The relationship between ventilator-associated pneumonia and chronic obstructive pulmonary disease: what is the current evidence?

  • Despoina Koulenti
  • Francesca Romana ParisellaEmail author
  • Elena Xu
  • Jeffrey Lipman
  • Jordi Rello


Chronic obstructive pulmonary disease (COPD) affects approximately 65 million people from which > 25% will require intensive care unit (ICU) admission. Ventilator-associated pneumonia (VAP) is the commonest ICU infection and results in increased morbidity/mortality and costs. The literature on the interaction between COPD and VAP is scarce and controversial. The project aimed to search the literature in order to address the following: (i) Is COPD a risk factor for VAP development? (ii) Does COPD impact the outcome of patients with VAP? (iii) Does VAP development impact the outcome of COPD patients? (iv) Does COPD impact the aetiology of VAP? Current evidence on the topic is controversial. Regarding the impact of VAP on COPD patients, the majority of the existing limited number of studies suggests that VAP development results in higher mortality and longer duration of mechanical ventilation and ICU stay. Also, the majority of the studies exploring the impact of COPD on VAP outcomes suggest that COPD is independently associated with a decrease in survival, although the number of such studies is limited. Regarding the aetiology, Pseudomonas aeruginosa is the most frequent pathogen in VAP patients with COPD. Noteworthy, one study suggests that P. aeruginosa is higher in COPD patients even in the early-onset VAP subgroup. This manuscript provides a comprehensive overview of the available literature on the interaction between COPD and VAP, highlighting the differences and limitations that may have led to controversial results, and it may act as a platform for further research with important clinical implications.


Respiratory infections Critically ill patient Intubation Chronic bronchitis Epidemiology Hospital-acquired pneumonia Mechanical ventilation COPD ICU VAP 



