What is the recommended protocol for preventing and treating ventilator-associated pneumonia (VAP) in at-risk patients?

Ventilator-Associated Pneumonia (VAP) Prevention Protocol

Implement a comprehensive VAP prevention bundle with head-of-bed elevation to 30-45°, oral care with toothbrushing (without chlorhexidine), closed endotracheal suctioning, subglottic secretion drainage for patients expected to be ventilated >72 hours, daily sedation interruption with spontaneous breathing trials, and early enteral nutrition. 1, 2

Core Prevention Bundle Components

Positioning and Airway Management

• Elevate the head of bed to 30-45° at all times unless medically contraindicated, as this single intervention significantly reduces aspiration risk 1, 2
• Use orotracheal intubation route rather than nasotracheal to reduce sinusitis and VAP risk 2, 3
• Insert gastric tubes via the oral route instead of nasal 2
• Avoid gastric overdistention during the intubation process 2

Oral Care Protocol

• Perform oral care with toothbrushing every 8 hours 1, 2
• Do NOT use chlorhexidine oral rinse for routine VAP prevention, as recent high-quality evidence shows it does not reduce mortality and may cause harm 1
• The exception is cardiac surgery patients perioperatively, where chlorhexidine gluconate 0.12% may be considered 1

Endotracheal Tube Management

• Use closed endotracheal suction systems changed only for each new patient and when clinically indicated, not on a schedule 1, 3
• Implement continuous subglottic secretion drainage for patients expected to be mechanically ventilated >72 hours, as this reduces early-onset VAP 1, 2
• Maintain endotracheal cuff pressure at 20 cm H₂O (minimum occlusive setting) 2
• Clear secretions from above the tube cuff before deflating or moving the endotracheal tube 1

Sedation and Ventilator Liberation

• Minimize sedation using protocols to reduce duration of mechanical ventilation 2
• Perform daily sedation interruption to assess readiness for extubation 2
• Conduct daily spontaneous breathing trials in patients without contraindications 2
• Implement formal weaning protocols to minimize mechanical ventilation duration 2

Ventilator Circuit Management

• Change ventilator circuits only when visibly soiled or malfunctioning, not on a scheduled basis 1, 2, 3
• Use heat-moisture exchangers (HME) when appropriate for patients without significant secretions, changing every 5-7 days or as clinically indicated 2, 3

Nutrition and Prophylaxis

• Provide early enteral nutrition rather than parenteral nutrition 1, 2
• Verify appropriate placement of feeding tubes routinely 1
• Do NOT use stress ulcer prophylaxis routinely for VAP prevention, as evidence shows no benefit and potential harm 1
• Do NOT monitor residual gastric volumes routinely 1

Hand Hygiene and Infection Control

• Maintain excellent hand hygiene at all times before and after patient contact 2
• Use proper respiratory care hygiene practices 1

Interventions NOT Recommended

Based on the most recent 2025 International Society for Infectious Diseases guidelines, the following should NOT be used for routine VAP prevention:

• Ultrathin polyurethane or tapered ETT cuffs 1
• Kinetic beds or prone positioning 1
• Chlorhexidine bathing 1
• Automated control of ETT cuff pressure 1
• Selective digestive decontamination with topical antibiotics alone 1

Implementation Strategy

Bundle compliance is critical—implementing these measures as a complete package rather than individual interventions yields the greatest VAP reduction 2. Large multinational studies across 374 ICUs in 35 countries demonstrated a 66% reduction in VAP rates with comprehensive bundle implementation 2.

Key Implementation Steps:

• Educate all healthcare providers on bundle components 2
• Establish surveillance and compliance monitoring systems 2
• Provide internal reporting and performance feedback 2
• Ensure multidisciplinary team involvement 4

Special Populations and Considerations

Postoperative Patients

• Instruct preoperative patients at high risk (age >60, abdominal/thoracic surgery, COPD, smoking history) about deep breathing and early ambulation 1
• Encourage all postoperative patients to take deep breaths and ambulate unless contraindicated 1
• Use incentive spirometry in postoperative patients 1

Patients with ARDS

• Maintain heightened suspicion for VAP, as clinical criteria have lower sensitivity (46% false-negative rate) 5
• Consider VAP diagnosis with even one clinical criterion or unexplained deterioration 5

Common Pitfalls to Avoid

• Do not use scheduled ventilator circuit changes—this increases costs without reducing VAP 1, 2, 3
• Avoid chlorhexidine oral rinse for routine VAP prevention despite older guidelines recommending it; the 2025 update shows no mortality benefit 1
• Do not rely solely on clinical criteria for VAP diagnosis, as purulent secretions are common in all ventilated patients and fever/leukocytosis are nonspecific 5
• Do not use kinetic beds routinely—while older 2004 guidelines suggested considering them, the 2025 update shows no benefit 1