What is ventilator-associated pneumonia in mechanical ventilation?

Updated: Apr 11, 2019
  • Author: Christopher D Jackson, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Answer

Answer

Ventilator-associated pneumonia (VAP) is a life-threatening complication with mortality rates of 33-50%. It is reported to occur in 8-28% of patients given mechanical ventilation. The incidence is 1-4 cases per 1000 ventilator days. The risk of VAP is highest immediately after intubation. VAP is estimated to occur at a rate of 3% per day for the first 5 days, 2% per day for next 5 days, and 1% per day thereafter. VAP occurs more frequently in trauma, neurosurgical, or burn units than in respiratory units and medical intensive care units.

VAP is defined as a new infection of the lung parenchyma that develops within 48 hours after intubation. The diagnosis can be challenging. VAP should be suspected when a new or changing pulmonary infiltrate in seen in conjunction with fever, leukocytosis, and purulent tracheobronchial secretions. However, many diseases can cause this clinical scenario. Examples include aspiration pneumonitis, atelectasis, pulmonary thromboembolism, drug reactions, pulmonary hemorrhage, and radiation-induced pneumonitis. Qualitative and quantitative cultures of protected brush and bronchoalveolar lavage specimens may help with the diagnosis, but the utility of these techniques is still debated.

Microorganisms implicated in VAP that occurs in the first 48 hours after intubation are flora of the upper airway, including Haemophilus influenza and Streptococcus pneumonia. After this early period, gram-negative bacilli such as Pseudomonas aeruginosa; Escherichia coli; and Acinetobacter, Proteus, and Klebsiella species predominate. Staphylococcus aureus, especially methicillin-resistant S aureus (MRSA), typically becomes a major infective agent after 7 days of intubation and mechanical ventilation. Most of the medical literature recommends initial therapy with broad-spectrum antibiotics that cover pathogens resistant to multiple drugs until the sensitivities of the causative organism are identified. Knowledge of organisms that cause VAP in the individual ICU and the pattern of antibiotic resistance is imperative. Choices of antibiotics should be tailored to the microorganisms and the antimicrobial resistance observed in each ICU. It is important to use an infection-prevention bundle to prevent VAP. One such bundle can be remembered by the mnemonic I COUGH. I is for incentive spirometry; C is for cough and deep breathing; O is oral care; U is for understanding; G is for getting out of bed; H is for head of bed elevated. [7]

Also see Ventilator-Associated Pneumonia.


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