Rea-Neto Alvaro, Youssef Nazah Cherif M, Tuche Fabio, Brunkhorst Frank, Ranieri V Marco, Reinhart Konrad, Sakr Yasser
Department of Anesthesiology and Intensive Care, Friedrich-Schiller-University Hospital, 07743 Jena, Germany.
Crit Care. 2008;12(2):R56. doi: 10.1186/cc6877. Epub 2008 Apr 21.
Early, accurate diagnosis is fundamental in the management of patients with ventilator-associated pneumonia (VAP). The aim of this qualitative review was to compare various criteria of diagnosing VAP in the intensive care unit (ICU) with a special emphasis on the value of clinical diagnosis, microbiological culture techniques, and biomarkers of host response.
A MEDLINE search was performed using the keyword 'ventilator associated pneumonia' AND 'diagnosis'. Our search was limited to human studies published between January 1966 and June 2007. Only studies of at least 25 adult patients were included. Predefined variables were collected, including year of publication, study design (prospective/retrospective), number of patients included, and disease group.
Of 572 articles fulfilling the initial search criteria, 159 articles were chosen for detailed review of the full text. A total of 64 articles fulfilled the inclusion criteria and were included in our review. Clinical criteria, used in combination, may be helpful in diagnosing VAP, however, the considerable inter-observer variability and the moderate performance should be taken in account. Bacteriologic data do not increase the accuracy of diagnosis as compared to clinical diagnosis. Quantitative cultures obtained by different methods seem to be rather equivalent in diagnosing VAP. Blood cultures are relatively insensitive to diagnose pneumonia. The rapid availability of cytological data, including inflammatory cells and Gram stains, may be useful in initial therapeutic decisions in patients with suspected VAP. C-reactive protein, procalcitonin, and soluble triggering receptor expressed on myeloid cells are promising biomarkers in diagnosing VAP.
An integrated approach should be followed in diagnosing and treating patients with VAP, including early antibiotic therapy and subsequent rectification according to clinical response and results of bacteriologic cultures.
早期准确诊断是呼吸机相关性肺炎（VAP）患者管理的基础。本定性综述的目的是比较重症监护病房（ICU）中诊断VAP的各种标准，特别强调临床诊断、微生物培养技术和宿主反应生物标志物的价值。
使用关键词“呼吸机相关性肺炎”和“诊断”进行MEDLINE检索。检索限于1966年1月至2007年6月发表的人体研究。仅纳入至少25例成年患者的研究。收集预先定义的变量，包括发表年份、研究设计（前瞻性/回顾性）、纳入患者数量和疾病组。
在满足初始检索标准的572篇文章中，选择了159篇进行全文详细综述。共有64篇文章符合纳入标准并纳入我们的综述。联合使用临床标准可能有助于诊断VAP，然而，应考虑到观察者间的显著差异和中等的诊断性能。与临床诊断相比，细菌学数据并未提高诊断准确性。通过不同方法获得的定量培养物在诊断VAP方面似乎相当。血培养对肺炎的诊断相对不敏感。包括炎症细胞和革兰氏染色在内的细胞学数据的快速可得性可能有助于疑似VAP患者的初始治疗决策。C反应蛋白、降钙素原和髓系细胞表面表达的可溶性触发受体是诊断VAP有前景的生物标志物。
诊断和治疗VAP患者应采用综合方法，包括早期抗生素治疗以及随后根据临床反应和细菌培养结果进行调整。
