Ventilator-associated tracheobronchitis (VAT): questions, answers, and a new paradigm?

Donald E Craven

doi:10.1186/cc6912

Abstract

Nosocomial lower respiratory tract infections are a common cause of morbidity and mortality in intensive care unit (ICU) patients. Although many studies have investigated the management and prevention of ventilator-associated pneumonia (VAP), few have focused on ventilator-associated tracheobronchitis (VAT). In this issue of Critical Care, Nseir and coworkers present interesting data from a randomized controlled study of antimicrobial therapy for VAT. Patients randomly assigned to antibiotic therapy had more mechanical ventilation-free days (P < 0.001), fewer episodes of VAP (13% versus 47%; P < 0.001), and a lower ICU mortality rate (18% versus 47%; P = 0.05) than those without antibiotic therapy. Although this study has limitations, the data suggest that VAT may be an important risk factor for VAP or overlap with early VAP. More importantly, targeted antibiotic therapy for VAT may improve patient outcomes and become a new paradigm for prevention or early therapy for VAP.

Highlights

Most bacteria enter the lower respiratory tract by leakage of bacteria and oropharyngeal secretions around the endotracheal tube cuff, resulting in colonization, ventilator-associated tracheobronchitis (VAT), or ventilator-associated pneumonia (VAP) [2]
Diagnoses of VAP rely on distal samples of bacteria obtained from bronchoscopic and non-bronchoalveolar lavage (≥104 cfu/mL) [2] or protected specimen brush (PSB) (≥103 cfu/mL)
Definitions of VAT and VAP have been based on different sampling techniques and microbiologic thresholds, which may make discrimination between VAT and VAP difficult

Summary

Introduction

Most bacteria enter the lower respiratory tract by leakage of bacteria and oropharyngeal secretions around the endotracheal tube cuff, resulting in colonization, VAT, or VAP [2]. In this issue of Critical Care, Nseir and coworkers [1] provide interesting data from a randomized trial of antibiotic therapy for ventilator-associated tracheobronchitis (VAT). The lower respiratory tract in the ventilated patient is a continuous ‘battleground’ between the numbers, types, and virulence of the incoming bacteria versus the lung’s incredible mechanical, cellular, and humoral defenses.

Results

Conclusion