Comprehensive strategies to prevent VAP (ventilator-associated pneumonia)
Although the IHI VAP-prevention bundle includes the following 4 strategies:
- Semirecumbent patient positioning, to at least 30 degrees
- Ventilator weaning, via periodic sedation vacations and daily assessment of extubation readiness.
- Peptic ulcer disease (PUD) prophylaxis.
- Deep-vein thrombosis (DVT) prophylaxis.
1. Semirecumbent positioning: Elevating the heads of ICU patients’ beds between 30 and 45 degrees (with the exception of certain fracture and post-neurosurgery patients and those with severe hypotension).
2. Sedation holiday: It is well established that the sooner patients are extubated, the lower their risk of developing VAP.
3. Continuous subglottic secretion removal: Several trials support the benefits of using tubes that continuously drain these secretions.
4. Oral vs. nasal feeding tubes: A growing body of evidence suggests that oral tubes may be better than nasal tubes in preventing VAP, Dr. Boiteau notes, but the evidence is largely inferential.
5. Oral hygiene with use of oral chlorhexidine gluconate washes: Strategies like stimulation of the gums, toothbrushing and use of oral washes—these practices are so benign and inexpensive that they are worth trying.
6. Stress ulcer prophylaxis: In general, the role of gastric pH in development of VAP remains poorly understood, and the practice could increase infection risks in some patients.
7. Selective digestive tract decontamination: While this practice is widely used to prevent VAP in Europe, experts say that it doesn’t translate well to North America. The problem has to do with well-known antibiotic-resistance issues in ICUs.
8. Deep-vein thrombosis (DVT) prophylaxis (unless contraindicated)
Reference:
Seven strategies to prevent VAP: a look at the evidence Why some popular approaches, from handwashing to good oral hygiene, may not be as evidence-based as you think by Bonnie Darves Published in the May 2005 issue of Today's Hospitalist
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