Sage Journals: Discover world-class research

Abstract

Ventilator-associated pneumonia (VAP) remains a significant problem in the hospital setting, with very high morbidity, mortality, and cost. We performed an evidence-based review of the literature focusing on clinically relevant pharmacological and nonpharmacological interventions to prevent VAP. Owing to the importance of this condition the implementation of preventive measures is paramount in the care of mechanically ventilated patients. There is evidence that these measures decrease the incidence of VAP and improve outcomes in the intensive care unit. A multidisciplinary approach, continued education, and ventilator protocols ensure the implementation of these measures. Future research will continue to investigate cost/benefit relationships, antibiotic resistance, as well as newer technologies to prevent contamination and aspiration in mechanically ventilated patients.

Keywords

hospital acquired pneumonia ICU-related infections preventive measures ventilator associated pneumonia

Introduction

Ventilator-associated pneumonia (VAP) is the leading cause of mortality due to nosocomial infections and is that with a greater impact on morbidity of patients hospitalized in the intensive care unit (ICU) [Tablan et al. 2004; Chastre and Fagon, 2002; Rello et al. 2002]. From 8% to 28% of the complications in patients on mechanical ventilation are secondary to VAP [National Nosocomial Infections Surveillance System, 2004]. The rates of VAP are approximately 3% per day in the first week of mechanical ventilation, 2% per day in the second week, and 1% per day in the third week and beyond [Cook and Kollef, 1998].

Risk factors for VAP are multiple and are divided into those that are modifiable and those that are nonmodifiable. Modifiable factors include the supine position, gastric overdistension, contamination of ventilator circuits, frequent patient transfers and low pressure of the endotracheal tube (ETT) cuff. Nonmodifiable factors include male gender, age over 60 years, acute respiratory distress syndrome, multiorgan failure, coma, chronic obstructive pulmonary disease, tracheostomy, re-intubation, neurosurgery and cranial trauma [Tablan et al. 2004; Kollef, 1999a; Cook et al. 1998b].

Factors such as etiologic microorganism, underlying comorbidities, host response mechanisms, and time of appearance have a direct influence on the morbidity and mortality of patients with VAP [Peleg and Hooper, 2010; Tejerina et al. 2006; Heyland et al. 1999; Fagon et al. 1993b; Rello et al. 1993]. Several reports have shown that patients who develop VAP have an increase in ICU stay of between 4.3 and 13 days [Heyland et al. 1999; Fagon et al. 1993b; Kappstein et al. 1992]. In addition, there is an increase in costs with each case of VAP (US$12,000 to US$40,000) [Tablan et al. 2004; Warren et al. 2003; Rello et al. 2002; Fagon et al. 1993a]. For these reasons, the prevention of VAP in the ICU must be considered a task of high importance. Decreasing the incidence of VAP by directed strategies could decrease the associated morbidity and mortality, the costs, and improve the safety of patients requiring mechanical ventilation [Muscedere et al. 2010]. The strategies to reduce the incidence of VAP have been investigated and there is clinical evidence that favor their use according to the recommendations in clinical practice guidelines [Muscedere et al. 2008; American Thoracic Society, 2005; Dodek et al. 2004; Tablan et al. 2004; Torres and Carlet, 2001; Pittet et al. 2000; Kollef, 1999b].

We group the preventive measures for VAP into four categories: (1) general measures, (2) early extubation, (3) prevention of aspiration, and (4) decontamination (see Figure 1 and Table 1).

Figure 1.

Preventive measures for ventilator-associated pneumonia.

Table 1.

Pharmacological and nonpharmacological measures to prevent ventilator-associated pneumonia.

Nonpharmacological Measures	Evidence grade	Pharmacological Measures	Evidence grade
Standard precautions	Level I	Oral decontamination	Level II
Hand hygiene	Level I	Selective digestive decontamination	Level II
Staff to patient ratio	Level II	Silver-coated endotracheal tube	Level I
Semiseated position	Level I	Daily sedation breaks	Level II
Adequate Endotracheal cuff pressure	Level II
Drainage of subglottic secretions	Level II
Avoidance of circuit manipulation	Level II
Early extubation	Level I

Evidence Grade

Level I (high): evidence comes from well-conducted, randomized controlled trials.

Level II (moderate): evidence comes from well-designed, controlled trials without randomization (including cohort patient series and case–control studies) and systematic analysis not collected in a randomized fashion.

Level III (low): evidence comes from case studies and expert opinion.

General measures

Standard precautions

Cross transmission of pathogens plays an important role in the development of all nosocomial infections [Boyce and Pittet, 2002; Garner, 1996; Larson, 1981]. Measures to control these infections were implemented to avoid the cross transmission between patients and staff and to optimize the safety of invasive devices used in the ICU [Boyce and Pittet, 2002; Rhame et al. 1986]. Effective strategies to prevent VAP should include an infection control program to educate the medical team and allow effective decontamination of the hands, use of barrier methods, and a protocol of microbiological surveillance [Tablan et al. 2004; Kollef, 1999b; Weinstein, 1991].

A microbiological surveillance program in the ICU ensures adequate measures to prevent the emergence of multidrug-resistant pathogens and aids in the selection of the empirical therapy in cases of VAP [Tablan et al. 2004; Weinstein, 1991; Haley et al. 1985]. Moreover, the presence of education programs for the health personnel in the ICU, would offer opportunities to improve the prevention of VAP, and be part of a more general effort to prevent all nosocomial infections [Babcock et al. 2004; Zack et al. 2002].

Multidisciplinary team members

Multidisciplinary team participation was associated with a decrease in nosocomial infections and VAP [Cho et al. 2003; Needleman et al. 2002]. This involves training of physicians, nurses, respiratory therapists, pharmacists, and other ancillary personnel on preventive strategies. Studies have shown that the implementation of multidisciplinary education programs reduced the incidence of VAP [Bloos et al. 2009; Rodvold, 2009; Salahuddin et al. 2004].

A higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day were associated with better care for hospitalized patients [Needleman et al. 2002]. Therefore, it is recommended to have a suitable ratio between the number of nurses and patients (ideally 1 : 1) and respiratory therapists in the ICU. In addition, the number of respiratory therapists and nurses can have a favorable influence on the duration of ICU stay and the incidence of VAP. This is probably due to the maintenance of higher standards of infection control [Cho et al. 2003; Needleman et al. 2002]. Involving respiratory therapists facilitates the success of education programs and the implementation of directed protocols to diminish the development of and the duration of mechanical ventilation [Baxter et al. 2005; Ely et al. 2001; Marelich et al. 2000]. It is recommended that all healthcare personnel involved in the management of patients at risk for VAP must take a proactive role in reducing its incidence.

Early extubation

Early weaning of mechanical ventilation

Every time that a decision for endotracheal intubation is undertaken, a strategy to remove the ETT should exist. Measures such as daily interruption of sedation and pursuing a protocol for early extubation are associated with shorter duration of mechanical ventilation [Wood et al. 2007; Horst et al. 1998; Kollef et al. 1997; Saura et al. 1996]. A shortened time of mechanical ventilation and therefore decreased time of ETT exposure reduces the risk of aspiration of contaminated secretions and the likelihood of developing VAP [Ely et al. 2001; Cook et al. 2000; Kress et al. 2000; Marelich et al. 2000]. The participation of nurses and respiratory therapists in protocols for early weaning from mechanical ventilation have also improved outcomes [Cook et al. 2000], reinforcing the importance of a multidisciplinary approach in the prevention of VAP.

Daily sedation breaks

Sedation is required frequently in the ICU setting when treating mechanically ventilated patients. Agents used to achieve sedation and analgesia are well known: benzodiazepines, propofol, haloperidol, dexmedetomidine, and opiates. The use of these medications can vary widely among ICUs [Sessler and Wilhelm, 2008]. Oversedation typically leads to side effects, including gastrointestinal motility disturbances and difficulty weaning from the ventilator. Prolonged intubation further increases the exposure to risk factors for infection, microaspiration, gastrointestinal motility, and microcirculatory disturbances [Nseir et al. 2010; Strøm et al. 2010]. The propulsive motility of the esophagus is significantly limited during any kind of prolonged sedation. Impaired esophageal motility is involved in the pathogenesis of gastrointestinal reflux disease, which, in turn, is associated as a cause of nosocomial pneumonia in critically ill patients [Kölbel et al. 2000]. The use of the least amount of sedation possible has been shown to decrease the duration of delirium in the ICU, number of ventilated days, and mortality [Shehabi et al. 2010; Ulldemolins et al. 2009; Arroliga et al. 2005; Kress et al. 2000]. In addition, the number of days of mechanical ventilation has been directly associated with the development of VAP [Cook et al. 1998b]. Nevertheless, no studies have shown a decreased rate of VAP directly related to an intermittent sedation strategy.

For the above reasons, all intubated patients should have daily sedation interruptions, while their clinical condition permits, to prevent the unnecessary accumulation of sedatives with an aim to extubate safely as promptly as possible. Also, a sedation protocol should be in place and actively followed to decrease the amount of sedation given [Schweickert and Kress, 2008; Kollef et al. 1997]. Further studies will compare different sedatives to investigate whether different agents increase the risk of nosocomial infections more than others.

Prevention of aspiration

Semiseated position

Gastric reflux and further aspiration of radio-labeled gastric contents can be prevented with a semiseated position in patients on mechanical ventilation [Orozco-Levi et al. 1995; Ibáñez et al. 1992; Torres et al. 1992]. When receiving enteral nutrition, a fully supine position facilitates patient’s aspiration of subglottic secretions [Drakulovic et al. 1999; Orozco-Levi et al. 1995; Huxley et al. 1978]. The semiseated position (45°) has demonstrated a diminished rate of oral gastric aspiration and VAP [Drakulovic et al. 1999; Kollef, 1993] when compared with neutral supine position (0°) [Drakulovic et al. 1999]. Similarly, a prospective clinical study of critically ill patients, who remained in the semiseated position of 30° for the first 24 hours of mechanical ventilation, and had a lower incidence of VAP compared with patients positioned at less than 30° [Kollef et al. 1999]. Other investigations have shown that the elevation of the bed rest at 45° at all times might not be feasible, but should be continued to be encouraged [van Nieuwenhoven et al. 2006]. Therefore, due to the low cost, easy application, and previous shown efficacy in VAP prevention; the semiseated position at 30–45° at all times is recommended in intubated patients, especially when receiving enteral nutrition [Alexiou et al. 2009].

Unnecessary changes and manipulation of ventilator circuits

Condensed fluids in the ventilator circuits have a risk of contamination. When contaminated, these fluids theoretically could increase the exposure of the patient to pathogens that could eventually cause VAP. Current evidence does not support frequent changes of these circuits [Cook et al. 1998a; Kollef et al. 1995; Dreyfuss et al. 1991; Craven et al. 1984]. In addition, numerous circuit changes may increase the incidence of colonization and eventually the development of VAP [Han and Liu, 2010]. Furthermore, it has been found that no routine changes in the ventilator circuits did not increase the incidence of VAP [Kollef et al. 1995]. Based on these findings, it is safe and justified not to change ventilator circuits unless they are visibly soiled [Han and Liu, 2010].

Caution should be exercised to prevent the accidental displacement of secretions from the ventilator circuits into the respiratory tract. Frequent emptying of circuit reservoirs and careful positioning of the tubing during patient transport and positioning is encouraged [Craven et al. 1998a, 1984; Craven and Steger, 1995].

