Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals 2014 Update Dr Neda Alijani

Strategies to Prevent VAP Basic practice Special approach Not recommended No recommendation

Basic Practices I. Basic Practices

A: Avoid intubation if possible Use noninvasive positive pressure ventilation in selected populations Br J Anaesth 2013;110(6):896–914 High Basic Practices

B. Minimize sedation 1-Manage patients without sedation whenever possible Preferentially use agents and strategies other than benzodiazepines to manage agitation, such as analgesics for patients in pain reassurance antipsychotics dexmedetomidine propofol Lancet 2010;375(9713):475–480 Moderate

Crit Care Med 2004;32(6):1272–1276 B. Minimize sedation 2-Interrupt sedation daily(spontaneous awakening trials) High Basic Practices

Am J Respir Crit Care Med 2006;174(8):894–900 3-Assess readiness to extubate daily Daily spontaneous breathing trials are associated with extubation 1–2 days earlier compared with usual care Basic Practices B.Minimize sedation

Lancet 2008;371(9607):126–134 4-Perform spontaneous breathing trials with sedatives turned off Basic Practices B. Minimize sedation

► Facilitate early mobility Early exercise and mobilization:  ↓ Length of stay  ↑ The rate of return to independent function  May be cost saving Basic Practices C. Maintain and improve physical conditioning Crit Care Med 2014;42(5):1024–1036

Basic Practices D. Minimize pooling of secretions above the endotracheal tube cuff Utilize endotracheal tubes with subglottic secretion drainage ports for pts expected to require > 48 or 72 h. of MV Crit Care Med 2011;39(8):1985–1991

Basic Practices Extubating patients to place a subglottic secretion drainage endotracheal tube is not recommended

Basic Practices Basic Practices E. Elevate the head of the bed Elevate the head of the bed to 30–45 J Crit Care 2009;24(4):515–522 poor

Basic Practices Basic Practices F. Maintain ventilator circuits 1-Change the ventilator circuit only if visibly soiled or malfunctioning Infect Control Hosp Epidemiol 2004;25(12):1077–1082

Special Approaches II. Special Approaches

Special Approaches A. Interventions that decrease duration of MV, length of stay, and/or mortality but for which insufficient data on possible risks are available

Special Approaches Special Approaches Selective oral or digestive decontamination Lancet Infect Dis 2013;13(4):328–341 This strategy has not yet been adopted: ↑MDR infections (CDI) Most studies do not indicate an elevated short-term risk for antimicrobial resistance, but long-term studies are lacking.

Special Approaches B. Interventions that may lower VAP rates but for which there are insufficient data at present to determine their impact on duration of MV, length of stay, and mortality

Special Approaches 1-Regular oral care with chlorhexidine JAMA Intern Med 2014;174(5):751–761

Special Approaches 2-Prophylactic probiotics Chest 2013;143(3):646–655

Probiotics Probiotics should not be used Compromised immune systems GI diseases

Probiotics  There are multiple case reports of: Fungemia Bacteremia Aerosol transmission of probiotics J Infect 2007;54(3):310–311

Special Approaches 3-Ultrathin polyurethane endotracheal tube cuffs Seal more uniformly against the tracheal wall Allow fewer secretions to seep around the cuff and into the lungs J Thorac Cardiovasc Surg 2008;135(4):771–776

Special Approaches 4- Automated control of endotracheal tube cuff pressure Am J Respir Crit Care Med 2011;184(9):1041–1047

Special Approaches 5- Saline instillation before tracheal suctioning Crit Care Med 2009;37(1):32–38

Special Approaches 6-Mechanical tooth brushing Crit Care Med 2013;41(2):646–655

III. Approaches that are generally not recommended for routine VAP prevention

A. Generally Not Recommended  Interventions that may lower VAP rates  But good-quality evidence suggests no impact on:  Duration of MV  Length of stay  Mortality

Generally Not Recommended 1- Silver-coated endotracheal tubes JAMA 2008;300(7):805–813

Generally Not Recommended 2- Kinetic beds Crit Care 2006;10(3):R70

Generally Not Recommended 3- Prone positioning N Engl J Med 2013;368(23):2159–2168

B. Definitively Not Recommended Interventions with good-quality evidence suggesting:  Neither lower VAP rates  Nor decrease duration of MV, length of stay, or mortality

Definitively Not Recommended 1-Stress ulcer prophylaxis lowers the risk of gastrointestinal bleeding Crit Care Med 2013;41(3):693–705 Stress ulcer prophylaxis may be indicated for reasons other than VAP prevention.

Definitively Not Recommended 2-Early tracheotomy Chest 2011;140(6):1456–1465

Definitively Not Recommended 3-Monitoring residual gastric volumes JAMA 2013;309(3):249–256

Definitively Not Recommended 4-Early parenteral nutrition Initiation of parenteral nutrition in critically ill patients within 48 hours of ICU admission is associated with an increased risk of nosocomial infections and mortality compared with initiating parenteral nutrition on or after 8 days N Engl J Med 2011;365(6):506–517

IV. Approaches that neither recommended nor discouraged

Neither Recommended Nor Discouraged Closed/in-line endotracheal suctioning Crit Care Med 2011;39(6):1313–1321

Strategies to Prevent VAP Basic practice Special approach Not recommended No recommendation

Basic Practices Noninvasive positive pressure Minimize sedation Early mobility Subglottic secretion drainage ports Change the ventilator circuit only if visibly soiled or malfunctioning Elevate the head of the bed to 30–45

Special Approaches Oral or digestive decontamination Oral care with chlorhexidine Prophylactic probiotics Ultrathin polyurethane endotracheal tube cuffs Automated control of endotracheal tube cuff pressure Saline instillation Mechanical tooth brushing

Generally Not Recommended Silver-coated endotracheal tubes Kinetic beds Prone positioning

Definitively Not Recommended Stress ulcer prophylaxis Early tracheotomy Monitoring residual gastric volumes Early parenteral nutrition

No Recommendation Closed/in-line endotracheal suctioning