Prevention of Ventilator associated Pneumonia
- Recommendations
Recommendations
|
Recommendations to Prevent VAP and/or VAE in Adult Patients |
Avoid intubation and prevent reintubation. Use high-flow nasal oxygen or non-invasive positive pressure ventilation (NIPPV) as appropriate whenever safe and feasible (Strong Recommendation, High Evidence Grade) |
Minimize sedation · Avoid benzodiazepines in favour of other agents · Use a protocol to minimize sedation · Implement a ventilator liberation protocol (Strong Recommendation, Moderate Evidence Grade) |
Maintain and improve physical conditioning (Strong Recommendation, Moderate Evidence Grade) |
Elevate the head of the bed to 30–45° (Strong Recommendation, Low Evidence Grade) |
Provide oral care with toothbrushing but without chlorhexidine (Strong Recommendation, Moderate Evidence Grade) |
We recommend early enteral nutrition in preference to parenteral nutrition (Strong Recommendation, High Evidence Grade) |
Change the ventilator circuit only if visibly soiled or malfunctioning (or per manufacturers’ instructions) (Strong Recommendation, High Evidence Grade) |
Consider early tracheostomy (Conditional Recommendation, Moderate Evidence Grade) |
Consider the use of endotracheal tubes with subglottic secretion drainage ports for patients expected to require >48–72 hours of mechanical ventilation (Conditional Recommendation, Moderate Evidence Grade) |
Consider post pyloric rather than gastric feeding for patients with gastric intolerance or at high risk for aspiration (Conditional Recommendation, Moderate Evidence Grade) |
Recommendations to Prevent VAP and/or VAE in Preterm Neonates |
Use non-invasive positive pressure ventilation in selected populations (Strong Recommendation, High Evidence Grade) |
Minimize the duration of mechanical ventilation (Strong Recommendation, High Evidence Grade) |
Use caffeine therapy to facilitate extubating (Strong Recommendation, High Evidence Grade) |
Assess readiness to extubate daily (Strong Recommendation, Low Evidence Grade) |
Manage patients without sedation whenever possible (Strong Recommendation, Low Evidence Grade) |
Avoid unplanned extubations and reintubations (Strong Recommendation, Low Evidence Grade) |
Provide regular oral care with sterile water (Strong Recommendation, Low Evidence Grade) |
Change the ventilator circuit only if visibly soiled or malfunctioning (or per manufacturer’s instructions) (Strong Recommendation, Low Evidence Grade) |
Apply lateral recumbent positioning (Conditional Recommendation, Low Evidence Grade) |
Apply reverse Trendelenburg positioning (Conditional Recommendation, Low Evidence Grade) |
Consider the use of closed/in-line suctioning systems (Conditional Recommendation, Low Evidence Grade) |
Consider oral care with maternal colostrum (Conditional Recommendation, Moderate Evidence Grade) |
Recommendations to Prevent VAP and/or PedVAE in Pediatric Patients |
Avoid intubation if possible. Use non-invasive positive pressure ventilation for selected populations (Strong Recommendation, Moderate Evidence Grade) |
Assess readiness to extubate daily in patients without contraindications (Strong Recommendation, Moderate Evidence Grade) |
Take steps to minimize unplanned extubations and reintubations (Strong Recommendation, Low Evidence Grade) |
Avoid fluid overload (Strong Recommendation, Moderate Evidence Grade) |
Provide regular oral care (i.e., toothbrushing or gauze if no teeth) (Strong Recommendation, Low Evidence Grade) |
Elevate the head of the bed unless medically contraindicated (Strong Recommendation, Low Evidence Grade) |
Change ventilator circuits only if visibly soiled or malfunctioning (or per manufacturer’s instructions) (Strong Recommendation, Moderate Evidence Grade) |
Prevent condensate from reaching the patient (Strong Recommendation, Low Evidence Grade) |
Use cuffed endotracheal tubes (Strong Recommendation, Low Evidence Grade) |
Maintain cuff pressure and volume at the minimal occlusive settings (Strong Recommendation, Low Evidence Grade) |
Suction of oral secretions should be performed before each position change (Strong Recommendation, Low Evidence Grade) |
Interrupt sedation daily (Conditional Recommendation, Moderate Evidence Grade) |
Consider early tracheostomy (Conditional Recommendation, Low Evidence Grade) |
Consider the use of endotracheal tubes with subglottic secretion drainage ports for older pediatric patients expected to require >48 or 72 hours of mechanical ventilation (Conditional Recommendation, Low Evidence Grade) |
Rationale
Hospitalized patients are at high risk for pneumonia and other pulmonary complications, particularly patients on mechanical ventilation. Hospital-acquired pneumonia is one of the most common nosocomial infections.
