Ventilator-Associated Tracheobronchitis: Pathophysiology, Prevention and Treatment

Purpose of Review: This review focuses on the pathophysiology of proximal airway infection in the ventilated patient and ways to prevent or treat it. Ventilator-associated tracheobronchitis (VAT) is increasingly recognized as an important entity. While there is some controversy whether VAT is always an essential step in the pathway from oral colonization to deep lung infection, all agree that it is an infection associated with its own morbidity and that it acts as a reservoir of highly resistant organisms. Recent Findings: Recent clinical trials have focused on new prophylactic and treatment protocols for ventilator-associated infection. There are multiple steps in the pathway from pathogenic oropharyngeal colonization to ventilator-associated tracheobronchitis, and/or to deep lung infection, ventilator-associated pneumonia (VAP) where intervention is possible. Oral care protocols, innovative types of endotracheal tubes and cuffs, and targeted therapy for VAT in recent investigations, have shown promise in improving clinical outcomes in the critically ill patients. However, even with diligent attention to all the modifiable risk factors for respiratory infection, complete elimination of VAT and VAP remains unlikely. As long as a patient requires an endotracheal tube which disturbs airway integrity, host defenses will be impaired, and resistant virulent organisms which result from our liberal use of systemic antibiotics will continue to challenge critical care specialists. Summary: This review will focus on: 1) the current understanding of the pathogenesis of VAT, 2) modifiable risk factors, and 3) new approaches to treatment in the ICU which may decrease systemic antibiotic use.