Journal of Critical Care
Volume 23, Issue 1 , Pages 126-137, March 2008

Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention☆

  • John Muscedere, MD

      Affiliations

    • Department of Medicine, Queen's University, Kingston, Canada K7L 2V7
    • ,
  • Peter Dodek, MD, MHSc

      Affiliations

    • University of British Columbia, British Columbia, Canada V6Z 1Y6
    • ,
  • Sean Keenan, MD, MSc

      Affiliations

    • University of British Columbia, British Columbia, Canada V6Z 1Y6
    • ,
  • Rob Fowler, MD, MDCM, MS

      Affiliations

    • University of Toronto and Sunnybrook Health Sciences Center, Toronto, Canada M4N 3M5
    • ,
  • Deborah Cook, MD, MSc

      Affiliations

    • Clinical Epidemiology and Biostatistics at McMaster University, Hamilton, Canada L8N 3Z5
    • ,
  • Daren Heyland, MD, MSc

      Affiliations

    • Department of Medicine, Queen's University, Kingston, Canada K7L 2V7
    • Corresponding Author InformationCorresponding author. Tel.: +1 613 549 6666#3339; fax: +1 613 548 2428.
    • ,
  • for the VAP Guidelines Committee and the Canadian Critical Care Trials Group

      Affiliations

    • 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.

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.

Keywords: Evidence-based clinical practice guidelines, Ventilator-associated pneumonia, Prevention

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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.

PII: S0883-9441(08)00005-1

doi:10.1016/j.jcrc.2007.11.014

Journal of Critical Care
Volume 23, Issue 1 , Pages 126-137, March 2008

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