Supported in part by Observership Grant Programme (ESCMID, Basel, Switzerland) and PCI Pneumonia - Centro de Investigacion Biomedica en Red en Enfermedades Respiratorias (CIBERES), Madrid, Spain.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    American Thoracic Society (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171:388–416. CrossRefGoogle Scholar
  2. 2.
    Kalil AC, Metersky ML, Klompas M et al (2016) Management of Adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 63:e61–e111. CrossRefGoogle Scholar
  3. 3.
    Koulenti D, Lisboa T, Brun-Buisson C et al (2009) Spectrum of practice in the diagnosis of nosocomial pneumonia in patients requiring mechanical ventilation in European intensive care units. Crit Care Med 37:2360–2369. CrossRefGoogle Scholar
  4. 4.
    Koulenti D, Tsigou E, Rello J (2017) Nosocomial pneumonia in 27 ICUs in Europe: perspectives from the EU-VAP/CAP study. Eur J Clin Microbiol Infect Dis 36:1999–2006. CrossRefGoogle Scholar
  5. 5.
    Koulenti D, Blot S, Dulhunty JM et al (2015) COPD patients with ventilator-associated pneumonia: implications for management. Eur J Clin Microbiol Infect Dis 34:2403–2411. CrossRefGoogle Scholar
  6. 6.
    Rello J, Lisboa T, Koulenti D (2014) Respiratory infections in patients undergoing mechanical ventilation. Lancet Respir Med 2:764–774. CrossRefGoogle Scholar
  7. 7.
    Warren DK, Shukla SJ, Olsen MA et al (2003) Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 31:1312–1317. CrossRefGoogle Scholar
  8. 8.
    Kollef MH, Hamilton CW, Ernst FR (2012) Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol 33:250–256. CrossRefGoogle Scholar
  9. 9.
    Melsen WG, Rovers MM, Groenwold RH et al (2013) Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis 13:665–671. CrossRefGoogle Scholar
  10. 10.
    Vandana Kalwaje E, Rello J (2018) Management of ventilator-associated pneumonia: need for a personalized approach. Expert Rev Anti-infective Ther 16:641–653. CrossRefGoogle Scholar
  11. 11.
    Celli BR (2010) Predictors of mortality in COPD. Respir Med 104:773–779. CrossRefGoogle Scholar
  12. 12.
    Rabe KF, Hurd S, Anzueto A et al (2007) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 176:532–555. CrossRefGoogle Scholar
  13. 13.
    World Health Organisation World Health Statistics 2008. 2008 ; Available from: [accessed 2018 December 18]
  14. 14.
    Akkutuk E, Karakurt Z, Salturk C et al (2014) How do COPD comorbidities affect ICU outcomes? Int J Chron Obstructive Pulm Dis:1187.
  15. 15.
    Chastre J, Fagon J-Y (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903. CrossRefGoogle Scholar
  16. 16.
    Restrepo MI, Sibila O, Anzueto A (2018) Pneumonia in patients with chronic obstructive pulmonary disease. Tuberc Respir Dis 81:187. CrossRefGoogle Scholar
  17. 17.
    Gursel G (2005) Determinants of the length of mechanical ventilation in patients with COPD in the intensive care unit. Respiration 72:61–67. CrossRefGoogle Scholar
  18. 18.
    Schmidt M, Demoule A, Deslandes-Boutmy E et al (2014) Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician’s decision-making process. Crit Care 18:R115. CrossRefGoogle Scholar
  19. 19.
    Funk G-C, Bauer P, Burghuber OC et al (2013) Prevalence and prognosis of COPD in critically ill patients between 1998 and 2008. Eur Respir J 41:792–799. CrossRefGoogle Scholar
  20. 20.
    Crim C, Calverley PMA, Anderson JA et al (2009) Pneumonia risk in COPD patients receiving inhaled corticosteroids alone or in combination: TORCH study results. Eur Respir J 34:641–647. CrossRefGoogle Scholar
  21. 21.
    Ernst P, Gonzalez AV, Brassard P, Suissa S (2007) Inhaled corticosteroid use in chronic obstructive pulmonary disease and the risk of hospitalization for pneumonia. Am J Respir Crit Care Med 176:162–166. CrossRefGoogle Scholar
  22. 22.
    Myles PR, McKEEVER TM, Pogson Z et al (2009) The incidence of pneumonia using data from a computerized general practice database. Epidemiol Infect 137:709. CrossRefGoogle Scholar
  23. 23.
    Vinogradova Y, Hippisley-Cox J, Coupland C (2009) Identification of new risk factors for pneumonia: population-based case-control study. Br J Gen Pract 59:e329–e338. CrossRefGoogle Scholar
  24. 24.
    Rodríguez A, Lisboa T, Solé-Violán J et al (2011) Impact of nonexacerbated COPD on mortality in critically ill patients. Chest 139:1354–1360. CrossRefGoogle Scholar
  25. 25.
    Tejerina E, Frutos-Vivar F, Restrepo MI et al (2006) Incidence, risk factors, and outcome of ventilator-associated pneumonia. J Crit Care 21:56–65. CrossRefGoogle Scholar
  26. 26.
    Hortal J, Giannella M, Pérez MJ et al (2009) Incidence and risk factors for ventilator-associated pneumonia after major heart surgery. Intensive Care Med 35:1518–1525. CrossRefGoogle Scholar
  27. 27.
    Pawar M, Mehta Y, Khurana P et al (2003) Ventilator-associated pneumonia: incidence, risk factors, outcome, and microbiology. J Cardiothorac Vasc Anesth 17:22–28. CrossRefGoogle Scholar
  28. 28.
    Sheng W, Xing Q, Hou W et al (2014) Independent risk factors for ventilator-associated pneumonia after cardiac surgery. J Investig Surg 27:256–261. CrossRefGoogle Scholar
  29. 29.
