Clinical presentation and

diagnostic evaluation of
ventilator-associated pneumonia/
event
 INTRODUCTION-

Ventilator-associated pneumonia/ event (VAP/E) is

a type of hospital-acquired pneumonia (HAP) that
develops after more than 48 hours of mechanical
ventilation . VAP is a common and serious problem
in the intensive care unit that is associated with an
increased risk of death.
• CLINICAL PRESENTATION

• Clinical features — Most patients with VAP present with a gradual

or sudden onset of the following more than 48 hours after
intubation
• ●Symptoms – dyspnea (few patients have symptoms since most
are nonverbal on mechanical ventilation)
• ●Signs – fever, tachypnea, increased or purulent secretions,
hemoptysis, rhonchi, crackles, reduced breath sounds,
bronchospasm
• ●Ventilator mechanics – reduced tidal volume, increased
inspiratory pressures
• ●Laboratory findings – worsening hypoxemia, leukocytosis
• ●Imaging – new or progressive infiltrate on chest radiograph or
computed tomography (CT) (see 'Chest imaging' below)
• Clinical definition of ventilator associated
pneumonia/event — VAP/E is diagnosed when a
patient who has been mechanically ventilated for ≥48
hours develops a new or progressive infiltrate with
associated signs and symptoms of infection (eg, new
onset of fever, purulent sputum, leukocytosis, decline in
oxygenation, altered respiratory mechanics) in whom
positive respiratory specimens are present (ie,
increased neutrophils are seen in the microscopic
analysis and growth of a pathogen in culture exceeds a
predefined threshold). (See
'Microscopic analysis and quantitative culture' above
and 'Microscopic analysis and nonquantitative culture'
above.)
• CDC definitions ventilator associated events (VAE-VAC-
IVAC-VAP) — The
CDC National Healthcare Safety Network implemented
ventilator-associated events (VAE) surveillance in
January 2013 . This term was proposed to provide a
more uniform and consistent manner of reporting cases
of ventilator-associated complications. The definitions
below are not intended to be used clinically, so their
impact on VAP prevention management is uncertain.
• The VAE system is a three-tier surveillance definition
that uses objective, readily available data to identify
complications, including VAP, that occur in mechanically
ventilated adult patients .
Ventilator-associated condition (VAC) – The
first tier definition, VAC, identifies patients with
a period of sustained respiratory deterioration
(changes in positive end-expiratory pressure
[PEEP] ≥3 cm H2O or fraction of inspired
oxygen [FiO2] ≥0.2 [ie, 20 points] for two days)
following a sustained period of stability or
improvement on the ventilator (greater than or
equal to two days)
• Infection-related ventilator-associated
complication (IVAC) – The second tier
definition, IVAC, requires that patients with
VAC also have an abnormal temperature
(below 36°C or above 38°C) or white blood
cell count (≤4000 or ≥12,000 cells/mm3) and
be started on one or more new antibiotics that
continue for four or more days.
• Possible and probable VAP – The third tier definitions,
possible and probable VAP, require that patients with
IVAC also have laboratory and/or microbiological
evidence of respiratory infection. Possible VAP is defined
as Gram stain evidence of purulent pulmonary secretions
or a pathogenic pulmonary culture in a patient with
IVAC . Probable VAP is defined as Gram stain evidence of
purulence plus quantitative or semiquantitative growth
of a pathogenic organism beyond specified thresholds .
Probable VAP can also be triggered by positive tests for
respiratory viruses, Legionella species, pleural fluid
cultures, and suggestive histopathology with or without
an abnormal Gram stain result.
• Ventilated hospital-acquired
pneumonia — Ventilated hospital-acquired
pneumonia (VHAP) represents pneumonia
occurring in patients hospitalized for more than
48 hours with the subsequent need for
mechanical ventilation . The importance of
VHAP is demonstrated by its greater overall
prevalence, and in some studies greater
mortality, compared with VAP . In general, the
epidemiology, pathogens, and outcomes of
VHAP are more similar to VAP than hospital-
acquired pneumonia (HAP)
 DIFFERENTIAL DIAGNOSIS
• Aspiration pneumonitis
• Pulmonary embolism with infarction –
Pulmonary embolism can mimic VAP if it
causes pulmonary infarction; it is
distinguished from VAP when imaging (eg,
computed tomography pulmonary angiography
[CTPA]) reveals pulmonary embolism.
 DDx
• Acute respiratory distress syndrome – Acute
respiratory distress syndrome (ARDS) is
distinguished from VAP by history (ie, risk
factors for ARDS may be present) and the
microscopic analysis and culture of respiratory
secretions.
 DDx
• Pulmonary hemorrhage – Both pulmonary
hemorrhage and VAP may cause hemoptysis.
Pulmonary hemorrhage tends to present with
frank bleeding while VAP often appears as
blood mixed with purulent secretions, but this
distinction is imperfect. Definitively
distinguishing pulmonary hemorrhage from
VAP requires that the cause of the hemoptysis
be identified, typically on bronchoscopy.
 DDx
• Lung contusion – Pulmonary contusion is due
to trauma, but it may be difficult to distinguish
from VAP because the clinical and
radiographic manifestations are similar and
often delayed following the trauma.
Pulmonary contusion is distinguished from
VAP by history (ie, recent trauma) and the
absence of organisms on microscopic analysis
and culture of respiratory secretions.
 DDx
• infiltrative tumor – The manifestations of a
diffuse infiltrative cancer are similar to VAP.
Diffuse infiltrative cancer is distinguished
from VAP by history (ie, history of
malignancy); culture and microscopic analysis
are negative but may be positive for malignant
cells. Lung biopsy may be necessary.
 DDx
• Radiation pneumonitis – Radiation-induced lung
injury may cause acute pneumonitis or chronic
fibrosis. The former develops approximately 4 to 12
weeks after irradiation, with symptoms and signs
that mimic VAP; it is distinguished from VAP by
history (ie, prior irradiation) and negative
microscopic analysis and culture of respiratory
secretions. (See "Radiation-induced lung injury".)
 DDx
• Cryptogenic organizing pneumonia – Clinical
features of cryptogenic organizing pneumonia
(COP) may be identical to VAP; it is
distinguished from VAP by history (ie, risk
factors for COP may be present, such as a
recent viral infection) and negative
microscopic analysis and culture of respiratory
secretions. Definitive diagnosis of COP
requires lung biopsy.
 DDx
• Vasculitis – Vasculitis (eg, systemic lupus
erythematosus) is a rare cause of progressive
pulmonary infiltrates that may present in a
patients with a known diagnosis of an
autoimmune disorder and can only be
distinguished by biopsy.
 TESTS OF LIMITED VALUE
• Biomarkers
• Procalcitonin — Unlike patients with suspected
community acquired pneumonia, where the role of
procalcitonin can facilitate the decision to start
antimicrobials, evidence is conflicting in patients
with in suspected VAP . Until higher quality studies
resolve the uncertainty, we believe that serum
procalcitonin levels should not be used for this
purpose.
• Other biomarker- such as C-reactive protein
(CRP) and soluble triggering receptor
expressed on myeloid cells-1 (sTREM-1),
were initially considered promising markers
for improving diagnostic strategies for VAP.
However, subsequent studies reported that the
measurement of such biomarkers in BAL fluid
has minimal diagnostic value
 Clinical Pulmonary Infection Score
(CPIS)
Temperature
≥36.5 or ≤38.4 = 0 point
≥38.5 or ≤38.9 = 1 point
≥39 or <36.5 = 2 points
Blood leukocytes, microL
≥4000 or ≤11,000 = 0 points
<4000 or >11,000 = 1 point
Band forms ≥50 percent = add 1 point
Tracheal secretions
Absence of tracheal secretions = 0 point
Presence of nonpurulent tracheal secretions = 1 point
Presence of purulent tracheal secretions = 2 points
Oxygenation

