Resp Care
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Ventilator management strategies can affect the risk for ventilator-associated pneumonia in 3 ways: the development of ventilator-induced lung injury; the need for potentially harmful tradeoffs in providing lung-protective ventilatory strategies; and the prolongation of the duration of mechanical ventilation from iatrogenic factors. Strategies to reduce ventilator-induced lung injury include a smaller tidal volume and careful attention to reducing the maximum pressures in the lung. ⋯ However, the weight of evidence suggests that beneficial outcomes from lung-protective strategies outweigh any potential harm from these tradeoffs. Finally, properly performed weaning protocols based on clinical evidence should reduce any iatrogenic delays in ventilator weaning and thereby minimize prolongation of unneeded mechanical ventilatory support.
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There has long been a controversy about whether to use a clinical or microbiologic approach to diagnose ventilator-associated pneumonia (VAP) and about which approach to use in managing patients. Although the clinical approach has often been criticized, a number of recent studies have shown that it is possible to use such an approach to effectively manage patients. This approach involves using all available clinical data to define the presence of pneumonia and then to initiate empiric therapy in a timely fashion, based on therapy guidelines, modified by local microbiologic data. ⋯ Based on this assessment, in conjunction with the results of tracheal aspirate cultures, therapy can be either modified or continued. A number of studies have shown that the clinical approach leads to a large number of patients receiving adequate empiric therapy, while still permitting de-escalation of antibiotic regimens, along with short durations of therapy. Thus a clinical approach to management can be successful in allowing for effective management of VAP, without promoting the unnecessary use of broad-spectrum antimicrobial therapy.
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Hospital-associated pneumonia (HAP) is one of the most common infections acquired among hospitalized patients. HAP is associated with excess mortality and increased medical care costs. The rise in HAP due to antibiotic-resistant bacteria has resulted in more common administration of inappropriate antimicrobial treatment, with an associated increased risk of hospital mortality. ⋯ Physicians treating patients with HAP and VAP should be aware of the predominant local pathogens associated with these infections and their antimicrobial susceptibility patterns. This will allow more appropriate initial antibiotic selection in order to optimize treatment regimens and clinical outcomes. Additionally, clinical strategies aimed at the prevention of HAP and VAP should be employed in all hospital settings caring for patients at risk for these infections.
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Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with major morbidity and attributable mortality. Strategies to prevent VAP are likely to be successful only if based upon a sound understanding of pathogenesis and epidemiology. The major route for acquiring endemic VAP is oropharyngeal colonization by the endogenous flora or by pathogens acquired exogenously from the intensive care unit environment, especially the hands or apparel of health-care workers, contaminated respiratory equipment, hospital water, or air. ⋯ Measures to prevent epidemic VAP include rigorous disinfection of respiratory equipment and bronchoscopes, and infection-control measures to prevent contamination of medical aerosols. Hospital water should be Legionella-free, and high-risk patients, especially those with prolonged granulocytopenia or organ transplants, should be cared for in hospital units with high-efficiency-particulate-arrestor (HEPA) filtered air. Routine surveillance of VAP, to track endemic VAPs and facilitate early detection of outbreaks, is mandatory.
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Ventilator-associated pneumonia (VAP) is a common complication of ventilatory support for patients with acute respiratory failure and is associated with increased morbidity, mortality, and costs. Awareness of the microbiology of VAP is essential for selecting optimal antibiotic therapy and improving these outcomes. The specific microbial causes of VAP are many and varied. ⋯ In conclusion, information about the microbiology of VAP serves to guide optimal antibiotic therapy. The risk of antibiotic-resistant pathogens can be estimated using simple clinical features and awareness of local microbiology patterns. The roles of atypical bacterial and nonbacterial pathogens in VAP are incompletely understood and should be investigated further.