    Tamayo E, Álvarez FJ, Martínez-Rafael B et al (2012) Ventilator-associated pneumonia is an important risk factor for mortality after major cardiac surgery. J Crit Care 27:18–25. CrossRefGoogle Scholar
  30. 30.
    Torres A, Aznar R, Gatell JM et al (1990) Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 142:523–528. CrossRefGoogle Scholar
  31. 31.
    He S, Chen B, Li W et al (2014) Ventilator-associated pneumonia after cardiac surgery: a meta-analysis and systematic review. J Thorac Cardiovasc Surg 148:3148–3155.e5. CrossRefGoogle Scholar
  32. 32.
    Chang L, Dong Y, Zhou P (2017) Investigation on risk factors of ventilator-associated pneumonia in acute cerebral hemorrhage patients in intensive care unit. Can Respir J 2017:1–4. Google Scholar
  33. 33.
    Karataş M, Saylan S, Kostakoğlu U, Yılmaz G (2016) An assessment of ventilator-associated pneumonias and risk factors identified in the intensive care unit. Pak J Med Sci 32.
  34. 34.
    Liu Y, Di Y, Fu S (2017) Risk factors for ventilator-associated pneumonia among patients undergoing major oncological surgery for head and neck cancer. Frontiers of Medicine 11:239–246. CrossRefGoogle Scholar
  35. 35.
    Al-Dorzi HM, El-Saed A, Rishu AH et al (2012) The results of a 6-year epidemiologic surveillance for ventilator-associated pneumonia at a tertiary care intensive care unit in Saudi Arabia. Am J Infect Control 40:794–799. CrossRefGoogle Scholar
  36. 36.
    Ibn Saied W, Souweine B, Garrouste-Orgeas M et al (2017) Respective impact of implementation of prevention strategies, colonization with multiresistant bacteria and antimicrobial use on the risk of early- and late-onset VAP: an analysis of the OUTCOMEREA network. PLoS One 12:e0187791. CrossRefGoogle Scholar
  37. 37.
    Rinaudo M, Ferrer M, Terraneo S et al (2015) Impact of COPD in the outcome of ICU-acquired pneumonia with and without previous intubation. Chest 147:1530–1538. CrossRefGoogle Scholar
  38. 38.
    Gursel G (2006) Does coexistence with bronchiectasis influence intensive care unit outcome in patients with chronic obstructive pulmonary disease? Heart Lung 35:58–65. CrossRefGoogle Scholar
  39. 39.
    Makris D, Desrousseaux B, Zakynthinos E et al (2011) The impact of COPD on ICU mortality in patients with ventilator-associated pneumonia. Respir Med 105:1022–1029. CrossRefGoogle Scholar
  40. 40.
    Lisboa T, Diaz E, Sa-Borges M et al (2008) The ventilator-associated pneumonia PIRO score. Chest 134:1208–1216. CrossRefGoogle Scholar
  41. 41.
    Rello J, Ausino V, Ricart M et al (1993) Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest 104:1230–1235. CrossRefGoogle Scholar
  42. 42.
    American Thoracic Society (1987) Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma. Am Rev Respir Dis 136:225–244. CrossRefGoogle Scholar
  43. 43.
    Nseir S, Di Pompeo C, Soubrier S et al (2005) Impact of ventilator-associated pneumonia on outcome in patients with COPD. Chest 128:1650–1656. CrossRefGoogle Scholar
  44. 44.
    Badawy MS, Omar HM, Mohamdien HA et al (2015) Evaluation of risk factors of ventilator associated pneumonia on outcome of acute exacerbation of chronic obstructive pulmonary disease. Egypt J Chest Dis Tuberc 64:799–803. CrossRefGoogle Scholar
  45. 45.
    Hadda V, Dubey G, Nallan R et al (2014) Impact of ventilator associated pneumonia on outcome in patients with chronic obstructive pulmonary disease exacerbation. Lung India 31:4. CrossRefGoogle Scholar
  46. 46.
    Talon D, Mulin B, Rouget C et al (1998) Risks and routes for ventilator-associated pneumonia with Pseudomonas aeruginosa. Am J Respir Crit Care Med 157:978–984. CrossRefGoogle Scholar
  47. 47.
    Rello J, Ausina V, Ricart M et al (1994) Risk factors for infection byPseudomonas aeruginosa in patients with ventilator-associated pneumonia. Intensive Care Med 20:193–198. CrossRefGoogle Scholar
  48. 48.
    Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36:309–332. CrossRefGoogle Scholar
  49. 49.
    Celli BR, MacNee W, Agusti A et al (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 23:932–946. CrossRefGoogle Scholar
  50. 50.
    Heyland DK, Cook DJ, Griffith L et al (1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. Am J Respir Crit Care Med 159:1249–1256. CrossRefGoogle Scholar
  51. 51.
    CDC (2003) NNIS criteria for determining nosocomial pneumoniaGoogle Scholar
  52. 52.
    Pugin J, Auckenthaler R, Mili N et al (1991) Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis 143:1121–1129. CrossRefGoogle Scholar
  53. 53.
    Yangco B (1989) CDC definitions for nosocomial infections. Am J Infect Control 17:42–43. CrossRefGoogle Scholar
  54. 54.
    American Thoracic Society (1995) Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 152(suppl):S77–S121Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.UQ Centre for Clinical Research, Faculty of MedicineThe University of QueenslandBrisbaneAustralia
  2. 2.Royal Brisbane Clinical Unit, Faculty of MedicineThe University of QueenslandBrisbaneAustralia
  3. 3.2nd Critical Care DepartmentAttikon University HospitalAthensGreece
  4. 4.Department of Intensive Care MedicineRoyal Brisbane and Women’s HospitalBrisbaneAustralia
  5. 5.Vall d’Hebron Institute of Research (VHIR) & CIBERESInstituto Salud Carlos IIIBarcelonaSpain

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