The best way to prevent VAP is to avoid intubation or other invasive respiratory procedures whenever possible. Noninvasive positive pressure ventilation is not appropriate for all patients, but this strategy decreases LOS and mortality rates as compared to invasive ventilation. Intubation and mechanical ventilation increase pneumonia risk so significantly (six- to 21-fold) that clinical guidelines state these interventions “should be avoided whenever possible.”
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For patients who must undergo mechanical ventilation, consistent and thorough hand hygiene is a tried-and-true strategy to prevent VAP. All healthcare personnel must wash their hands not only after patient contact, but before and after contact with a patient’s respiratory equipment or respiratory secretions. Even if gloves are used, staff should wash hands before and after donning them. One meta-analysis found enhanced hand washing protocols lowered VAP risk by up to 65.5%. Regular hand-washing audits can help encourage compliance. One hospital found that announced hand-hygiene audits reduced VAP rates by 59%. Incorporating alcohol-based hand rubs into care protocols can also lower VAP incidence, although to a lesser degree than hand washing. Combination strategies are optimal, such as those that include hand-washing protocols, alcohol-based disinfectant dispensers placed near each ICU bed, and foot-activated sinks. Implementing these three strategies simultaneously reduced overall VAP mortality from 44.3% to 32.5% at one hospital.
In general, VAP prevention centers around reducing microbial colonization and aspiration in ventilated patients. Early intervention is most effective, as VAP risk is highest early on in ventilation and decreases over time. Reducing colonization begins with the intubation route. Oral intubation is associated with lower VAP rates than nasal intubation. Secretions are common in the upper airways of patients receiving mechanical ventilation. If transmitted to the airway, secretions can cause VAP. Elevating the head of the bed to 30–45° is a simple, common strategy that improves drainage.
Oral decontamination should be ongoing. Oral hygiene—from tooth brushing to thoroughly suctioning secretions from the mouth—decreases oropharynx colonization by potentially harmful pathogens. Antibiotic oral rinses can also reduce colonization rates. Secretions may pool in elements of the ventilator equipment, such as the tube cuff. This presents a hazard for patients and places them at risk of aspiration. Endotracheal tubes with subglottic secretion drainage ports should be used for patients expected to require multiple days of mechanical ventilation. These ports, used for suction, help keep tubes clear of secretions and have been shown to reduce VAP rates by 55%. Oral care programs have been shown to be a cost-effective way to reduce VAP rates in ICUs.
Minimizing sedation can also lower VAP rates. Providers should avoid prescribing sedatives unless absolutely necessary, instead relying on other pain-management approaches or antipsychotics when indicated. Sedation medications are immunosuppressive and may put mechanically-ventilated patients at increased risk for VAP. Many experts recommend daily sedation interruptions for mechanically-ventilated patients. These “sedation vacations” can reduce mechanical ventilation days for patients and LOS, lowering their risk of VAP. This could be due in part to the fact that a break from sedatives provides a window for patients to show they can breathe independently. “Patients are more likely to pass a spontaneous breathing trial and be extubated if they are maximally awake at the time of the breathing trial,” writes one group of providers. Daily sedative interruptions can help providers properly evaluate patients for extubation. Reassuringly, a study of 2,553 mechanically-ventilated patients found “daily sedation vacations” did not lead to patient-initiated, unplanned extubation.
Hospitals often choose to “bundle” common VAP-prevention strategies into single interventions (see sidebar). With thoughtful procedure selection, evidence suggests bundles can lower VAP rates. One study of 120 Belgian ICUs cut VAP rates from 28% of ventilated patients to 10.1% over six years by implementing a bundle. The VAP bundle included: assessment of sedation, endotracheal cuff pressure control, oral care with chlorhexidine, and semirecumbant position. More comprehensive bundles, that integrate process surveillance in addition to prevention practice interventions, are also effective. One study of 11 hospitals in Argentina successfully reduced VAP rates by 52% across 14 ICUs with such an approach.
ICU patients have benefitted from VAP bundles that include daily rounding checklists. Checklists serve as a guide for hospital staff and include common interventions such as hand hygiene, aspiration prophylaxis, sedation checks, respiratory device checks, and prophylactic medications. In one Taiwanese hospital, a comprehensive bundle checklist helped cut VAP incidence by over half across 27,125 surgical ICU patients. Checklists are one measure that can support hospital staff charged with spearheading VAP bundle programs. Identifying a nurse champion for a VAP bundle program may also help maximize its efficacy. One high-volume U.S. ICU team emphasized “developing nurse and physician champions is vital” when implementing VAP and other bundles. The team successfully increased bundle compliance by using nurse and physician champions. They also noted “the support of our medical director, associate director of clinical nursing, and administration leadership along with staff involvement [was] a key factor to our success.”
There are many studies highlighting benefits of VAP bundles, but each bundle is different. VAP bundle components remain controversial. Data to support VAP interventions are not yet comprehensive and VAP definitions still vary from hospital to hospital. Hospitals may want to develop VAP bundles “using a systematic approach to elicit clinician perceptions on potential interventions,” writes one clinical care team. By following this approach, the team identified 65 possible interventions! Hospitals seeking clinician input may have similar, potentially overwhelming results. Yet the team found “obtaining clinician input on what interventions to include increases the likelihood that providers will adhere to the bundle.”
Tried-and-true strategies are published to help hospitals narrow lists of VAP prevention measures into manageable bundles. The Institute for Healthcare Improvement describes several evidence-based VAP prevention measures in a how-to guide for hospitals interested in creating VAP bundles. The Society for Healthcare Epidemiology of America also regularly updates VAP prevention guidelines.
VAP Care Bundles
Hospitals have bundled treatment and prevention strategies in an effort to combat VAP. However, according to guidelines that are endorsed by the CDC, “there is no consensus on which care processes to include in a VAP-prevention bundle.” Prevention bundles vary, and consequently, have varying efficacies. Common bundle measures include:
- Patient head elevation to 30–45° to prevent aspiration;
- Daily sedation breaks to allow assessments of readiness to extubate;
- Oral hygiene to limit contaminated respiratory secretions; and
- Prophylaxes to improve outcomes unrelated to VAP, but that may worsen VAP prognosis.
Each of these measures has potential to improve VAP outcomes. But given the heterogeneity in VAP bundles, VAP treatment is beyond the scope of this article. Several resources are available to help hospitals develop bundles that align with VAP management guidelines. The Institute for Healthcare Improvement provides a how-to guide that describes key evidence-based VAP bundle components. Examples of bundles are also available from the Centers for Medicare and Medicaid Services.
Many VAP prevention measures may seem elementary to experienced providers. Yet the most effective strategies are often small interventions. A comprehensive review urges:
“The clinician must give careful attention to the mundane and seemingly small interventions, such as regularly assessing endotracheal cuff pressure, performing endotracheal suctioning, draining ventilator tube condensate, avoiding gastric overdistention, avoiding the supine position, avoiding unnecessary ventilator circuit changes, application of heat and moisture exchangers (HMEs) when appropriate, minimizing out-of-ICU transports, and regular hand cleaning with soap or alcohol disinfectant.”
Together, these are tried-and-true strategies to prevent VAP.