Drainage of subglottic secretions

Oropharyngeal bacterial colonization and mircoaspiration of subglottotic secretions are important mechanisms for developing VAP [Bonten et al. 2004]. When an ETT is present, oral and gastrointestinal secretions can accumulate above the ETT cuff [Greene et al. 1994]. The presence, colonization, and microaspiration of these secretions are inevitable. Even adequate cuff pressure control cannot prevent microaspiration [Valencia et al. 2007].

The association of microaspiration with VAP is clearly established [Valencia et al. 2007; Craven and Steger, 1996; Valles et al. 1995; Mahul et al. 1992; Torres et al. 1992]. A strategy to perform a continuous aspiration of subglottic secretions has been developed through an ETT with an additional dorsal channel to allow the continuous or intermittent aspiration of subglottic secretions (Hi-Lo Evac tube, TYCO Healthcare/Mallinckrodt, St Louis, MO, USA). The use of a subglottic secretion ETT showed a decrease in VAP incidence, especially early VAP, but not in mortality, ICU stay, or time on mechanical ventilation [Bouza et al. 2008; Kollef, 2004; Dezfulian et al. 2005; Smulders et al. 2002; Kollef et al. 1999; Valles et al. 1995; Mahul et al. 1992]. Importantly, the dorsal channel may obstruct and prevent the continuous aspiration of secretions in up to 34% of the cases. However, newer designs from the initial models have placed the dorsal channel closer to the cuff which may have prevented this problem [Rello et al. 1996].

The incorporation of an ETT with an ultrathin polyurethane membrane cuff (7 µm compared with 50 µm in the conventional cuffs) that reduces the formation of channels and the escape of subglottic secretions to the distal airway has been used (Kimberly-Clark Microcuff^®) [Dullenkopf et al. 2003]. When compared with a conventional tube, this modality, in addition to the subglottic secretion drainage, had a significant decrease in the incidence of early and delayed VAP [Lorente et al. 2007].

The incorporation of an ETT with a dorsal channel for subglottic secretion aspiration is recommended as a preventive strategy when considering the high cost of developing VAP, low risk, and proven benefit, especially in patients mechanically ventilated for more than 48 hours [Rello et al. 2002].

Endotracheal tube cuff pressure

An adequate ETT cuff pressure should provide airway sealing, no alteration of the mucosal perfusion, and prevention of aspiration of subglottic secretions into the airways. [Rello et al. 1996]. Even with an optimal cuff pressure, the possibility of draining of secretions into the distal airway persists. This can be explained by the formation of folds or longitudinal channels in the cuff [Valencia et al. 2007]. In addition, specific ventilator settings may have an influence on the passage of secretions [Pitts et al. 2010]. The recommended optimal cuff pressure, obtained from experimental animal models and intubated patients, should be between 20 and 35 cm of H₂O [American Thoracic Society, 2005; Sengupta et al. 2004; Cook and Kollef, 1998; Seegobin and van Hasselt, 1984]. Respiratory therapists and staff in the ICU should monitor adequate cuff pressure frequently.

Decontamination strategies

Oral decontamination

The pathophysiology of VAP involves a secondary colonization of the upper respiratory tract by nosocomial pathogens, accumulation of secretions above the ETT cuff, and ultimately, aspiration of these contaminated secretions into the respiratory tract [Bonten et al. 2004]. Current evidence regarding the use of topical antibiotics for oral decontamination as a preventive therapy is controversial [Dallas and Kollef, 2009].

Several agents have been studied for oral decontamination. These include iseganan, chlorhexidine, and povidone iodine. Iseganan has failed to show any significant benefit over placebo in preventing VAP in a large randomized trial [Kollef et al. 2006]. Povidone iodine was demonstrated to be effective in decreasing the rate of VAP in patients with severe head trauma, but it has not been studied in other patient populations [Seguin et al. 2006].

Chlorhexidine in varying concentrations (0.12%, 0.2%, and 2%) has been studied in both medical and surgical ICU patient populations. It is useful in preventing VAP in patients who have undergone heart surgery [Chlebicki and Safdar, 2007; Pineda et al. 2006]. Unfortunately, there have been mixed results in noncardiac patients [Panchabhai et al. 2009]. It is theorized that chlorhexidine only delays the development of VAP, as it had no benefit in mortality, number of days on mechanical ventilation, and other patient outcomes. This is reflected by the benefit seen in patient populations that were intubated for a shorter period of time comparatively. When higher concentrations were used (i.e. 2%) there were significant reductions in VAP rates [Tantipong et al. 2008; Koeman et al. 2006]. This evidence postulates that higher concentrations may be more effective in preventing VAP. Other measures, such as electric toothbrushing, have not showed effectiveness in the prevention of VAP [Pobo et al. 2009].

We recommend the use of povidone iodine or chlorhexidine (preferably at higher concentrations) as an intervention of low cost for oral decontamination, as current evidence supports a significant decrease in VAP incidence [Liberati et al. 2009; Chan et al. 2007; Mori et al. 2006; Tablan et al. 2004].

Selective decontamination of the gastrointestinal tract

A selective decontamination of the digestive tract (SDD) has been proposed as a strategy to prevent primary and secondary endogenous infections in mechanically ventilated patients. The term ‘selective’ is derived from the eradication of Gram-negative bacilli, Staphylococcus aureus and fungi [Taylor et al. 2007], while not affecting the normal endogenous flora (anaerobic bacteria, Streptococcus viridans, Enterococcus spp., and coagulase negative Staphylococcus), which are protective against colonization by Gram- negative microorganisms [van der Waaij, 1982].

