UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Clinical presentation and diagnosis of ventilator-associated pneumonia

Author
Marin H Kollef, MD
Section Editors
Polly E Parsons, MD
John G Bartlett, MD
Deputy Editor
Geraldine Finlay, MD

INTRODUCTION

Ventilator-associated pneumonia (VAP) is a type of hospital-acquired (ie, nosocomial) pneumonia that develops after more than 48 hours of mechanical ventilation. It is a common and serious problem, with an estimated incidence of 10 to 25 percent and an all-cause mortality of 25 to 50 percent [1,2]. Early diagnosis is important because prompt, appropriate treatment can be lifesaving.

The clinical presentation and diagnosis of VAP are reviewed here. The risk factors for VAP and its prevention and treatment are discussed separately. (See "Treatment of hospital-acquired and ventilator-associated pneumonia in adults" and "Risk factors and prevention of hospital-acquired and ventilator-associated pneumonia in adults" and "The ventilator circuit and ventilator-associated pneumonia".).

CLINICAL FEATURES

Presentation — Ventilator-associated pneumonia (VAP) typically presents with a new or progressive pulmonary infiltrate and one or more of the following findings: fever, purulent tracheobronchial secretions, leukocytosis, increased respiratory rate, decreased tidal volume, increased minute ventilation, and decreased oxygenation [3]. These symptoms and signs may develop gradually or suddenly.

Medical history — Patients with VAP are typically unable to provide any history because they are either sedated or their ability to communicate is impaired by the endotracheal or tracheostomy tube. Those few patients who are able to convey symptoms are likely to report dyspnea or chest congestion.

Physical examination — Fever and an increased volume of purulent tracheobronchial secretions are common among patients with VAP. On auscultation, patients typically have diffuse, asymmetric rhonchi due to the tracheobronchial secretions that the patient is unable to mobilize. The rhonchi are often accompanied by focal findings, such as crackles and decreased breath sounds. In addition, many patients are tachypneic with increased respiratory effort. Bronchospasm (wheezing and increased expiratory time) and hemoptysis are also common. These pulmonary signs may be accompanied by systemic abnormalities, such as encephalopathy or sepsis. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Sepsis'.)

             

