Thoracic Critical Care

1.1 Ventilator associated pneumonia Ventilator associated pneumonia (VAP) is one of the sub-types of nosocomial acquired pneumonia occur in patients admitted to ICU who are under ventilator assistant mechanical ventilation occurring more than 48 h after patients have been intubated and received mechanical ventilation. Between 250,000 and 300,000 cases per year occur in the United States solely, which is an incidence rate of 5 to 10 cases per 1,000 hospital admissions1. The incidence of VAP increases with the duration of mechanical ventilation higher in day 10 compare to day five2, and it is associated with high mortality rates (0-50%) in ICU patients, and pneumonia accounts for second cause of death in ICU patients3, although Using various scoring systems for the mortality prediction along with the guideline-based medicine have helped decrease in VAP mortality rates4,5. Although mortality of viral VAP is not determined in ICU patients, the scoring systems provide an acceptable clinical index for such cases [46]. The misuse of insufficient dose or inappropriate antibiotic will lead to outgrow multi drug resistant serotypes of bacterial VAP and induce higher mortality6. This high mortality rate also depends on the type of underlying disease, with highest mortality attributable to VAP in patients with trauma or acute respiratory distress syndrome7, and the type of organism affecting the patient. Higher mortality rates have been explored in VAP caused by Pseudomonas aeruginosa (in patients with underlying respiratory problems) 8, Acinetobacter, and Stenotrophomonas maltophilia than those associated with other organisms9. Bacterial VAP can be due to colonization and spread of organisms from oropharynx, sinus cavities, nares, dental plaque, gastrointestinal tract, patient-to-patient contact, and the ventilator circuit to the lungs10. Essentially, each ICU should have an established protocol in place to initial empirical therapy based on previously accepted guidelines modified by local knowledge of prevalence of resistant serotypes unique to that ICU. Notably, empiric therapy should be both appropriate by using more specific antibiotics and adequate by using correct dose and good penetration to the site of infection11. Duration of antibiotics are also been a point of controversy; although 8 days of therapy has been effective in nonresistant organisem, but duration of antibiotic therapy for multiple drug resistant (MDR) organism such as P aeruginosa and Acinetobacter spp, is unknown12.