For example, Pugin and colleagues [25] found that inflammatory cy

For example, Pugin and colleagues [25] found that inflammatory cytokines and IL-8 increased rapidly after intubation and positive pressure http://www.selleckchem.com/products/Oligomycin-A.html ventilation in patients with ACLE, although these levels were lower than in patients with ALI. Considering that our samples were obtained shortly after intubation through the s-Cath procedure, the increased absolute PMN count in patients with ACLE was probably not related to ventilator-induced lung injury. We speculate that this finding may indicate an inflammatory process during the hydrostatic form of pulmonary oedema. Although the mean plasma C-reactive protein level in patients with ACLE was significantly lower than the level recorded in the group of patients with ALI/ARDS, the raised C-reactive protein concentration in patients with the hydrostatic form of lung oedema, devoid of any treatment with corticosteroids or clinical and bacteriological evidence of infection, is notable.

Dysregulation of C-reactive protein in the setting of acute hydrostatic lung oedema seems to be a common finding that could be associated with a concomitant inflammatory process, therefore perhaps playing a role in the evolution of this form of oedema [26,27].Our study has some limitations. A lack of agreement between s-Cath and mini-BAL may occur for several reasons: the variability of instilled volume of the mini-BAL may have influenced the results; the techniques have two distinct dilution features, the region of the lung where oedema is sampled is achieved blindly and the lung injury is heterogeneous; and the difficulty in wedging the mini-BAL catheter properly in a distal airway may further represent a barrier in achieving comparable results.

Another limitation for using s-Cath is the presence of sticky airways secretions, typically found in primary ALI/ARDS following bilateral pneumonia, making it impossible to obtain free-flowing oedema fluid. This problem was the main reason for excluding few patients from our paired analysis.Studies assessing the impact of pulmonary heterogeneity in patients with ALI, ARDS or ACLE would therefore be helpful in the future for evaluating sampling agreement of different techniques. Finally, although we tried to study our patients as early as possible after the clinical recognition of injury, some patients were not investigated with the mini-BAL procedure at exactly the same time as the s-Cath sampling but all the procedures were completed within a four-hour time window.

Nevertheless, we consider this frame of time as likely to be representative of the functional status of lung neutrophils and protein concentration because lung PMN and total protein does not change significantly over the first three days after the onset of ARDS when measured by the traditional bBAL procedure Batimastat [28-30].

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