Four points are proposed in the protocol of SDD: (1) use of a combination of nonabsorbable antibiotics, polymyxin, tobramycin and amphotericin B or nystatin in the oropharynx and through the enteral tube during the time of stay in the ICU; (2) use of intravenous antibiotics, specifically a third-generation (or second-generation) cephalosporin for 4–9 days; (3) preventive measures to avoid cross colonization; and (4) taking cultures from the oropharynx and rectum on admission and twice per week to monitor the effectiveness of the decontamination and the appearance of resistant organisms [Bonten and Krueger, 2006; Bonten, 2006].

A meta-analysis of 36 case–controlled trials including 6922 patients demonstrated that SDD is associated with a significant reduction in the incidence of VAP and mortality [Liberati et al. 2009]. Other authors have reported an absolute reduction in mortality [Krueger et al. 2002], number of days in the ICU, and intrahospital mortality [de Smet et al. 2009; de La Cal et al. 2005; de Jonge et al. 2003]. These benefits have been established in postsurgical, posttrauma, medical, surgical, and burn patients [de La Cal et al. 2005; de Jonge et al. 2003; Krueger et al. 2002].

In spite of the low cost and existence of clinical evidence, SDD is not accepted widely [Jongerden et al. 2010; Taylor et al. 2007; Dodek et al. 2004; Tablan et al. 2004]. The main concern is the high risk for selection of multiresistant pathogens. The antibiotics used in SDD do not treat most Gram-positive bacteria, so an expected increase in colonization rates and infection with Enterococcus sp and methicillin-resistant Staphylococcus aureus (MRSA) has been reported [de La Cal et al. 2005; Lingnau et al. 1997; Verwaest et al. 1997; Wiener et al. 1995; Bonten et al. 1993]. SDD has also been associated with a gradual increase in antibiotic resistance in the respiratory tract [Oostdijk et al. 2010]. Authors in favor of this strategy have proposed the addition of topical and intravenous vancomycin to control MRSA in the ICUs where this pathogen is endemic [Silvestri et al. 2004]. Some authors have documented no selection of multiresistant Gram-negative bacteria with SDD [de Jonge et al. 2003]. On the other hand, the benefit of SDD is not clear in ICUs where MRSA, vancomycin-resistant Enterococcus and multiresistant Gram-negative bacteria are endemic [Bonten, 2006; Lingnau et al. 1997; Verwaest et al. 1997; Wiener et al. 1995].

Defining whether SDD is useful and safe remains controversial, especially in hospitals with a high prevalence of multiresistant pathogens. The inappropriate use of antibiotics remains a threat for resistance and may affect effective treatment of different infections, in particular, those acquired in the hospital. Future studies will evaluate the cost-effectiveness of these measures.

Prevention of biofilm formation/silver-coated endotracheal tubes

Through the regulation of specific genes, microcolonies of bacteria can secrete a polymeric extracellular substance that allows adherence to a selected surface (i.e. ETT) forming a viscous layer called a biofilm [Donlan and Costerton, 2002]. This has been shown to occur as early as 24 hours after intubation [Perkins et al. 2010]. These biofilms are prevalent in humid surfaces. Its viscous and adherent nature complicates elimination and offers mechanical protection to the bacteria; as antibiotics cannot penetrate this substance. Moreover, bacteria have greater resistance to antibiotics due to their hypometabolic state [Stewart, 2003]. When the biofilm accumulates it can be dislodged during procedures (i.e. tracheal suctioning and bronchoscopy) and directly inoculate the endobronchial surface [Adair et al. 1999; Inglis et al. 1989].

Antiseptic substances, such as silver, can prevent biofilm formation in the ETT [Olson et al. 2002; Hartmann et al. 1999]. A prospective, randomized, and multicentered pilot study reported that the use of the silver-coated ETT was safe, slowed down the colonization, and reduced the formation of the biofilm [Rello et al. 2006]. In November of 2007, the US Food and Drug Administration (FDA), authorized the use of the silver-coated ETT, based on the diminution of the risk of VAP with its use. Further studies have demonstrated a significant reduction in the incidence of VAP and delayed time to VAP occurrence [Afessa et al. 2010; Kollef et al. 2008]. The cost-effectiveness of these devices is still under debate [Gentile and Siobal, 2010], but there is evidence that this strategy may result in hospital savings [Shorr et al. 2009].

Conclusion

We have focused on the evidence related to the pharmacologic and nonpharmacologic therapeutic maneuvers involved in the prevention of VAP. Owing to the high cost, morbidity, and mortality of VAP, preventive measures are paramount in the care of mechanically ventilated patients. There is evidence that these measures decrease mortality and improve outcomes in the ICU, and include general measures, early extubation, aspiration prevention, and decontamination. A multidisciplinary approach, continued education, and ventilator protocols ensure the implementation of these measures. Future research will continue to investigate cost/benefit relationships, antibiotic resistance, as well as newer technologies to prevent contamination and aspiration in mechanically ventilated patients.

Footnotes

Funding

Dr Restrepo’s time is supported by the National Institute of Health and National Heart, Lung and Blood Institute (NIH/NHLBI) (award number K23HL096054). The content is solely the responsibility of the author and does not necessarily represent the official views of the NIH/NHLBI. The funding agencies had no role in the preparation, review, or approval of this presentation. The views expressed in this presentation are those of the author and do not necessarily represent the views of the Department of Veterans Affairs, nor the UTHSCSA.

Conflict of interest statement

No conflicts of interest were reported by Dr Maselli. Dr Restrepo has served on the advisory board of Ortho-McNeil-Janssen/Johnson & Johnson, Theravan, Forest Laboratories, and Novartis. He has also served as a consultant for Theravan and Pfizer (Wyeth).

References

Adair

C.G.

Gorman

S.P.

