospective evaluation of the protected specimen brush for the diagnosis of pulmonary infections in ventilated patients. Am Rev Respir Dis 130:924–929
Meduri GU, Belenchia JM, Estes RJ, Leeper KV, Wunderink RG (1991) Fibroproliferative phase of ARDS: clinical findings and effects of corticosteroids. Chest. 100:943–952
Meduri GU, Chinn AJ, Leeper KV et al (1994) Corticosteroid rescue treatment of progressive fibroproliferation in late ARDS. Patterns of response and predictors of outcome. Chest 105:1516–1527
Fagon JY, Chastre J, Hance AJ, Guiget M, Troullet JL, Domart Y, Pierre J, Gibert C (1988) Detection of nosocomial lung infection in ventilated patients: use of a protected specimen brush and quantitative culture techniques in 147 patients. Am Rev Respir Dis 138:110–116
Fagon JY, Chastre J, Hance AJ, Domart Y, Trouillet JL, Gibert C (1993) Evaluation of clinical judgement in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest 103:547–553
Meduri GU, Wunderink RG, Leeper KV, Beals DH (1992) Management of bacterial pneumionia in ventilated patients: the role of protected bronchoalveolar lavage. Chest 101:500–508
Winer-Muram HT, Rubin SA, Ellis JV, Jennings SG, Arheart KL, Leeper KV, Wunderink RG, Meduri GU (1993) Penomonia and ARDS in the ventilated patient: diagnostic accuracy of the chest radiograph. Radiology 188:479–485
Torres A, Aznar R, Gatell JM, Jimenez P, Gonzalez J, Ferrer A, Celis R, Rodriquez-Roisin R (1990) Incidence, risk, and prognosis factors of nosocomial penumonia in mechanically ventilated patients. Am Rev Respir Dis 142:523–528
Meduri GU, Mauldin GL, Wunderink RG, Leeper KV, Jones C, Tolley E, Mayhall G (1994) Causes of fever and pulmonary densities in patients with clinical mainifestations of ventilator-associated pneumonia. Chest 106:221–233
Fowler AA, Hamman RF, Zerbe GO, Benson KN, Hyers TM (1985) Adult respiratory distress syndrome: prognosis after onset. Am Rev Respir Dis 132:472–478
Meduri GU, Beals D, Maijub G, Baselski V (1991) Protected bronchoalveolar lavage: a new bronchoscopic technique to retrieve uncontaminated distal airway serections. Am Rev Respir Dis 143:855–864
Lavender JP, Lowe JR et al (1971) Gallium67-citrate scanning in neoplastic and inflammatory lesions. Br J Radiol 44: 361–366
Tsan MF (1985) Mechanism of gallium67-accumulation in inflammatory lesions. J Nucl Med 26:88–92
Bégin R, Caton A, Drapeau G, Lamoureux G, Boctor M, Massé S, Rola-Pleczczynski M (1983) Pumonary uptake of gallium-67 in absestos-exposed humans and sheep. Am Rev Respir Dis 127:623–630
Staab EV, McCartney WH (1978) Role of gallium67 in inflammatory disease. Semin Nucl Med 8:219–234
Niden AH, Mishkin FS, Khurana MML (1976)67Gallium citrate lung scans in intestitial lung disease. Chest 69:266–268
Siemens JK, Grebe SF, Waxman AD (1978) The use of gallium67- in pulmonary disorders. Sem Nucl Med 8:235–249
Thadepalli H, Rambhatla K, Mishkin F.S, Khurana MM, Niden AH (1977) Correlation of microbiologic findings and67gallium scans in patients with pulmonary infections. Chest 72:442–448
Meduri GU, Stein D (1992) Pulmonary mannifestations of acquired immunodeficiency syndrome. Clin Infect Dis 14: 98–113
Greene NB, Solinger AM, Baughman RP (1987) Patients with collagen vascular disease and dyspnea: the value of gallium scanning and bronchoalveolar lavage in predicting response to steroid therapy and clinical outcome. Chest 91:698–703
Line BR, Fulmer RD, Reynolds HY, Robest WC, Jones AE, Harris EK, Crytal RG (1978) Gallium67-citrate scanning in the staging of indiographic pulmonary fibrosis: correlation with physiologic and morphotolotic features and bronchaoaveolar lavage. Am Rev Respir Dis 118:355–365
Hooper RG, Kearl RA (1990) Established ARDS treated with a sustanied course of andrenocortical steroids. Chest 97:138–143.
Hooper RG, Kearl RA (1991) Treatment of established ARDS-steroids, antibiotics, and antifungal therapy. Chest 100:137S
Passamonte PM, Martinez AJ, Singh A (1984) Pulmonary gallium concentration in the adult repiratory distress syndrome. Chest 85:828–830
Hardoff R, Burzsztein-De Mytteraere S (1992) Ga-67 lung uptake in patients with the adult respiratory distress syndrome. Association with lung infection and patient's prognosis. Clin Nucl Med 17: 853–858
Ranaldo JE, Rogers RM (1982) Adult respingratory distress syndrome. N Engl J Med 306:900–909
Turner-Warwick M (1991) Intestitial lung disease of unknow etiology. Chest 100: 232–233
Kelly CA, Fenwick JD, Corris PA, Fleetwood A, Hendrick DJ, Walters EH (1988) Fluid dynamics during bronchoalveolar lavage. Am Rev Respir Dis 138:81–84
keogh BA, Hunninghake GW, Line BR, Crystal RG (1983) The aveolitis of pulmonary sarcoidosis: evaluation of natural history and alveolitis-dependent changes in lung function. Am Rev Respir Dis 129: 256–265
Baughman RP, Fernandez M, Bosken CH, Mantil J, Hurtubise P (1984) Comparison of gallium67- scanning, bronchoalveolar lavage, and serum angiotensin-converting enzyme levels in pulmonary sarcoidosis: predicting response to therapy. Am Rev Respir Dis 129:676–681
Ashbaugh DG, Maier RV (1985) Idiopathic pulmonary fibrosis in dult respiratory distress syndrome. Arch Surg 120: 530–535
Ferrucci JT, van Sonnenberg E (1981) Intra-abdominal abscess: radiological diagnosis and treatment. JAMA 246: 2728–2733
Maderazo EG, Hickingbotham NB, Woronick CL, Sziklas JJ (1988) The influence of various factors on the accuracy of gallium67-imaging for occult infectin. J Nucl Med 29:608–615
Holzapfel L, Chevret S, Madinier G et al (1993) Influence of long-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of prospective, randomized, clinical trial. Crit Care Med 21:1132–1138
Rouby JJ, Laurent P, Gosnach M, Cambau E, Lamas G, Zouaoui A, Leguillou JL, Bodin L et al (1994) Risk factors and clinical relevance of nosocominal maxillary sinusitis in the critially ill. Am J Respir Crit Care Med 150: 776–783
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Meduri, G.U., Belenchia, J.M., Massie, J.D. et al. The role of gallium-67 scintigraphy in diagnosing sources of fever in ventilated patients. Intensive Care Med 22, 395–403 (1996). https://doi.org/10.1007/BF01712154
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DOI: https://doi.org/10.1007/BF01712154