Recent studies in patients with VAP have shown that appropriate antimicrobial treatment improves outcome, and that decision-making based on clinical criteria and results of tracheal aspirate is frequently erroneous. In ventilated patients, bronchoscopy with collection of distal respiratory secretions by PSB and BAL is at present, despite its limitation, the most reliable method to establish the presence of pneumonia and to identify its microbiologic identity. Since bronchoscopy is performed at some risk to the patient and no study has yet assessed whether ventilated patients diagnosed as having (or not having) pneumonia by bronchoscopy do better clinically, opinions differ on the need or timing of the procedure. We have previously described a diagnostic approach that, in our experience, has significantly diminished therapeutic empiricism and confusion. ventolin 100 mcg
In agreement with others, we have also found VAP to be less common than clinically suspected and identified clinically important alternative causes for fever and infiltrates in patients who had negative bronchoscopic findings. In this regard, it is important to recognize that overzealous use of antimicrobials is not without complications, and that pneumonia developing in ventilated patients receiving previous antibiotic therapy is frequently caused by virulent organisms and carries a significant mortality rate. In patients with CAP, diagnostic bronchoscopy could be appropriate for the ones who require admission to the ICU and do not have an etiologic diagnosis established by noninvasive means’ or for the ones who are hospitalized and fail to respond to seemingly appropriate antibiotic treatment. In the latter group, the differential diagnosis broadens to include processes other than infectious that can be detected with BAL cytologic study.
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