الفهرس 
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Abstract
Ventilator-associated pneumonia (VAP) is a subset of (HAP) that develops after more than 48 hours of initiation of endotracheal intubation and mechanical ventilation (MV). VAP is the most frequent ventilator-associated complication (VAC).
VAP represent a major cause of deaths, morbidity and resources utilization in hospitalized patients, most notably in those with sever underlying condition.
The pathogenesis of ventilator-associated pneumonia (VAP) is related to the number and virulence of microorganisms entering the lower respiratory tract and the response of the host (eg, mechanical, humeral, and cellular host defenses).The primary route of infection of the lungs is through micro aspiration of organisms that have colonized the oropharyngeal tract (or, to lesser extent, the gastrointestinal tract).
Diagnosis of VAP is dependent on the clinical criteria (CPIS more than 6), the microbiological criteria, and the radiological criteria and biomarkers whish help diagnosis, assess prognosis, and to follow up treatment. Quantitative cultures of both BAL and NB-BAL were studied and evaluated.
Appropriate antibiotic therapy significantly improves survival for patients with ventilator-associated pneumonia (VAP).When therapy is given, antimicrobial selection should be based upon risk factors for multidrug-resistant (MDR) pathogens , including recent antibiotic therapy, the resident flora in the hospital or intensive care unit (ICU), the presence of underlying diseases, and available culture data (interpreted with care). For patients with risk factors for MDR pathogens, empiric broad-spectrum, multi drug therapy is
recommended. Once the results of pre therapy cultures are available, therapy should be narrowed based upon the susceptibility pattern of the pathogens identified.
The aim of this study is to compare the diagnostic value of various methods of collecting respiratory samples which include bronchoscopic BAL and non-bronchoscopic protected BAL, in patients with VAP.
This study was conducted in critical care unit (ICU) at Menoufyia University Hospitals. 20 patients with ventilator associated pneumonia were concluded in the study. Clinical pulmonary infection score was used to diagnose VAP. History, clinical examination, routine laboratory investigation and chest X-ray were done before sampling. Two respiratory samples were collected which include bronchoscopic BAL, and NB-BAL. all samples transported for quantitative culture and the growths were expressed as number of colony forming units (CFU)/ml. The thresholds applied to quantitative cultures for the diagnosis of VAP were 104 CFU/ml for NB-BAL and bronchoscopic BAL.
The result of our study showed that the patient’s demographics data not significantly affect the result of cultures in both techniques.
Poly microbial and MDR organisms were isolated by both techniques in early and late onset VAP in our ICU.
Comorbidities were significantly affecting the type of microorganisms and MDR organisms were isolated in all patients with underlying chest problems Kelibseilla pneumonia was the commonest organism isolated in both techniques followed by acenitobacter and pseudomonas organisms.
Hypoxia and arrhythmia are the commonest complication detected and there are detected on BAL more than NB-BAL.
Percentage of concordance between non-bronchoscopic protected BAL and CPIS was 90% and between bronchoscopic BAL and CPIS was 95%.
We observed high concordance for the type of microorganisms between non-bronchoscopic protected BAL and bronchoscopic BAL.
According to our results and previous studies done on this issue, NB-BAL can replace BAL in distal airway sampling for diagnosis of VAP as it has a high concordance with BAL and less expensive, easy to be done as there is no need for expertise, lesser cost and lesser complication.
NB-BAL is a blind procedure and used mainly in case of right sided or bilateral diffuse infiltrate in chest X ray not in left sided infiltrate as it cannot be directed to left main bronchus.