Ventilator-Associated
Pneumonia: What can we do
to prevent it?
Elevation of the Head of the Bed
Elevation of HOB: Evidence
• Semi-recumbent position decreases gastro-
esophageal reflux and subsequent aspiration
– Study with radioactively-labeled gastric contents
demonstrated reflux and aspiration reduced when HOB at
45°
– Various degrees of HOB elevation have not been
compared, but some degree of elevation appears
warranted
• Prospective cohort study of 277 patients requiring
mechanical ventilation
– Supine head position associated with 3-fold increase in risk
of VAP
Torres A, et al. Ann Intern Med. 1992;116:540. Kollef M, et al. JAMA. 1993;270:1965.
Elevation of HOB: Evidence
• RCT in 2 ICUs
• 3 of 39 (8%) pts in semi-
recumbent group (45°)
vs. 16/47 (34%) in supine
group (0°) developed
VAP (p=0.003)
• Study terminated early
at interim analysis
Drakulovic M, et al. Lancet. 1999;354:1851.
Elevation of HOB: Recommendation
• HOB should be elevated ≥30°
– Exceptions
• 15-30° < 1 year of age
• ECMO
• Oscillator
• Premature neonates (<30 wks gestational age) during
first month of life
• Patients for whom attending physician is concerned
there is a contraindication (must document reason)
• Procedures during which elevated HOB is prohibitive
Chlorhexidine Oral Care
CHG Oral Care: Evidence
• Gingival and dental plaque rapidly becomes
colonized with bacteria in intubated patients due to
poor oral hygiene and lack of mechanical
elimination
• Meticulous oral care reduces microbial burden in
upper airway
• Safety and feasibility of CHG oral care appear
favorable
DeRiso A, et al. Chest. 1996;109:1556. Chan E, et al. BMJ. 2007;10:1136. Chlebicki M,
et al. 2007. 35:595.
CHG Oral Care: Evidence
• Oral decontamination for prevention of VAP in
mechanically ventilated patients: meta-analysis
– 7 RCTs with 2144 patients found that oral antiseptics
significantly reduced incidence of VAP by 44% (RR 0.56,
0.39-0.81)
• Topical CHG for prevention of VAP: meta-analysis
– 7 RCTs with 1650 patients found a trend towards decreased
VAP with use of oral CHG care (RR 0.70; 0.47-1.04)
CHG Oral Care: Recommendations
• Chorhexidine 0.12% oral solution (15 ml bid until 24
hours after extubation) for all intubated patients
– Exceptions
• Hypersensitivity to component of solution
• <18 years of age
• Brush patients’ teeth bid with soft toothbrush to
remove dental plaque prior to using CHG
• Continue routine q4-6 hr routine oral care: cleaning
and moistening mouth using oral swabs or sterile
water and gauze
Subglottic Suctioning
Subglottic Suctioning: Evidence
• Drainage of subglottic secretions lessens the risk of
aspiration
• Specially designed endotracheal tubes have been
developed to provide continuous or intermittent
subglottic secretion removal
Kollef M, et al. Chest. 1999;116:1339. Smulders K, et al. Chest 2002;121:858.
Device for Continuous Aspiration of Subglottic Secretions
Valles J, et al. Ann Intern Med. 1995;122:179.
Subglottic Suctioning: Evidence
• Subglottic secretion drainage for the prevention of
VAP: meta-analysis
– 13 RCTs with 2442 patients
– 12/13 studies reported reduction in VAP rates in subglottic
secretion arm
– Overall reduction in VAP rates was 45%
– Subglottic secretion drainage also associated with
reduced duration of mechanical ventilation and ICU LOS
Muscedere J, et al. Crit Care Med. 2011;39:1985.
Subglottic Suctioning:
Recommendations
• Continuous subglottic suctioning system
recommended for patients expected to be
mechanically ventilated for >72 hours
– Exceptions
• Units that do not use cuffed ETTs: continue routine q1-2
hr and prn suctioning
Sedation Vacation
Sedation Vacation: Definition
• Daily scheduled interruptions of sedation based on
criteria
– If candidate for sedation interruption, sedation decreased
or turned off to determine if extubation criteria met
– If extubation criteria met, patient is extubated
Sedation Vacation: Evidence
• Weaning patients from ventilator easier when
patients able to assist with extubation by coughing
and controlling secretions
• Lightening sedation decreases amount of time
patients remain mechanically ventilated
– RCT of 128 mechanically ventilated pts: >2 day reduction in
duration of mechanical ventilation in arm with scheduled
interruption of sedation(~7 to 5 days, p<0.01)
Schewickert W, et al. Crit Care Med. 2004;32;1272.
Sedation Vacation:
Recommendations
• Lighten or discontinue sedation at least once daily
until patient is awake, can follow commands, or
until he/she becomes uncomfortable or agitated
– Use validated sedation scale (i.e., RASS)
– Usually performed by nursing and RT, but will leave to
discretion of individual units
– Caution: Patients not sedated as deeply have potential for
self-extubation and associated risks
– Exception
• Patients for whom attending physician is concerned
there is a contraindication (must document reason)
Curtis N, et al. Am J Respir Crit Care Med. 2002;166:1338.
Assessment of Readiness to Extubate
Assessment of Readiness to
Extubate: Evidence
• Decreased time on ventilator = decreased risk of
VAP
• Before-and-after study of standardized nurse and
RT-driven ventilator weaning protocol
– Reduced VAP rates by 10%
Dries D, et al. J Trauma. 2004;56:943.
Assessment of Readiness to
Extubate: Recommendation
• Daily spontaneous awakening and breathing trials
when sedation is weaned
– Assess adequate hemodynamic and respiratory status as
well as ability to manage secretions
– Usually performed by nursing and RT, but will leave to
discretion of individual units
– Patients deemed candidates for extubation should be
discussed with ICU physicians
– Exception
• Patients for whom attending physician is concerned
there is a contraindication (must document reason)
Summary
1- HOB ≥30°
2- Chlorhexidine oral care
3- Subglottic suctioning
4- Sedation vacation
5- Assessment of Readiness to extubate
