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Posted: January 13th, 2024

Preventing Ventilator-Associated Pneumonia

Preventing Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is a serious and potentially fatal complication of mechanical ventilation that affects millions of patients worldwide every year. VAP is defined as a lung infection that develops in a patient who is on a ventilator for more than 48 hours. VAP can increase the length of stay, morbidity, mortality, and costs of hospitalization for critically ill patients. Therefore, preventing VAP is a key priority for infection prevention and control in acute care settings.

The main risk factor for VAP is the presence of an endotracheal tube (ETT) that bypasses the natural defenses of the upper airway and allows the aspiration of contaminated secretions into the lower respiratory tract. Other factors that may contribute to VAP include poor oral hygiene, supine positioning, inadequate ventilator circuit care, suboptimal sedation and analgesia management, and inappropriate use of antibiotics.

Several strategies have been proposed to prevent VAP, such as elevating the head of the bed, performing daily oral care with chlorhexidine, implementing a ventilator bundle, using subglottic suctioning, applying continuous lateral rotation therapy, minimizing sedation and promoting early mobilization, and implementing antimicrobial stewardship programs. However, the evidence supporting these interventions is variable and sometimes conflicting, and the optimal combination of preventive measures is still unclear.

Moreover, the diagnosis of VAP is challenging and often relies on subjective clinical criteria and nonspecific microbiological tests. This may lead to overdiagnosis and overtreatment of VAP, which can have negative consequences for patients and healthcare systems. To address this issue, the Centers for Disease Control and Prevention (CDC) developed a new surveillance definition for ventilator-associated events (VAE) in 2013, which is based on objective and measurable indicators of worsening oxygenation and ventilator settings. The VAE definition includes three tiers: ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and possible or probable VAP. The VAE definition is intended to standardize and simplify the surveillance of ventilator-associated complications, but it has some limitations, such as low sensitivity and specificity for VAP, poor interrater reliability, and lack of clinical relevance.

Another important aspect of VAP prevention is the recognition and management of nonventilator hospital-acquired pneumonia (NV-HAP), which is defined as a pneumonia that occurs in hospitalized patients who are not on mechanical ventilation at the time of diagnosis or within 48 hours before. NV-HAP is a common and often overlooked complication that affects patients in various settings, such as medical-surgical wards, emergency departments, rehabilitation units, and long-term care facilities. NV-HAP can have similar or worse outcomes than VAP, such as increased mortality, length of stay, and costs. However, NV-HAP is less well studied than VAP and there are no standardized definitions or guidelines for its prevention and treatment.

The purpose of this blog post is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent VAP, VAE, and NV-HAP in adults, children, and neonates. These recommendations are based on the latest evidence and expert consensus from various organizations and societies with content expertise. The recommendations are intended to be adaptable to different contexts and resources, and to be integrated into existing quality improvement initiatives.

The following sections will provide an overview of the recommended strategies to prevent VAP, VAE, and NV-HAP in different patient populations, as well as suggestions for performance measures and implementation strategies. The references for each recommendation are provided at the end of the post.

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