Ventilator associated events should trump ventilator associated pneumonia

Hellyer et al. ¹ report the recommendations of the Intensive Care Society for the prevention of ventilator associated pneumonia (VAP). In 2013, the Centers for Disease Control and Prevention noted the lack of a reliable definition for VAP and adopted a surveillance programme based on ventilator adverse events (VAE) using objective criteria. ² An additional reason for the change was the recognition that some of the greatest improvement in patient outcomes results from strategies (sedative interruption and lung protective ventilation) that do not target pneumonia.

Indeed, interventions that target pneumonia do not necessarily show an improvement in patient outcomes. Meta-analysis of subglottic secretion drainage reveals no benefits in duration of mechanical ventilation, ICU or hospital stay, VAEs or mortality. ³ Semi-recumbent positioning has not been associated with reduction in mortality^4,5 or in duration of mechanical ventilation and ICU stay. ⁵

This is the case even when a reduction in VAP (however defined) is shown: no reduction in mortality.^3,4 How is this to be explained? Either the intervention reduces pneumonia yet has unidentified but lethal side effects, or VAP does not kill people.

Therefore, I would argue that the persistent emphasis on prevention of VAP is misguided and the recommended strategies off-target. The worst case is that attention and resources are diverted from areas where intervention would be more effective. A wider focus on VAEs would embed best practice for ventilation generally and ensure those strategies known to reduce mortality are implemented for all patients receiving mechanical ventilation.