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Aug 04 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61.
  2. Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002; 165:867.
  3. Meduri GU. Diagnosis and differential diagnosis of ventilator-associated pneumonia. Clin Chest Med 1995; 16:61.
  4. Andrews CP, Coalson JJ, Smith JD, Johanson WG Jr. Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury. Chest 1981; 80:254.
  5. Fagon JY, Chastre J, Hance AJ, et al. 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 1988; 138:110.
  6. Fagon JY, Chastre J, Hance AJ, et al. Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest 1993; 103:547.
  7. Torres A, el-Ebiary M, Padró L, et al. Validation of different techniques for the diagnosis of ventilator-associated pneumonia. Comparison with immediate postmortem pulmonary biopsy. Am J Respir Crit Care Med 1994; 149:324.
  8. Dotson RG, Pingleton SK. The effect of antibiotic therapy on recovery of intracellular bacteria from bronchoalveolar lavage in suspected ventilator-associated nosocomial pneumonia. Chest 1993; 103:541.
  9. Chastre J, Fagon JY, Bornet-Lecso M, et al. Evaluation of bronchoscopic techniques for the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 1995; 152:231.
  10. Timsit JF, Misset B, Renaud B, et al. Effect of previous antimicrobial therapy on the accuracy of the main procedures used to diagnose nosocomial pneumonia in patients who are using ventilation. Chest 1995; 108:1036.
  11. Rubin SA, Winer-Muram HT, Ellis JV. Diagnostic imaging of pneumonia and its complications in the critically ill patient. Clin Chest Med 1995; 16:45.
  12. Wunderink RG, Woldenberg LS, Zeiss J, et al. The radiologic diagnosis of autopsy-proven ventilator-associated pneumonia. Chest 1992; 101:458.
  13. Pham LH, Brun-Buisson C, Legrand P, et al. Diagnosis of nosocomial pneumonia in mechanically ventilated patients. Comparison of a plugged telescoping catheter with the protected specimen brush. Am Rev Respir Dis 1991; 143:1055.
  14. Marik PE, Brown WJ. A comparison of bronchoscopic vs blind protected specimen brush sampling in patients with suspected ventilator-associated pneumonia. Chest 1995; 108:203.
  15. Papazian L, Thomas P, Garbe L, et al. Bronchoscopic or blind sampling techniques for the diagnosis of ventilator-associated pneumonia. Am J Respir Crit Care Med 1995; 152:1982.
  16. Rouby JJ, Martin De Lassale E, Poete P, et al. Nosocomial bronchopneumonia in the critically ill. Histologic and bacteriologic aspects. Am Rev Respir Dis 1992; 146:1059.
  17. Kollef MH, Bock KR, Richards RD, Hearns ML. The safety and diagnostic accuracy of minibronchoalveolar lavage in patients with suspected ventilator-associated pneumonia. Ann Intern Med 1995; 122:743.
  18. Marquette CH, Georges H, Wallet F, et al. Diagnostic efficiency of endotracheal aspirates with quantitative bacterial cultures in intubated patients with suspected pneumonia. Comparison with the protected specimen brush. Am Rev Respir Dis 1993; 148:138.
  19. el-Ebiary M, Torres A, González J, et al. Quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia. Am Rev Respir Dis 1993; 148:1552.
  20. Marquette CH, Copin MC, Wallet F, et al. Diagnostic tests for pneumonia in ventilated patients: prospective evaluation of diagnostic accuracy using histology as a diagnostic gold standard. Am J Respir Crit Care Med 1995; 151:1878.
  21. Jourdain B, Novara A, Joly-Guillou ML, et al. Role of quantitative cultures of endotracheal aspirates in the diagnosis of nosocomial pneumonia. Am J Respir Crit Care Med 1995; 152:241.
  22. Sanchez-Nieto JM, Torres A, Garcia-Cordoba F, et al. Impact of invasive and noninvasive quantitative culture sampling on outcome of ventilator-associated pneumonia: a pilot study. Am J Respir Crit Care Med 1998; 157:371.
  23. Fagon JY, Chastre J, Wolff M, et al. Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia. A randomized trial. Ann Intern Med 2000; 132:621.
  24. Shorr AF, Sherner JH, Jackson WL, Kollef MH. Invasive approaches to the diagnosis of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 2005; 33:46.
  25. Rello J, Vidaur L, Sandiumenge A, et al. De-escalation therapy in ventilator-associated pneumonia. Crit Care Med 2004; 32:2183.
  26. Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006; 355:2619.
  27. Berton DC, Kalil AC, Teixeira PJ. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database Syst Rev 2014; :CD006482.
  28. Kollef MH. Diagnosis of ventilator-associated pneumonia. N Engl J Med 2006; 355:2691.
  29. Estella A, Alvarez-Lerma F. [Should the diagnosis of ventilator associated pneumonia be improved?]. Med Intensiva 2011; 35:578.
  30. Kirtland SH, Corley DE, Winterbauer RH, et al. The diagnosis of ventilator-associated pneumonia: a comparison of histologic, microbiologic, and clinical criteria. Chest 1997; 112:445.
  31. Wimberley N, Faling LJ, Bartlett JG. A fiberoptic bronchoscopy technique to obtain uncontaminated lower airway secretions for bacterial culture. Am Rev Respir Dis 1979; 119:337.
  32. Baselski VS, el-Torky M, Coalson JJ, Griffin JP. The standardization of criteria for processing and interpreting laboratory specimens in patients with suspected ventilator-associated pneumonia. Chest 1992; 102:571S.
  33. Baker AM, Bowton DL, Haponik EF. Decision making in nosocomial pneumonia. An analytic approach to the interpretation of quantitative bronchoscopic cultures. Chest 1995; 107:85.
  34. Timsit JF, Misset B, Goldstein FW, et al. Reappraisal of distal diagnostic testing in the diagnosis of ICU-acquired pneumonia. Chest 1995; 108:1632.
  35. Berton DC, Kalil AC, Teixeira PJ. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database Syst Rev 2012; 1:CD006482.
  36. Christ-Crain M, Jaccard-Stolz D, Bingisser R, et al. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet 2004; 363:600.
  37. Schuetz P, Christ-Crain M, Thomann R, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA 2009; 302:1059.
  38. Bouadma L, Luyt CE, Tubach F, et al. Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010; 375:463.
  39. Ramirez P, Garcia MA, Ferrer M, et al. Sequential measurements of procalcitonin levels in diagnosing ventilator-associated pneumonia. Eur Respir J 2008; 31:356.
  40. Luyt CE, Combes A, Reynaud C, et al. Usefulness of procalcitonin for the diagnosis of ventilator-associated pneumonia. Intensive Care Med 2008; 34:1434.
  41. Stolz D, Smyrnios N, Eggimann P, et al. Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a randomised study. Eur Respir J 2009; 34:1364.
  42. Luyt CE, Guérin V, Combes A, et al. Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia. Am J Respir Crit Care Med 2005; 171:48.
  43. Seligman R, Meisner M, Lisboa TC, et al. Decreases in procalcitonin and C-reactive protein are strong predictors of survival in ventilator-associated pneumonia. Crit Care 2006; 10:R125.
  44. Hillas G, Vassilakopoulos T, Plantza P, et al. C-reactive protein and procalcitonin as predictors of survival and septic shock in ventilator-associated pneumonia. Eur Respir J 2010; 35:805.
  45. Linssen CF, Bekers O, Drent M, Jacobs JA. C-reactive protein and procalcitonin concentrations in bronchoalveolar lavage fluid as a predictor of ventilator-associated pneumonia. Ann Clin Biochem 2008; 45:293.
  46. Anand NJ, Zuick S, Klesney-Tait J, Kollef MH. Diagnostic implications of soluble triggering receptor expressed on myeloid cells-1 in BAL fluid of patients with pulmonary infiltrates in the ICU. Chest 2009; 135:641.
  47. Fagon JY. Biological markers and diagnosis of ventilator-associated pneumonia. Crit Care 2011; 15:130.
  48. Pugin J, Auckenthaler R, Mili N, et al. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic "blind" bronchoalveolar lavage fluid. Am Rev Respir Dis 1991; 143:1121.
  49. Fartoukh M, Maitre B, Honoré S, et al. Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med 2003; 168:173.
  50. Corley DE, Kirtland SH, Winterbauer RH, et al. Reproducibility of the histologic diagnosis of pneumonia among a panel of four pathologists: analysis of a gold standard. Chest 1997; 112:458.
  51. Klompas M. Complications of mechanical ventilation--the CDC's new surveillance paradigm. N Engl J Med 2013; 368:1472.
  52. Magill SS, Klompas M, Balk R, et al. Developing a new, national approach to surveillance for ventilator-associated events*. Crit Care Med 2013; 41:2467.
  53. Boyer AF, Schoenberg N, Babcock H, et al. A prospective evaluation of ventilator-associated conditions and infection-related ventilator-associated conditions. Chest 2015; 147:68.