Feron

B.M.

Byers

L.M.

Jones

D.S.

Goldsmith

C.E.

(1999) Implications of endotracheal tube biofilm for ventilator-associated pneumonia. Intensive Care Med 25: 1072–1076.

Afessa

Shorr

A.F.

Anzueto

Craven

D.E.

Schinner

Kollef

M.H.

(2010) Association between a silver-coated endotracheal tube and reduced mortality in patients with ventilator-associated pneumonia. Chest 137: 1015–1021.

Alexiou

V.G.

Ierodiakonou

Dimopoulos

Falagas

M.E.

(2009) Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. J Crit Care 24: 515–522.

American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med (2005) 171: 388–416.

Arroliga

Frutos-Vivar

Hall

Esteban

Apezteguía

Soto

(2005) Use of sedatives and neuromuscular blockers in a cohort of patients receiving mechanical ventilation. Chest 128: 496–506.

Baxter

A.D.

Allan

Bedard

Malone-Tucker

Slivar

Langill

(2005) Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia. Can J Anaesth 52: 535–541.

Babcock

H.M.

Zack

J.E.

Garrison

Trovillion

Jones

Fraser

V.J.

(2004) An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest 125: 2224–2231.

Bloos

Müller

Harz

Gugel

Geil

Egerland

(2009) Effects of staff training on the care of mechanically ventilated patients: a prospective cohort study. Br J Anaesth 103: 232–237.

Bonten

M.J.

(2006) Selective digestive tract decontamination—will it prevent infection with multidrug-resistant gram-negative pathogens but still be applicable in institutions where methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci are endemic? Clin Infect Dis 43(Suppl. 2): S70–S74.

10.

Bonten

M.J.

Krueger

W.A.

(2006) Selective decontamination of the digestive tract: cumulating evidence, at last? Semin Respir Crit Care Med 27: 18–22.

11.

Bonten

M.J.

Kollef

M.H.

Hall

J.B.

(2004) Risk factors for ventilator-associated pneumonia: from epidemiology to patient management. Clin Infect Dis 38: 1141–1149.

12.

Bonten

M.J.

van Tiel

F.H.

van der Geest

Stobberingh

E.E.

Gaillard

C.A.

(1993) Enterococcus faecalis pneumonia complicating topical antimicrobial prophylaxis. N Engl J Med 328: 209–210.

13.

Bouza

Perez

M.J.

Muñoz

Rincon

Barrio

J.M.

Hortal

(2008) Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest 134: 938–946.

14.

Boyce

J.M.

Pittet

(2002) Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control 30: S1–S46.

15.

Chan

E.Y.

Ruest

Meade

M.O.

Cook

D.J.

(2007) Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 334: 889–889.

16.

Chastre

Fagon

J.Y.

(2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165: 867–903.

17.

Chlebicki

M.P.

Safdar

(2007) Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med 35: 595–602.

18.

Cho

S.H.

Ketefian

Barkauskas

V.H.

Smith

D.G.

(2003) The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nurs Res 52: 71–79.

19.

Cook

D.J.

De Jonghe

Brochard

Brun-Buisson

(1998a) Influence of airway management on ventilator-associated pneumonia: evidence from randomized trials. JAMA 279: 781–787.

20.

Cook

D.J.

Kollef

M.H.

(1998) Risk factors for ICU-acquired pneumonia. JAMA 279: 1605–1066.

21.

Cook

D.J.

Meade

Guyatt

Griffith

Booker

(2000) Criteria for weaning from mechanical ventilation. Evid Rep Technol Assess 23: 1–4.

22.

Cook

D.J.

Walter

S.D.

Cook

R.J.

Griffith

L.E.

Guyatt

G.H.

Leasa

(1998b) Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 129: 433–440.

23.

Craven

D.E.

Goularte

T.A.

Make

B.J.

(1984) Contaminated condensate in mechanical ventilator circuits. A risk factor for nosocomial pneumonia? Am Rev Respir Dis 129: 625–6628.

24.

Craven

D.E.

Steger

K.A.

(1995) Epidemiology of nosocomial pneumonia. New perspectives on an old disease. Chest 108: 1S–16S.

25.

Craven

D.E.

Steger

K.A.

(1996) Nosocomial pneumonia in mechanically ventilated adult patients: epidemiology and prevention in 1996. Semin Respir Infect 11: 32–53.

26.

Dallas

Kollef

(2009) Oral decontamination to prevent ventilator-associated pneumonia: is it a sound strategy? Chest 135: 1116–1118.

27.

de Jonge

Schultz

M.J.

Spanjaard

Bossuyt

P.M.

Vroom

M.B.

Dankert

(2003) Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 362: 1011–1016.

28.

de La Cal

M.A.

Cerda

García-Hierro

van Saene

H.K.

Gomez-Santos

Negro

(2005) Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, double-blind trial. Ann Surg 241: 424–430.

29.

de Smet

A.M.

Kluytmans

J.A.

Cooper

B.S.

Mascini

E.M.

Benus

R.F.

van der Werf

T.S.

(2009) Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med 360: 20–31.

30.

Dezfulian

Shojania

Collard

H.R.

Kim

H.M.

Matthay

M.A.

Saint

(2005) Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med 118: 11–18.

31.

Dodek

Keenan

Cook

Heyland

Jacka

Hand

(2004) Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 141: 305–313.

32.

Donlan

R.M.

Costerton

J.W.

(2002) Biofilms: survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev 15: 167–193.

33.

Drakulovic

M.B.

Torres

Bauer

T.T.

Nicolas

J.M.

Nogue

Ferrer

(1999) Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Lancet 354: 1851–1858.

34.

Dreyfuss

Djedaini

Weber

Brun

Lanore

J.J.

