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VENTILATOR – ACQUIRED PNEUMONIA By Prof. Adel Salah Professor of Respiratory Medicine PowerPoint Presentation
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VENTILATOR – ACQUIRED PNEUMONIA By Prof. Adel Salah Professor of Respiratory Medicine Zagazig University . Definition. VAP refers to pneumonia that arises more than 48 hours after intubation of trachea and initiation of M. ventilation .

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  • By
  • Prof. Adel Salah
  • Professor of Respiratory Medicine
  • Zagazig University


VAP refers to pneumonia that arises more than 48 hours after intubation of trachea and initiation of M. ventilation.

  • According to the microbial pattern and the clinical outcome, VAP can be divided into:
  • Early onset VAP.
  • Late onset VAP.

Determinants of the microbiologic spectrum of VAP:

  • Prior use of antibiotics.
  • Duration of time on mechanical ventilation

Risk Factors for MDR Pathogens Causing VAP and HAP(Am J Respir Crit Care Med , 2005)



  • Colonization of aero-digestive tract .
  • Aspiration of infected secretions .
  • Insertion of an ETT:
    • comprises the natural barrier.
    • facilitates pooling and leakage of contaminated secretions.
    • eliminates the cough reflex.
    • impair mucociliary clearance.
    • bacterial biofilm .
    • injure the epithelial surface .
    • Other factors: supine position, frequency of ventilator circuit changes, tracheal suctioning, and contaminated respiratory care equipment .
    • Compromise of the normal host defense mechanisms.

Diagnosis of VAP

The clinical pulmonary infection score (CPIS) used for the diagnosis of VAP (Luna et al., 2003)

CPIS > 6 is associated with a high likelihood of pneumonia.


Signs and symptoms are very nonspecific and lead to overdiagnosis of pneumonia.

So why it is difficult to accurately diagnose VAP?

  • Fever and leucocytosis.
  • Increased tracheal secretion.
  • Oropharyngeal colonization.
  • Chest radiographic changes.
  • Blood or pleural fluid culture.

­How can pneumonia be differentiated from all these other diseases?

Confirmation of VAP usually relies on a lower respiratory tract quantitative cultures


What is the rationale for QCs

Infection is more likely the higher the density of microorganisms in a particular space.

A critical density must be reached in order to cause clinical infection.

A certain threshold is therefore used in order to separate true infection from colonization.

  • B.PSB > 100-1000 CFU/ml
  • B.BAL > 1000-10000 CFU/ml
  • Deep endotrahceal aspirates > 105-106 CFU/ml

The most commonly used of QCs techniques

  • Bronchoscopic:
  • Bronchoalveolarlavage
  • Protected specimen brush
  • Deep tracheal aspirates.
  • Nonbronchoscopic catheters.
  • Distal sampling, mini-BAL (e.g., Combicath)
  • Nonbronchoscopic protected specimen brush

Advantages and disadvantages of QCs

Is one bronchoscopic technique better than the other?


Role of biomarkers as diagnostic and prognostic markers of VAP

  • Procalcitonin (PCT):
  • Low PCT levels (< 0.25 µg/l) in patients with no clinical signs of severe illness suggest safe withdrawal of antibiotics, thereby limiting the use of unnecessary antibiotics.
  • Alternatively PCT > 0.5 µg/ml strongly recommends antibiotic treatment as it is indicative of active bacterial infection.
  • PCT was shown to be elevated on an average 2 days prior to the clinical diagnosis of VAP and therefore can be used as an early marker for diagnosis of VAP.

The other biomarkers: like natriuretic peptides, copeptin and CRP levels are useful prognostic markers and may be of great help in the risk stratification of patients.


Differential diagnosis

  • Other diagnoses should be considered in a patients without typical signs and symptoms or those who do not respond to empirical antibiotic therapy.
  • The differential diagnosis of VAP includes:
  • congestive heart failure.
  • Atelectasis.
  • Acute respiratory distress syndrome (ARDS).
  • pulmonary embolism with infarction.
  • chemical pneumonitis from aspiration.
  • alveolar hemorrhage.
  • Lung contusion in trauma patient.


  • Patients who remain ill after initiation of appropriate antibiotic therapy may have developed complications of pneumonia.
  • Common complications include :
  • complicated parapneumonic effusions, frank empyema.
  • ARDS.
  • Spreading of infection to other organs.
  • sepsis, with multiple organ dysfunction, Renal failure hepatic failure, disseminated intravascular coagulation, hemodynamic instability, and coma may all occur in this setting.

Antibiotic treatment of VAP

2 overriding principles

  • Adequate initial empiric antibiotic therapy.
  • Avoiding unnecessary antibiotics.

Duration of therapy

Antibiotic class rotation


Treatment Failure

  • criteria indicate treatment failure: (usually after 3 days from AB initiation):
  • failure to improve the PaO2/FiO2 ratio after antibiotic initiation.
  • persistence of fever or hypothermia plus purulentrespiratory secretions.
  • worsening of the pulmonary infiltrate by 50%.
  • development of septic shock or multiple organ failure syndrome.


  • Wrong diagnosis.
  • Host factors: underlying diseases (e.g., endobronchial malignancy or foreign body), superinfectionswith organisms that are not sensitive to the antibiotics given, or any of a variety of types of immunosuppression.
  • Bacterial factors : associated with failure of initial therapy include primary or acquired resistance to the initial antibiotic.
  • Complications of the initial infection: (e.g., empyema, abscess formation).

Prevention strategies

  • Guard against Bacterial colonization :
  • Effective hand washing by hospital personnel.
  • Protective gowns and gloves.
  • Oral (nonnasal) intubation.
  • Limiting stress ulcer prophylaxis to high risk critically ill patients such as those who require mechanical ventilation or have a coagulopathy.
  • Avoiding unnecessary antibiotics.
  • Adequate initial empiric antibiotic therapy.
  • Antibiotic class rotation.
  • Chlorhexidine oral rinse.
  • Selective digestive decontamination
  • Probiotics.
  • Antimicrobial coating of tracheal tubes.

Guard against aspiration of contaminated secretions:

  • Keeping mechanically ventilated patients semirecumbent.
  • Reducing excessive use of narcotics.
  • Continuous subglottic suctioning.
  • Use of a closed endotracheal suctioning system.
  • Use of weaning protocols to shorten duration of mechanical ventilation.
  • Do not routinely change the ventilator circuit. Only change when visibly soiled or malfunctioning.
  • Consider non invasive ventilation
  • Drain circuit condensate.
  • Use only sterile fluid for humidification or nebulization.
  • Avoiding large gastric volumes.
  • Avoid patient transport.
  • Reduce accidental extubations.