Theme Issue Editorial
Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention

https://doi.org/10.1016/j.jcrc.2007.11.014Get rights and content

Abstract

Background

Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients.

Purpose

To develop evidence-based guidelines for the prevention of VAP.

Data Sources

MEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials.

Study Selection

The authors systematically searched for all relevant randomized, controlled trials and systematic reviews on the topic of prevention of VAP in adults that were published from 1980 to October 1, 2006.

Data Extraction

Independently and in duplicate, the panel scored the internal validity of each trial. Effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. Scores for the safety, feasibility, and economic issues were assigned based on consensus of the guideline panel.

Levels of Evidence

The following statements were used: recommend, consider, do not recommend, and no recommendation due to insufficient or conflicting evidence.

Data Synthesis

To prevent VAP:

  • We recommend:

    that the orotracheal route of intubation should be used for intubation; a new ventilator circuit for each patient; circuit changes if the circuit becomes soiled or damaged, but no scheduled changes; change of heat and moisture exchangers every 5 to 7 days or as clinically indicated; the use of a closed endotracheal suctioning system changed for each patient and as clinically indicated; subglottic secretion drainage in patients expected to be mechanically ventilated for more than 72 hours; head of bed elevation to 45° (when impossible, as near to 45° as possible should be considered).

  • Consider:

    the use of rotating beds; oral antiseptic rinses.

  • We do not recommend:

    use of bacterial filters; the use of iseganan

  • We make no recommendations regarding:

    the use of a systematic search for sinusitis; type of airway humidification; timing of tracheostomy; prone positioning; aerosolized antibiotics; intranasal mupirocin; topical and/or intravenous antibiotics.

Conclusion

There are a growing number of evidence-based strategies for VAP prevention, which, if applied in practice, may reduce the incidence of this serious nosocomial infection.

Introduction

Ventilator associated pneumonia (VAP) is a healthcare-associated infection that commonly causes morbidity and mortality in mechanically ventilated patients [1]. For example, VAP is associated with an increased duration of mechanical ventilation, crude death rates of 5% to 65% [2], [3], [4], [5], and increased healthcare costs [6], [7], [8]. However, VAP is preventable and many practices have been demonstrated to reduce the incidence of VAP and its associated burden of illness [9], [10]. Because the body of literature on VAP is extensive and in some cases, conflicting, it has become increasingly difficult for critical care practitioners to assimilate and apply best evidence into clinical practice [11]. The synthesis of large bodies of knowledge into clinical practice guidelines (CPGs) is one method of improving the accessibility and utility of medical literature to clinicians [12]. For the management of critically ill patients, guidelines can improve the processes, outcomes, and costs of critical care [13], [14], [15], [16]. The optimal method to implement guidelines is uncertain, but active strategies are superior to passive ones, periodic updates are necessary, and continued efforts to effect behavior change are required [17].

The guidelines committee of the Canadian Critical Care Society and Canadian Critical Care Trials Group developed evidence-based CPGs for the prevention of VAP in 2004 [18]. However, only research evidence published before April 1, 2003, was incorporated into those guidelines. Since then, new randomized controlled trials (RCTs) of strategies to prevent VAP have been published, and updating is necessary [19]. Therefore, the Canadian Critical Care Trials Group commissioned the development of up-to-date and comprehensive evidence-based CPGs for the prevention, diagnosis, and treatment of VAP. Herein, we report on the guidelines for the prevention of VAP. The guidelines for the diagnosis and treatment of VAP are reported in a companion manuscript in this issue [20].

Section snippets

Methods

A multispecialty and multidisciplinary panel was created to develop the comprehensive VAP CPGs. This group was composed of 20 intensivists from university-affiliated and community hospitals, 4 infectious disease specialists, 3 intensive care unit (ICU) nurses, an infection control nurse, an ICU pharmacist, an ICU respiratory therapist, and a representative from the Canadian Patient Safety Institute [21]. Panel members were experts in critical care medicine (n = 20), infectious diseases (n = 5),

Results

The final evidence summaries and recommendations for each of the interventions are reported. The results are divided into physical strategies, positional strategies, and pharmacologic strategies, and are summarized in Table 1. The semiquantitative scores for each intervention are reported in Table 2 and the agreement scores are reported in Table 3.

Route of endotracheal intubation

On the basis of 1 level 2 trial [33], we conclude that orotracheal intubation is associated with a trend toward a reduction in VAP compared to nasotracheal intubation.

Furthermore, this trial and 4 other level 2 trials have found that orotracheal intubation is associated with a decreased incidence of sinusitis and that incidence of VAP is lower in patients who do not develop sinusitis [34], [35], [36], [37].

Recommendation: We recommend that the orotracheal route of intubation should be used when

Discussion

Ventilator associated pneumonia continues to be a cause of significant morbidity and mortality in critically ill patients [99], and the literature on VAP prevention continues to evolve. To synthesize the growing research evidence on VAP prevention, thereby aiding in knowledge transfer, we developed this CPG. Guidelines require periodic updates to reflect current knowledge [19]; accordingly, the recommendations in this article reflect an update of our prior work [18] after reviewing evidence

Acknowledgments

The authors thank the Canadian Critical Care Trials Group and Canadian Critical Care Society for their support of this initiative and the professional societies, which reviewed and critiqued this guideline. We are grateful to Drs Christian Brun-Buisson and Andrew Shorr for constructive criticisms on this document.

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    Grant support: This project was supported by a research grant from the Department of Medicine, Queen's University, Kingston, Ontario, and an unrestricted grant from Pfizer Canada, Inc.

    1

    VAP Guidelines committee was composed of Martin Albert, Clarence Chant, Sue Elliott, Richard Hall, Lori Hand, Rick Hodder, Carolyn Hoffman, Mike Jacka, Lynn Johnston, Jim Kutsogiannis, David Leasa, Kevin Laupland, Martin Legare, Claudio Martin, Mike Miletin, Brenda Morgan, Linda Nusdorfer, Juan Ronco, Taz Sinuff, Derek Townsend, Louis Valiquette, Christine Weir, Karl Weiss, and Dan Zuege.

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