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Abstract
Ventilator associated pneumonia (VAP) is a common and major compl ication during mechanical ventilation, leading to increasing morbidity, mortality and cost. Accurate cl inical diagnosis rernams problematic. Difficulties in
diagnosis of V AP have led to the development of new diagnostic
techniques such as bronchoalveolar lavage and the bronchoscopic
protected specimen brush.
The development of preventative strategies depends upon an
understanding of the pathogenesis of V AP. The pathogenesis begins with
upper airway and gastrointestinal colonisation, laryngopharyngeal pooling
of secretions, then aspiration past the tracheal tube cuff leading to the
overwhelming of compromised lung defences. The recent development of
tracheal tube cuff prototypes that prevent aspiration are promising and
need further eval uation. Useful preventative strategies include: strict infection control procedures; improvements in upper airway hygiene: the avoidance of nasal intubation; the use of sucral fate, rather than gastric alkal inisation; infrequent ventilator circuit changes; and possibly heat and moisture exchange filters and kinetic beds. Appropriate antimicrobial treatment of an established YAP requires early empirical therapy based on a knowledge of the epidemiology of
early- and late-onset pneumonia, local pathogen patterns, recent antibiotic
treatment, underlying lung disease and recent microbiological cultures,
followed by the use of narrow-spectrum antibiotics after organism identification. All the practical difficulties of diagnosing and treating pneumonia in patients undergoing artificial ventilation have encouraged a more detailed investigation of the determinants of YAP in the hope of developing more successful preventive strategies in the near future.