PaO2/FIO2, mmHg >240 or ARDS (defined as PaO2/FIO2 ≤200, PAWP ≤18 mmHg and acute
bilateral infiltrates) = 0 points

PaO2/FIO2 ≤240 and no ARDS = 2 points

Pulmonary radiography

No infiltrate = 0 point

Diffuse (patchy) infiltrate = 1 point

Localized infiltrate = 2 points

Progression of pulmonary infiltrate

No radiographic progression = 0 point

Radiographic progression (after HF and ARDS excluded) = 2 points

Progression of pulmonary infiltrate

No radiographic progression = 0 point

Radiographic progression (after HF and ARDS excluded) = 2 points

Culture of tracheal aspirate

Pathogenic bacteria cultured in rare or few quantities or no growth = 0 point

Pathogenic bacteria cultured in moderate or heavy quantity = 1 point

Same pathogenic bacteria seen on Gram stain, add 1 point

Total (a score of >6 was considered suggestive of pneumonia)

• DIAGNOSIS- VAP is a clinical diagnosis made in a patient who has been
mechanically ventilated for ≥48 hours who develops a new or
progressive lung infiltrate on imaging with clinical evidence that the
infiltrate is of infectious origin (eg, fever, purulent sputum,
leukocytosis, and decline in oxygenation), together with a positive
pathogen identified on microbiologic respiratory sample . A positive
microbiologic sample in a patient with a normal chest radiograph
should raise the suspicion for tracheobronchitis. VAP cannot be
confirmed or excluded until the culture results are complete, which
generally takes two to three days; thus the diagnosis is retrospective
during which time empiric therapy is ongoing.

• Importantly, we and others do not include use of the entities of

ventilator-associated conditions (VAC) and infection-related ventilator-
associated complications (IVACs), which were introduced by the United
States Centers for Disease Control and Prevention (CDC) for the
purposes of surveillance and quality improvement . These definitions
do not aid diagnosis and treatment decisions for individual patients.
• Suspected nosocomial pneumonia in the
intensive care unit
VENTILATER- ASSOCIATED EVENTS (VAE ) SURVEILLANCE ALGORITHM –
1-BASELINE PERIOD OF STABILITY ON THE VENTILATER, DEFINED BY >2
CALENDER DAYS OF STABLE OR DEC. DAILY MINI. FIO2 /PEEP VALUES.
THE BASELINE PERIOD IS DEFINED AS THE 2 CALANDER DAYS OR IMMEDIATELY
PRECEDING THE FIRST DAY OF INCREASED DAILY MINI, PEEP OR FIO2.

DAILY MINI DEFINED BY LOWEST VALUE OF FIO2-OR PEEP DURING A CALANDER

DAY THAT IS MAINTAINED FOR >1 HRS .

2. AFTER A PERIOD OF STABILITY OR IMPROVEMENT ON THE VENTILATER, THE

PT’S HAS AT LEAST ONE OF THE FOLLOWING INDICATION OF W