This Task Force was supported and endorsed by the following Societies: European Respiratory Society, European Society of Intensive Care Medicine, European Society of Clinical Microbiology and Infectious Diseases and European Society of Anaesthesiology.

⇓In the last decade, considerable investigational efforts have been made in the field of the management of ventilator-associated pneumonia (VAP). Several studies have provided important insights into the relationship of histology and bacteriology of VAP, which remain fundamental for all future research. Moreover, epidemiological research has allowed establishment of concepts for empiric initial antimicrobial treatment that are expected to improve clinical outcomes. Important contributions have also been made regarding prevention of VAP.



Fig. 1.— 

However, despite these advances, the majority of issues related to the management of VAP remain unresolved and are subject to controversy. This is particularly true for the diagnostic evaluation of the patient with suspected VAP. The lack of consensus regarding the best way to diagnose VAP explains in part why incidence rates vary widely from one study to another, from 5 to >50% of mechanically ventilated intensive care unit (ICU) patients.

In this review, a panel of experts in the field of VAP from four European societies has tried to provide an overview of the most important aspects under debate. In order to stimulate further research and discussion, presentation of the main topics was focussed on the breaking current knowledge. The issue of attributable mortality, which is also a matter of controversy, will not be addressed in this review. Each section of the review has been written in an attempt to answer three main questions: 1) what is not controversial, 2) what is still controversial and 3) what should be investigated? The following topics were reviewed: clinical diagnosis, bacteriological and histological aspects, aetiology, diagnostic techniques, antimicrobial treatment and prevention.

#### What is not controversial?

Clinical criteria for the diagnosis …

https://erj.ersjournals.com/content/erj/17/5/1034.full.pdf

Ventilator-associated pneumonia

Long-term complications of artificial airways

Objective To evaluate the use of maxillary sinus puncture as a routine diagnostic procedure to exclude or confirm purulent sinusitis in intensive care unit (ICU) patients presenting with fever or a septic state of unknown origin.



Study Design Retrospective.



Methods All patients admitted to the ICU at the University Hospital Ghent who required ENT examination to exclude acute sinusitis as possible cause of their otherwise inexplicable fever or septic state underwent maxillary sinus puncture via the inferior meatus. The results of clinical examination and the relation between the presence of foreign bodies (e.g., nasogastric tubes) and culture results from the middle meatus and sinuses were analyzed.



Results One hundred five punctures were performed in 53 patients. Macroscopic purulent effusions were obtained from 25 and nonpurulent effusions from 19 sinuses. The presence of a nasogastric tube did not influence puncture results but significantly increased colonization of the middle meatus. Staphylococcus aureus and Gram-negative agents were frequently cultured from sinus aspirates. Although purulent secretions often reveal no growth, most patients present with a multibacterial (40%) or monobacterial (28%) infection. Simple anterior rhinoscopy reduces the need for antral puncture. Only 8% of punctures in patients with a normal clinical examination were positive.



Conclusions Antral puncture proves to be a simple, fast, safe, inexpensive, and effective procedure for immediate diagnosis of acute nosocomial sinusitis in ICU patients and is therefore recommended as first procedure in these patients, even when only minor clinical abnormalities are present.

Value of Antral Puncture in the Intensive Care Patient With Fever of Unknown Origin

Ventilator-associated sinusitis in adults: systematic review and meta-analysis.

An overview of common otorhinolaryngological (ORL) problems and procedures in the intensive care unit (ICU) is presented Diagnostic, management, and treatment aspects of some conditions are discussed with emphasis on the potential difficulties encountered in the ICU Approach recommendations are outlined as well as a list of required basic equipment Otorhinolaryngology should be included in intensive care continuing medical education programs

https://link.springer.com/content/pdf/10.1007%2Fs00134-003-1764-5.pdf

Otorhinolaryngological problems occurring within the intensive care unit.

Nosocomial pansinusitis (N P) is most often described in nasotracheally intubated patients with craniocerebral or facial trauma. We retrospectively reviewed its occurrence and complications in the course of prolonged mechanical ventilation in orotracheally intubated patients without maxillofacial or cranial injuries. N P was deemed to be present when (1) CT scan showed opacification and/or air-fluid levels in the maxillary, ethmoid and sphenoid sinuses and (2) aspiration of both maxillary sinuses yielded pus, cultures of which revealed a high concentration of micro organisms. Nosocomial pneumonia and bacteremia were considered related to the N P if the organisms found in the sinus were identical to those recovered from the blood and/or the bronchi. During an 18-month study period, 38 cases of sinusitis were diagnosed. N P was present in 13 patients: 18 organisms (12 Gram-negative, 5 Gram-positive and 1 Candida albicans) were isolated. Pneumonia occurred in 8 patients, 6 with multi-resistant Pseudomonas aeruginosa and 2 with methicillin resistant Staphylococcus aureus. Pseudomonas aeruginosa was isolated from the blood, lung and sinus in two patients. This study demonstrates that N P is relatively frequent in patients requiring long-term mechanical ventilation, even in the absence of predisposing factors. N P in these patients is mostly monomicrobial with multi-resistant Pseudomonas aeruginosa and Staphylococcus aureus as the main causative agents.

Nosocomial pansinusitis in orotracheally intubated critically ill patients.

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Nosocomial pansinusitis in orotracheally intubated critically ill patients.