Rahmani

(1991) Prospective study of nosocomial pneumonia and of patient and circuit colonization during mechanical ventilation with circuit changes every 48 hours versus no change. Am Rev Respir Dis 143: 738–743.

35.

Dullenkopf

Gerber

Weiss

(2003) Fluid leakage past tracheal tube cuffs: evaluation of the new Microcuff endotracheal tube. Intensive Care Med 29: 1849–1853.

36.

Ely

E.W.

Meade

M.O.

Haponik

E.F.

Kollef

M.H.

Cook

D.J.

Guyatt

G.H.

(2001) Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: evidence-based clinical practice guidelines. Chest 120: 454S–463S.

37.

Esteban

Frutos-Vivar

Ferguson

N.D.

Arabi

Apezteguía

González

(2004) Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 350: 2452–2460.

38.

Fagon

J.Y.

Chastre

Hance

A.J.

Domart

Trouillet

J.L.

Gibert

(1993a) Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest 103: 547–553.

39.

Fagon

J.Y.

Chastre

Hance

A.J.

Montravers

Novara

Gibert

(1993b) Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med 94: 281–288.

40.

Garner

J.S.

(1996) Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 17: 53–80.

41.

Gentile

M.A.

Siobal

M.S.

(2010) Are specialized endotracheal tubes and heat-and-moisture exchangers cost-effective in preventing ventilator associated pneumonia? Respir Care 55: 184–197.

42.

Greene, R., Thompson, S., Jantsch, H.S., Teplick, R., Cullen, D.J., Greene, E.M. et al. (1994) Detection of pooled secretions above endotracheal-tube cuffs: value of plain radiographs in sheep cadavers and patients. AJR Am J Roentgenol 163: 1333–1337.

43.

Haley

R.W.

Culver

D.H.

White

J.W.

Morgan

W.M.

Emori

T.G.

(1985) The nationwide nosocomial infection rate. A new need for vital statistics. Am J Epidemiol 121: 159–167.

44.

Han

Liu

(2010) Effect of ventilator circuit changes on ventilator-associated pneumonia: a systematic review and meta-analysis. Respir Care 55: 467–474.

45.

Hartmann

Guttmann

Müller

Hallmann

Geiger

(1999) Reduction of the bacterial load by the silver-coated endotracheal tube (SCET), a laboratory investigation. Technol Health Care 7: 359–370.

46.

Heyland

D.K.

Cook

D.J.

Griffith

Keenan

S.P.

Brun-Buisson

(1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. Am J Respir Crit Care Med 159: 1249–1256.

47.

Horst

H.M.

Mouro

Hall-Jenssens

R.A.

Pamukov

(1998) Decrease in ventilation time with a standardized weaning process. Arch Surg 133: 483–489.

48.

Huxley

E.J.

Viroslav

Gray

W.R.

Pierce

A.K.

(1978) Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med 64: 564–568.

49.

Ibáñez

Peñafiel

Raurich

J.M.

Marse

Jorda

Mata

(1992) Gastroesophageal reflux in intubated patients receiving enteral nutrition: effect of supine and semirecumbent positions. J Parenter Enteral Nutr 16: 419–422.

50.

Inglis

T.J.

Millar

M.R.

Jones

J.G.

Robinson

D.A.

(1989) Tracheal tube biofilm as a source of bacterial colonization of the lung. J Clin Microbiol 27: 2014–2018.

51.

Jongerden

I.P.

de Smet

A.M.

Kluytmans

J.A.

te Velde

L.F.

Dennesen

P.J.

Wesselink

R.M.

(2010) Physicians’ and nurses’ opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey. Crit Care 14: 132–132.

52.

Kappstein

Schulgen

Beyer

Geiger

Schumacher

Daschner

F.D.

(1992) Prolongation of hospital stay and extra costs due to ventilator-associated pneumonia in an intensive care unit. Eur J Clin Microbiol Infect Dis 11: 504–508.

53.

Koeman

van der Ven

A.J.

Hak

Joore

H.C.

Kaasjager

de Smet

A.G.

(2006) Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 173: 1348–1355.

54.

Kölbel

C.B.

Rippel

Klar

Singer

M.V.

van Ackern

Fiedler

(2000) Esophageal motility disorders in critically ill patients: a 24-hour manometric study. Intensive Care Med 26: 1421–1427.

55.

Kollef

M.H.

(1993) Ventilator-associated pneumonia. A multivariate analysis. JAMA 270: 1965–1970.

56.

Kollef

M.H.

(1999a) Epidemiology and risk factors for nosocomial pneumonia. Emphasis on prevention. Clin Chest Med 20: 653–670.

57.

Kollef

M.H.

(1999b) The prevention of ventilator-associated pneumonia. N Engl J Med 340: 627–634.

58.

Kollef

M.H.

(2004) Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med 32: 1396–1405.

59.

Kollef

M.H.

Afessa

Anzueto

Veremakis

Kerr

K.M.

Margolis

B.D.

(2008) Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA 300: 805–813.

60.

Kollef

M.H.

Pittet

Sanchez Garcia

Chastre

Fagon

J.Y.

Bonten

(2006) A randomized double-blind trial of iseganan in prevention of ventilator-associated pneumonia. Am J Respir Crit Care Med 173: 91–97.

61.

Kollef

M.H.

Shapiro

S.D.

Fraser

V.J.

Silver

Murphy

D.M.

Trovillion

(1995) Mechanical ventilation with or without 7-day circuit changes. A randomized controlled trial. Ann Intern Med 123: 168–174.

62.

Kollef

M.H.

Shapiro

S.D.

Silver

St John

R.E.

Prentice

Sauer

(1997) A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med 25: 567–574.

63.

Kollef

M.H.

Skubas

N.J.

Sundt

T.M.

(1999) A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest 116: 1339–1346.

64.

