Clinical presentation and diagnosis of ventilator-associated pneumonia
- Marin H Kollef, MD
Marin H Kollef, MD
- Professor of Medicine
- Washington University School of Medicine
- Section Editors
- Polly E Parsons, MD
Polly E Parsons, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Critical Care
- Professor of Medicine
- University of Vermont College of Medicine
- John G Bartlett, MD
John G Bartlett, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — HIV; Pulmonary Infections
- Professor Emeritus
- Johns Hopkins University School of Medicine
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".).
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 . 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'.)
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- CLINICAL FEATURES
- Medical history
- Physical examination
- Ventilator performance
- DIAGNOSTIC EVALUATION
- Chest imaging
- Respiratory sampling
- Microscopic analysis
- Respiratory culture
- - Quantitative culture
- - Semiquantitative culture
- Other diagnostic tests
- DIAGNOSTIC CRITERIA
- DIFFERENTIAL DIAGNOSIS
- VENTILATOR ASSOCIATED EVENTS
- SUMMARY AND RECOMMENDATIONS