CURRENT Essentials of Critical Care.pdf

Chapter 8 Respiratory Failure 111■■■Ventilator-Associated PneumoniaEssentials of Diagnosis• In patient on mechanical ventilation, three or more of fever, newinfiltrates, leukocytosis, purulent secretions• Occurs in 10–25% of mechanically ventilated patients, resultingin 5–30% increase in mortality; increased duration of ventilation• Due to aspiration of bacterial-laden oropharyngeal secretions orgastric contents through or around endotracheal tube and cuff• Community-acquired bacteria if pneumonia occurs 4 days afteradmission; otherwise Gram-negative bacilli, staphylococcusmore common• Culture of sputum helpful for antibiotic selection, not for diagnosis;contamination-protected brushes, bronchoscopic sampling,or bronchoalveolar lavage possibly helpful if quantitativecultures usedDifferential Diagnosis• Community-acquired pneumonia• Pulmonary edema, ARDS• Aspiration pneumonitis• Atelectasis• Pulmonary thromboembolismTreatment• Suction secretions, chest physical therapy (only if increase insputum production)• Antibiotics directed against community-acquired organisms (Spneumoniae, H influenzae) if 4 days; if 4 days, antibioticsagainst aerobic Gram-negative bacilli, (E coli, K pneumoniae,Pseudomonas, Acinetobacter) and S aureus• Plan to reduce spectrum of antibiotic coverage within 3–7 daysusing clinical response, cultures, epidemiology of bacteria inICU• Prevention: Suction secretions above endotracheal tube cuff;continuous enteral feedings■ PearlNoninvasive positive pressure ventilation is associated with decreasedrisk of infection.ReferenceHoffken G et al: Nosocomial pneumonia: the importance of a deescalatingstrategy for antibiotic treatment of pneumonia in the ICU. Chest2002;122:2183. [PMID: 12475862]