Ventilator associated pneumonia (VAP): an impossible diagnosis? Call for a pragmatic approach.

Many years after the introduction of the protected specimen brush (PSB) by Wimberley et al. as a tool to diagnose ventilator associated pneumonia (VAP), new sampling techniques have increased the controversy concerning the diagnosis of VAP. Agreement exists only on the high sensibility and low specificity of the clinical symptoms combined with imaging data. However, sampling methods, qualitative/quantitative microbiological evaluation and the value of ''markers'' still appear to be unresolved issues. Because a proven diagnosis is very rare, a more pragmatic approach to VAP diagnosis seems necessary. More specifically, the questions we must focus on include the following: ''Which patients with possible pneumonia or lower respiratory infection require antibiotic treatment ?'' and ''In which patients with possible/suspected VAP is empiric treatment not immediately necessary and for which of these patients can empiric treatment be limited or discontinued?''