Patients on mechanical ventilation are at risk for a variety of serious complications in addition to pneumonia as acute respiratory distress syndrome, fluid overload, atelectasis, pneumothorax, barotrauma, and pulmonary embolism.
Implementation of VAP prevention strategies
Multidimensional approach includes six components: (a) bundle, (b) education, (c) surveillance of VAP, (d) monitoring compliance with recommendations to prevent VAP, (e) internal reports of VAP rates, and (f) performance feedback have been conducted, achieving a significant reduction in rates of VAP and mortality in numerous studies.
1. Bundles: Care “bundles” in infection prevention and safety are simple sets of evidence-based practices that, when implemented collectively, improve the reliability of their delivery and improve patient outcomes. Prevention bundles are widespread in critical care and have been associated with decreases in VAP, VAE, Non-Ventilator Hospital-Acquired Pneumonia, and in some cases, length of stay and mortality. Ventilator bundle components potentially associated with lower mortality rates include staff education, performance feedback, and in adults, elevating the head of the bed, minimizing sedation, and assessing readiness for extubation. Additional promising strategies include conservative fluid management, low tidal volume ventilation, and early mobility. In addition to oral and hand hygiene, subglottic suctioning, and cuff pressure control. Head-of-bed elevation and oral hygiene were among the most widely used interventions.
2. Education: Healthcare professionals, patients, and caregivers participating in the care of a MV should receive training and demonstrate competence, commensurate with their roles, in understanding the recommendations to prevent VAP
3. Surveillance of VAP: Employ uniform surveillance methods and definitions to facilitate the comparison of data with benchmark standards. As the one published by the CDC/ National Healthcare Safety Network (NHSN).
4. Internal reporting of VAP rates: These measures are crafted to enhance internal hospital quality improvement initiatives, and it is important to convey these measures to senior hospital leadership, nursing leadership, and clinicians engaged in the care of patients at risk for VAP. When providing internal reporting as a benchmark, compare the VAP rates of the given hospital against data from the CDC/NHSN.
5. Monitoring compliance with recommendations to prevent VAP: Assess compliance with mechanical ventilator (MV) connection and maintenance guidelines by employing a documented paper, assigning knowledgeable healthcare personnel (HCP) to this task. Document MV connection procedures, encompassing all relevant measures.
6. Performance feedback: For the performance feedback, infection control practitioners present charts, showcasing data related to attending HCPs' monthly degree of compliance with infection prevention practices. The infection control tool plays a crucial role, enabling HCPs to identify areas for improvement in cases of low degree of compliance with infection prevention practices.
Practices for preventing VAP and/or VAEs in Adult Patients
1. Using high-flow nasal oxygen may help avert intubation in patients with hypoxemic respiratory failure and prevent reintubation after extubation of critically ill patients and postoperative patients compared to conventional oxygen therapy. High-flow nasal oxygen has also been associated with a trend toward less nosocomial pneumonia in patients with hypoxemic respiratory failure.
2. NIPPV is associated with lower rates of intubation, reintubation, VAP, and mortality compared to conventional oxygen therapy in patients with acute hypercapnic or hypoxemic respiratory failure.
3. Potential strategies to minimize sedation include protocols for targeted light sedation and daily sedative interruptions (ie, spontaneous awakening trials) for patients without contraindications were associated with significantly shorter ICU length of stay in meta-analysis studies.
4. Maintain and improve physical conditioning by initiating exercise and mobilization programs at an early stage could potentially decrease the duration of MV, shorten the LOS in the ICU, decrease the incidence of VAP, and enhance the likelihood of patients returning to independent function.
5. Early enteral nutrition is associated with a lower risk of nosocomial pneumonia, shorter ICU length of stay, and shorter hospital length of stay compared to early parenteral nutrition.
6. Changing the ventilator circuit as needed rather than on a fixed schedule has no impact on VAP rates or patient outcomes but decreases costs so, follow manufacturers’ instructions for use if they differ from this recommendation.
7. Reductions in duration of mechanical ventilation with subglottic secretion drainage appear to be limited to patients expected to require >48–72 hours of mechanical ventilation. Endotracheal tubes with subglottic secretion drainage ports should therefore be reserved for patients likely to require >48–72 hours of intubation. Patients requiring emergency intubation in the hospital and preoperative patients at risk for prolonged mechanical ventilation are reasonable candidates. followed by immediate reintubation to exchange a conventional endotracheal tube for a subglottic secretion drainage endotracheal tube is not recommended.
