Background
Diagnosis of VAP
VAP criteria | Inflammatory marks | Sputum | Chest radiography/LUS | Microbiologic or histopathology marks | PEEP/FiO2
|
---|---|---|---|---|---|
CDC criteria [11] | Temperature >38 °C, or >36 °C, or WBC ≥12,000 or ≤4000 cells/mm3 and new antimicrobial agent is started for ≥4 days | Purulent respiratory secretions | Microbiologic quantitative-positive Endotracheal aspirate ≥105 CFU/mL Broncho-alveolar lavage ≥104 CFU/mL Protected specimen brush ≥103 CFU/mL or histological-positive Lung tissue ≥104 CFU/g or positive for Legionella, influenza virus, RSV, adenovirus, or parainfluenza | After a period of stability or improvement on the ventilator, Minimum daily FiO2 increase to 0.20 remain for 2 d or daily PEEP values increase to 3 cm H2O | |
CPIS (a score of 6 is suggestive of VAP) [12] | Temperature 38.5–38.9 °C = 1 point; ≥39 or <36.5 °C = 2 points WBC <4000 or >11,000/mm3 = 1 point | Non-purulent respiratory secretions = 1 point; purulent respiratory secretions = 2 points | Chest radiography Diffuse infiltrate = 1 point Localized infiltrate = 2 points Progressive infiltrate (without cardiac disease or ARDS) = 2 points | Moderate or heavy microbiologic quantitative or heavy microbiologic quantitative-positive = 1 point Microbiologic quantitative-positive and same pathogenic bacteria seen on Gram stain = 2 points | PaO2/FiO2 ≤ 240 without ARDS = 2 points |
CEPPIS (a score of 5 is suggestive of VAP) [12] | Temperature 38.5–38.9 °C = 1 point; ≥39 or <36.5 °C = 2 points Procalcitonin (ng/mL) ≥0.5 and <1 = 1 point; ≥1 = 2 points | Non-purulent respiratory secretions = 1 point; purulent respiratory secretions = 2 points | LUS-positive (sub-pleural echo-poor region or more with tissue-like echo texture) = 2 points | Microbiologic culture-positive = 2 points | PaO2/FiO2 ≤ 240 without ARDS = 2 points |
CHEST [13] | Temperature >38 °C WBC <4000/mc3 or >12,000/mm3
| Purulent respiratory secretions | Chest radiography New or progressive consolidation | ||
Johanson criteria [14] | Temperature >38 °C WBC <12,000/mc3
| Purulent respiratory secretions | Chest radiography New or progressive radiographic infiltrate |
Comparison of imaging tools to monitor VAP in the ICU
Basic applications of LUS in the ICU
Applications of LUS in CAP and VAP
Diagnosis and management of VAP
Pneumonia | Lung atelectasis | Tumor consolidation | Pulmonary embolism | |
---|---|---|---|---|
Presence of flow signal | Detected | Detected | Detected | None detected |
Flow signal density | High | Low | Low | None |
PI ([Peak systolic velocity − End diastolic velocity]/Mean velocity) | Median | High | Low | None |
RI ([Peak systolic velocity − End diastolic velocity]/Peak systolic velocity) | Median | High | Low | None |
AT (duration from the beginning to the peak systolic velocity) | Median | Low | High | None |
The feature of blood flow | Moderate-impedance flow | High-impedance flow | Low-impedance flow | No flow |
Lung aeration score | Lung aeration change score (re-aeration/loss of aeration) | |||
---|---|---|---|---|
Application object | Lung aeration evaluation to predict post extubation distress [60] Lung aeration evaluation to patients with ARDS [55] | PEEP-induced lung aeration changes in patients with ARDS [61] Antibiotic-induced lung aeration changes in patients with VAP [28] | ||
Value | N B1 B2 C | 0 point 1 point 2 points 3 points | N ↔ B1; B1 ↔ B2; B2 ↔ C N ↔ B2; B2 ↔ C B2 ↔ C | 1 point 3 points 5 points |