It is difficult to avoid airway contamination from exogenous sources, but changing
ventilators only for infection control and not allowing the build up of condensation in the
ventilator circuit can minimize contamination (152). Contaminated condensates should be
carefully emptied from ventilator circuits, and their entry into the endotracheal tube or in-line
medication nebulizer should be avoided (157,161,162).
Silver-coated endotracheal tubes have been reported to reduce the incidence of
Pseudomonaspneumonia in intubated dogs and to delay airway colonization in intubated
patients, although patient subsets likely to benefit from this practice still need to be identified
before the system can be applied on a large scale (163–165)]. The use of antiseptic-impregnated
endotracheal tubes is described as unresolved in the SHEA/IDSA recommendations (150).
Daily interruption of sedation or its reduction and avoiding agents that could depress the
cough reflex have proved effective in the prevention of VAP (128). Making sure that there are
adequate numbers of staff in the ICU will reduce length of stay, improve infection-control
practices, and reduce the duration of mechanical ventilation (129,130,166,167).
A selective transfusion policy should be adopted for the transfusion of red blood cells or
other allogeneic blood products (24). Leukocyte-depleted red blood cell transfusion can help to
reduce HAP in some patient populations (168–171).
Intensive insulin therapy to keep serum glucose levels in the range 80 to 100 mg/dl has
been explored in ICU patients as a way to reduce nosocomial blood stream infection, duration
of mechanical ventilation, ICU stay, morbidity, and mortality, but more studies are required
before recommendation for widespread use can be made (172,173).
Preventive measures are ineffective if not put into practice by all medical staff.
Accordingly, multidisciplinary educational programs directed toward ICU staff that empha-
size preventive strategies have been associated with decreased rates of VAP (152,174). For
example, Babcock et al. (175) showed a 46% reduction in the VAP rate following a training
program focusing on preventive measures.
Although not mentioned in the healthcare infection control practices advisory committee
(HICPAC) guidelines, two further promising preventive measures are the implementation of
protocols for ventilator management (176) and the use of antimicrobial agents in the ICU.
Indeed, a ventilator management protocol was able to reduce the duration of ventilatory
support and the incidence of VAP in a small study (130), and the SHEA/IDSA guideline
recommends daily assessments of readiness to wean and the use of weaning protocols
(128,150). In a French ICU, the results of a four-year study indicated that the rotation and
restricted use of antibiotics reduced the frequency of VAP associated with MDR bacteria,
findings that have been subsequently confirmed (177,178). The proportions of VAP caused by
MSSA increased from 40% to 60% and those of MDR gram-negative bacilli decreased from 61%
to 49%. These findings warrant further investigation.
The program started by the Institute for Healthcare Improvement (IHI), the “100,000 Lives
Campaign,” was a voluntary initiative to protect patients from 100,000 incidents of medical harm
for a period of two years (December 2006 to December 2008). One of its interventions was the
prevention of VAP by implementing a series of interdependent, scientifically grounded steps
denoted “the Ventilator Bundle.” Care bundles are sets of best practices for managing a disease
process. Individually, these measures improve care, but when applied together, they give rise to
a substantial improvement. The scientific basis for each bundle component has been sufficiently
established to be considered the care standard. Hence, the IHI’s ventilator bundle is a group of
evidence-based practices that, when applied to all patients on mechanical ventilation, leads to a
dramatic reduction in the rate of ventilator-associated pneumonia.
The following four measures comprised the ventilator bundle:
- Elevate the bed headrest (30 8 to 45 8 ) so that the patient adopts a semirecumbent position
- Interrupt sedation daily and assess readiness to extubate daily
- Prophylaxis for peptic ulcer disease
- Prophylaxis for deep vein thrombosis unless contraindicated
The use of the ventilator bundle in the care of ventilated patients can markedly reduce
the incidence of VAP. This reduction was estimated at 45% on an average in a recent ICU
collaborative improvement IHI project. The results of this campaign will soon be reported.
186 Bouza and Burillo