What are the steps to mitigate or minimize Ventilator-Associated Pneumonia (VAP)?

From the Guidelines

To minimize ventilator-associated pneumonia (VAP), healthcare providers should implement a comprehensive bundle of preventive measures, including semi-recumbent positioning, use of closed endotracheal suction systems, and heat and moisture exchangers, as recommended by the evidence-based clinical practice guideline 1. The key steps to mitigate or minimize VAP include:

• Semi-recumbent positioning in the absence of contraindications to reduce aspiration risk
• Use of closed endotracheal suction systems that are changed for each new patient and as clinically indicated to prevent cross-contamination
• Implementation of heat and moisture exchangers in the absence of contraindications, with weekly changes, to maintain a humid environment and prevent dryness in the airways
• Consideration of subglottic secretion drainage and kinetic beds for patients at high risk of VAP
• Avoidance of routine changes of ventilator circuits, unless they are soiled, to prevent unnecessary disruption of the ventilator system
• Avoidance of sucralfate to prevent VAP in patients at high risk for gastrointestinal bleeding, as well as topical antibiotics to prevent VAP, due to lack of evidence supporting their effectiveness 1. It is essential to note that the implementation of these measures should be tailored to the individual patient's needs and contraindications, and that a comprehensive approach to VAP prevention is crucial to reducing morbidity, mortality, and healthcare costs associated with this condition 1.

From the Research

Steps to Mitigate or Minimize Ventilator-Associated Pneumonia

The following steps can be taken to mitigate or minimize ventilator-associated pneumonia:

• Hand hygiene, wearing gloves, endotracheal tube suctioning, head of bed at 30°, stress ulcer prophylaxis, turning patient side to side at least every two hours, and giving the patient a sedation vacation each morning 2
• Oral hygiene, oral suctioning, endotracheal tube cuff pressure, artificial humidification, using the beach chair position and early mobilization, and the VAP bundle 2
• Multidisciplinary teamwork, involvement of local champions, and networking among peers to enhance adoption of VAP prevention interventions 3
• Training sessions and developing succinct summaries of the evidence to educate staff on VAP prevention 3
• Standardization of care processes and building redundancies into routine care to execute VAP prevention strategies 3
• Measuring performance and providing feedback to staff to evaluate the effectiveness of VAP prevention strategies 3

Suctioning Techniques

• Closed suction systems have no clear advantage over open suction, but may better prevent late-onset ventilator-associated pneumonia 4
• Subglottic secretion drainage reduces ventilator-associated pneumonia incidence 4, 5
• Open versus closed suction combined with subglottic secretion drainage requires ongoing research 4

Effectiveness of Subglottic Secretion Drainage

• Subglottic secretion drainage significantly reduces VAP incidence and mortality 5
• Subglottic secretion drainage is an effective measure to reduce VAP incidence, despite not improving the duration of mechanical ventilation and ICU and/or hospital length of stay 5