Kress

J.P.

Pohlman

A.S.

O’Connor

M.F.

Hall

J.B.

(2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342: 1471–1477.

65.

Krueger

W.A.

Lenhart

F.P.

Neeser

Ruckdeschel

Schreckhase

Eissner

H.J.

(2002) Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions, and mortality in critically ill surgical patients: a prospective, stratified, randomized, double-blind, placebo-controlled clinical trial. Am J Respir Crit Care Med 166: 1029–1037.

66.

Larson

E.L.

(1981) Persistent carriage of gram-negative bacteria on hands. Am J Infect Control 9: 112–119.

67.

Liberati

D’Amico

Pifferi

Torri

Brazzi

Parmelli

(2009) Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev 7: CD000022–CD000022.

68.

Lingnau

Berger

Javorsky

Lejeune

Mutz

Benzer

(1997) Selective intestinal decontamination in multiple trauma patients: prospective, controlled trial. J Trauma 42: 687–694.

69.

Lorente

Lecuona

Jiménez

Mora

M.L.

Sierra

(2007) Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am J Respir Crit Care Med 176: 1079–1083.

70.

Mahul

Auboyer

Jospe

Ros

Guerin

el Khouri

(1992) Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Med 18: 20–25.

71.

Marelich

G.P.

Murin

Battistella

Inciardi

Vierra

Roby

(2000) Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest 118: 459–467.

72.

Mori

Hirasawa

Oda

Shiga

Matsuda

Nakamura

(2006) Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med 32: 230–236.

73.

Muscedere

J.G.

Day

Heyland

D.K.

(2010) Mortality, attributable mortality, and clinical events as end points for clinical trials of ventilator-associated pneumonia and hospital-acquired pneumonia. Clin Infect Dis 51: S120–S125.

74.

Muscedere

J.G.

Dodek

Keenan

Fowler

Cook

D.J.

Heyland

(2008) Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention. J Crit Care 23: 126–137.

75.

National Nosocomial Infections Surveillance System (2004) National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 32: 470–485.

76.

Needleman

Buerhaus

Mattke

Stewart

Zelevinsky

(2002) Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 346: 1715–1722.

77.

Nseir

Makris

Mathieu

Durocher

Marquette

C.H.

(2010) Intensive Care Unit-acquired infection as a side effect of sedation. Crit Care 14: R30–R30.

78.

Olson

M.E.

Harmon

B.G.

Kollef

M.H.

(2002) Silver-coated endotracheal tubes associated with reduced bacterial burden in the lungs of mechanically ventilated dogs. Chest 121: 863–870.

79.

Oostdijk

E.A.

de Smet

A.M.

Blok

H.E.

Thieme Groen

E.S.

van Asselt

G.J.

Benus

R.F.

(2010) Ecological effects of selective decontamination on resistant gram-negative bacterial colonization. Am J Respir Crit Care Med 181: 452–457.

80.

Orozco-Levi

Torres

Ferrer

Piera

el-Ebiary

de la Bellacasa

J.P.

(1995) Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med 152: 1387–1390.

81.

Panchabhai

T.S.

Dangayach

N.S.

Krishnan

Kothari

V.M.

Karnad

D.R.

(2009) Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open-label randomized trial with 0.01% potassium permanganate as control. Chest 135: 1150–1156.

82.

Peleg

A.Y.

Hooper

D.C.

(2010) Hospital-acquired infections due to Gram-negative bacteria. N Engl J Med 362: 1804–1813.

83.

Perkins

S.D.

Woeltje

K.F.

Angenent

L.T.

(2010) Endotracheal tube biofilm inoculation of oral flora and subsequent colonization of opportunistic pathogens. Int J Med Microbiol 300: 503–511.

84.

Pineda

Saliba

El Solh

(2006) Effect of oral decontamination with chlorhexidine on the incidence of nosocomial pneumonia: a meta-analysis. Critical Care 10: R35–R35.

85.

Pittet

Hugonnet

Harbarth

Mourouga

Sauvan

Touveneau

(2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 356: 1307–1312.

86.

Pitts

Fisher

Sulemanji

Kratohvil

Jiang

Kacmarek

(2010) Variables affecting leakage past endotracheal tube cuffs: a bench study. Intensive Care Med [ePub ahead of print].

87.

Pobo

Lisboa

Rodriguez

Sole

Magret

Trefler

(2009) A randomized trial of dental brushing for preventing ventilator-associated pneumonia. Chest 136: 433–439.

88.

Rello

Ausina

Ricart

Castella

Prats

(1993) Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest 104: 1230–1235.

89.

Rello

Kollef

Diaz

Sandiumenge

del Castillo

Corbella

(2006) Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study. Crit Care Med 34: 2766–2772.

90.

Rello

Ollendorf

D.A.

Oster

Vera-Llonch

Bellm

Redman

(2002) Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest 122: 2115–2121.

91.

Rello

Soñora

Jubert

Artigas

Rué

Vallés

(1996) Pneumonia in intubated patients: role of respiratory airway care. Am J Respir Crit Care Med 154: 111–115.

92.

Rhame

F.S.

Streifel

McComb

Boyle

(1986) Bubbling humidifiers produce microaerosols which can carry bacteria. Infect Control 7: 403–407.

93.

Rodvold

K.A.

(2009) Collaborative strategies for improving clinical resource utilization: how pharmacists can make a difference. J Manag Care Pharm 15: S10–S14.

94.

Salahuddin

Zafar

Sukhyani

Rahim

Noor

M.F.

Hussain

(2004) Reducing ventilator-associated pneumonia rates through a staff education programme. J Hosp Infect 57: 223–227.

95.

Saura

Blanch

Mestre

Valles

Artigas

Fernandez

(1996) Clinical consequences of the implementation of a weaning protocol. Intensive Care Med 22: 1052–1056.

