[Diagnosis of pneumonia in intubated patients: a controversy without resolution?]

There is yet no accurate, fast, innocuous and inexpensive method for the diagnosis of pneumonia associated to ventilation (NAV). Here we analyse three diagnostic lines of increasing level of certainty. CLINICA METHOD: Associates radiological image, pus in the trachea and temperature changes and or leukocytosis. Although it is quite sensitive in the absence of distress, is it not very specific. Nevertheless, it must be appreciated for its function as a guide, recalling that in its absence bacterial counts are of scarce value. QUANTITATIVE BACTERIOLOGICAL STUDIES OF DEEP SPECIMENS: Broncho-alveolar lavage (BAL) and protected brush (PB) serve a double objective: to discriminate colonisation from infection, and the identification of the etiological agent. The sensitivity of BAL/PB is approximately 70% while specificity is close to 80%. The method performs better in the absence of previous antibiotic therapy. HISTOLOGICAL DIAGNOSIS: Almost never obtained while the patient is alive, it is nevertheless the golden standard. The absolute diagnosis of NAV is: histological for pneumonia, with a positive tissue culture. USE OF DIAGNOSIS IN THERAPY: Empirical treatment results in a 40% failure rate. The specific treatment requires therapeutic changes in more than 1/3 of cases. Treatment when the micro-organism is known is followed by longer survival. Perhaps the correct approach would be: early empirical treatment after taking deep samples and correction according to the results obtained.