8. Meta-analysis studies suggests that early tracheostomy (within 7 days of intubation) may be associated with a 40% decrease in VAP rates, less time on mechanical ventilation, and fewer ICU days but no difference in mortality.
9. Postpyloric feeding is associated with less aspiration and less pneumonia compared to gastric-tube feeding. Postpyloric tube placement requires special expertise that is not available in all centers and may incur delay in placement. Postpyloric feeding should therefore be reserved for patients with gastric feeding intolerance and for patients at high risk for aspiration as detailed in nutrition society.
Practices for preventing VAP and/or VAEs in neonatal Patients
1. Nasal CPAP ventilation (with or without nasal intermittent mechanical ventilation) and high-flow oxygen via nasal cannula are viable alternatives to intubation in most preterm infants, but success rates are greatest for those delivered at >28 weeks gestation. Many premature neonates (especially those with a gestational age >28 weeks) can be successfully supported with non-invasive positive pressure ventilation in the delivery room and subsequently in the NICU.
2. Minimize duration of mechanical ventilation
a. Manage patients without sedation whenever possible.
b. Use caffeine therapy for apnea of prematurity within 72 hours after birth to facilitate extubation.
c. Assess readiness to extubate daily.
d. Take steps to minimize unplanned extubations and reintubations: Use nasal CPAP or nasal NIPPV in the postextubation period to help prevent the need for reintubation.
e. Provide regular oral care with sterile water (extrapolated from practice in infants and children, no data in preterm neonates)
f. Change the ventilator circuit only if visibly soiled or malfunctioning or per manufacturers’ instructions for use (extrapolated from studies in adults and children, no data in preterm neonates)
3. Additional approaches for preterm neonates
These interventions have minimal risks of harm, but their impact on VAE and VAP rates is unknown.
● Lateral recumbent positioning
● Reverse Trendelenburg positioning
● Closed/in-line suctioning
● Oral care with maternal colostrum
Practices for preventing VAP and/or VAEs in Pediatric Patients
1. Avoid intubation if possible:
a. Risks of NIPPV in pediatric patients mirror those for adults with the added issue that pediatric patients often need sedation to tolerate NIPPV.
b. CPAP may be superior to high flow oxygen by nasal cannula to avoid intubation in infants with bronchiolitis.
2. Minimize duration of mechanical ventilation
a. Assess readiness to extubate daily in patients without contraindications through daily spontaneous breathing trials can decrease mean duration of ventilation and Pediatric ICU length of stay in postoperative cardiac surgery
b. Steps to minimize unplanned extubations and reintubations to reduce unplanned extubations.
c. Meta-analysis studies found fluid overload is associated with increased risk for prolonged mechanical ventilation (>48 hours).
3. Studies of VAP bundles that emphasized on regular oral care reported significant decreases in VAP rates following bundle implementation. The American Dental Association recommends beginning oral hygiene a few days after birth in term infants. Wipe the gums with a gauze pad after each feeding to remove plaque and residual formula that could harm erupting teeth. After oral hygiene, rinse and suction the mouth. Keep the oral mucosa and lips clean, moist, and intact using sponge-tipped applicators dipped in non-alcohol, nonperoxide mouth rinse.
4. Elevate the head of the bed unless medically contraindicated
5. Changing the ventilator circuit as needed rather than on a fixed schedule has no impact on VAP rates or patient outcomes but decreases costs so, follow manufacturers’ instructions for use if they differ from this recommendation.
6. Remove condensate from the ventilator circuit frequently to avoid draining the condensate toward the patient.
7. Endotracheal tube selection and management
a. Use cuffed endotracheal tubes: Paediatric intensivists have historically favoured uncuffed tubes due to concern that cuffs may induce subglottic stenosis in pediatric airways. Cuffing has proven safe, however, and may decrease the risk of microaspiration. Cuffed tubes are now recommended for term newborns and children.
b. Maintain cuff pressure and volume at the minimal occlusive settings to prevent clinically significant air leaks around the endotracheal tube, typically 20–25 cm H2O. This “minimal leak” approach is associated with lower rates of post-extubation stridor.
8. Daily sedative interruptions decreased duration of mechanical ventilation and ICU length of stay without increases in adverse event rates.