96.

Schweickert

W.D.

Kress

J.P.

(2008) Strategies to optimize analgesia and sedation. Crit Care 12: S6–S6.

97.

Seegobin

R.D.

van Hasselt

G.L.

(1984) Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs. Br Med J (Clin Res Ed) 288: 965–968.

98.

Seguin

Tanguy

Laviolle

Tirel

Mallédant

(2006) Effect of oropharyngeal decontamination by povidone-iodine on ventilator-associated pneumonia in patients with head trauma. Crit Care Med 34: 1514–1519.

99.

Sengupta

Sessler

D.I.

Maglinger

Wells

Vogt

Durrani

(2004) Endotracheal tube cuff pressure in three hospitals, and the volume required to produce an appropriate cuff pressure. BMC Anesthesiol 4: 8–8.

100.

Sessler

C.N.

Wilhelm

(2008) Analgesia and sedation in the intensive care unit: an overview of the issues. Crit Care 12(Suppl. 3): S1–S1.

101.

Shehabi

Riker

R.R.

Bokesch

P.M.

Wisemandle

Shintani

Ely

E.W.

(2010) Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care unit patients. Crit Care Med [ePub ahead of print].

102.

Shorr

A.F.

Zilberberg

M.D.

Kollef

(2009) Cost-effectiveness analysis of a silver-coated endotracheal tube to reduce the incidence of ventilator-associated pneumonia. Infect Control Hosp Epidemiol 30: 759–763.

103.

Silvestri

van Saene

H.K.

Milanese

Fontana

Gregori

Oblach

(2004) Prevention of MRSA pneumonia by oral vancomycin decontamination: a randomised trial. Eur Respir J 23: 921–926.

104.

Smulders

van der Hoeven

Weers-Pothoff

Vandenbroucke-Grauls

(2002) A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest 121: 858–862.

105.

Stewart

P.S.

(2003) New ways to stop biofilm infections. Lancet 361: 97–97.

106.

Strøm

Martinussen

Toft

(2010) A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 375: 475–480.

107.

Tablan

O.C.

Anderson

L.J.

Besser

Bridges

Hajjeh

(2004) Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 53: 1–36.

108.

Tantipong

Morkchareonpong

Jaiyindee

Thamlikitkul

(2008) Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia. Infect Control Hosp Epidemiol 29: 131–136.

109.

Taylor

van Saene

H.K.

Abella

Silvestri

Vucic

Peric

(2007) Selective digestive decontamination. Why don’t we apply the evidence in the clinical practice? Med Intensiva 31: 136–145.

110.

Tejerina

Frutos-Vivar

Restrepo

M.I.

Anzueto

Abroug

Palizas

(2006) Incidence, risk factors, and outcome of ventilator-associated pneumonia. J Crit Care 21: 56–65.

111.

Torres

Carlet

(2001) Ventilator-associated pneumonia. European Task Force on ventilator-associated pneumonia. Eur Respir J 17: 1034–1045.

112.

Torres

Serra-Batlles

Ros

Piera

Puig de la Bellacasa

Cobos

(1992) Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 116: 540–543.

113.

Ulldemolins

Restrepo

M.I.

Rello

(2009) Pharmacologic measures for the prevention of mechanical ventilation-associated pneumonia. Med Clin (Barc) [ePub ahead of print].

114.

Valencia

Ferrer

Farre

Navajas

Badia

J.R.

Nicolas

J.M.

(2007) Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trial. Crit Care Med 35: 1543–1549.

115.

Valles

Artigas

Rello

Bonsoms

Fontanals

Blanch

(1995) Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med 122: 179–186.

116.

van der Waaij

(1982) Colonization resistance of the digestive tract: clinical consequences and implications. J Antimicrob Chemother 10: 263–270.

117.

van Nieuwenhoven

C.A.

Vandenbroucke-Grauls

van Tiel

F.H.

Joore

H.C.

van Schijndel

R.J.

van der Tweel

(2006) Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 34: 396–402.

118.

Verwaest

Verhaegen

Ferdinande

Schetz

Van den Berghe

Verbist

(1997) Randomized, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit. Crit Care Med 25: 63–71.

119.

Warren

D.K.

Shukla

S.J.

Olsen

M.A.

Kollef

M.H.

Hollenbeak

C.S.

Cox

M.J.

(2003) Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med 31: 1312–1317.

120.

Weinstein

R.A.

(1991) Epidemiology and control of nosocomial infections in adult intensive care units. Am J Med 91: 179S–184S.

121.

Wiener

Itokazu

Nathan

Kabins

S.A.

Weinstein

R.A.

(1995) A randomized, double-blind, placebo-controlled trial of selective digestive decontamination in a medical-surgical intensive care unit. Clin Infect Dis 20: 861–867.

122.

Wood

MacLeod

Moffatt

(2007) Weaning from mechanical ventilation: physician-directed vs a respiratory-therapist-directed protocol. Respir Care 40: 219–224.

123.

Zack

J.E.

Garrison

Trovillion

Clinkscale

Coopersmith

C.M.

Fraser

V.J.

(2002) Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med 30: 2407–2412.

Strategies in the prevention of ventilator-associated pneumonia

Abstract

Keywords

Introduction

General measures

Standard precautions

Multidisciplinary team members

Early extubation

Early weaning of mechanical ventilation

Daily sedation breaks

Prevention of aspiration

Semiseated position

Unnecessary changes and manipulation of ventilator circuits

Drainage of subglottic secretions

Endotracheal tube cuff pressure

Decontamination strategies

Oral decontamination

Selective decontamination of the gastrointestinal tract

Prevention of biofilm formation/silver-coated endotracheal tubes

Conclusion

Footnotes

Funding

Conflict of interest statement

References