Ventilator-associated pneumonia (VAP) is a pervasive and expensive nosocomial infection that is largely related to instrumentation of the airway with an endotracheal tube (ETT), followed by microaspiration of contaminated secretions. VAP prevention will probably be most effective via a multifaceted approach, which includes meticulous attention to basic infection-control methods during patient care, proper patient positioning, oral hygiene, and removal of the ETT as soon as indicated. Modification of the ETT to reduce microaspiration and/or biofilm formation may also play an important role in VAP prevention. However, despite numerous studies of various such interventions, there is insufficient evidence upon which to base strong recommendations, and important safety concerns remain regarding the use of some devices. Most importantly, cost-effectiveness data are lacking for modified ETTs designed to prevent VAP. It is critical that future studies of ETTs designed to prevent VAP be adequately powered to demonstrate efficacy on important patient outcomes and safety, in addition to cost-effectiveness.
VincentJL, BihariDJ, SuterPM, BruiningHA, WhiteJ, Nicolas-ChanoinMH, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA, 1995; 274(8):639–644.
2.
CelisR, TorresA, GatellJM, AlmelaM, Rodriguez-RoisinR, Agusti-VidalA. Nosocomial pneumonia. A multivariate analysis of risk and prognosis. Chest, 1988; 93(2):318–324.
3.
LangerM, CigadaM, MandelliM, MosconiP, TognoniG. Early onset pneumonia: a multicenter study in intensive care units. Intensive Care Med, 1987; 13(5):342–346.
4.
ChevretS, HemmerM, CarletJ, LangerM. Incidence and risk factors of pneumonia acquired in intensive care units. Results from a multicenter prospective study on 996 patients. European Cooperative Group on Nosocomial Pneumonia. Intensive Care Med, 1993; 19(5):256–264.
5.
CrossAS, RoupB. Role of respiratory assistance devices in endemic nosocomial pneumonia. Am J Med, 1981; 70(3):681–685.
6.
CunnionKM, WeberDJ, BroadheadWE, HansonLC, PieperCF, RutalaWA. Risk factors for nosocomial pneumonia: comparing adult critical-care populations. Am J Respir Crit Care Med, 1996; 153(1):158–162.
7.
RichardsMJ, EdwardsJR, CulverDH, GaynesRP. Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Crit Care Med, 1999; 27(5):887–892.
8.
RichardsMJ, EdwardsJR, CulverDH, GaynesRP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol, 2000; 21(8):510–515.
9.
ChastreJ, FagonJY. Ventilator-associated pneumonia. Am J Respir Crit Care Med, 2002; 165(7):867–903.
10.
CookDJ, WalterSD, CookRJ, GriffithLE, GuyattGH, LeasaD, et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med, 1998; 129(6):433–440.
11.
FagonJY, ChastreJ, DomartY, TrouilletJL, PierreJ, DarneC, GibertC. Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis, 1989; 139(4):877–884.
12.
FagonJY, ChastreJ, VuagnatA, TrouilletJL, NovaraA, GibertC. Nosocomial pneumonia and mortality among patients in intensive care units. JAMA, 1996; 275(11):866–869.
13.
LangerM, MosconiP, CigadaM, MandelliM. Long-term respiratory support and risk of pneumonia in critically ill patients. Intensive Care Unit Group of Infection Control. Am Rev Respir Dis, 1989; 140(2):302–305.
14.
MosconiP, LangerM, CigadaM, MandelliM. Epidemiology and risk factors of pneumonia in critically ill patients. Intensive Care Unit Group for Infection Control. Eur J Epidemiol, 1991; 7(4):320–327.
15.
EggimannP, HugonnetS, SaxH, TouveneauS, ChevroletJC, PittetD. Ventilator-associated pneumonia: caveats for benchmarking. Intensive Care Med, 2003; 29(11):2086–2089.
16.
CookD, GuyattG, MarshallJ, LeasaD, FullerH, HallR, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. N Engl J Med, 1998; 338(12):791–797.
17.
FagonJY, ChastreJ, HanceAJ, MontraversP, NovaraA, GibertC. Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J Med, 1993; 94(3):281–288.
18.
HeylandDK, CookDJ, GriffithL, KeenanSP, Brun-BuissonC. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med, 1999; 159(4 Pt 1):1249–1256.
19.
PapazianL, BregeonF, ThirionX, GregoireR, SauxP, DenisJP, et al. Effect of ventilator-associated pneumonia on mortality and morbidity. Am J Respir Crit Care Med, 1996; 154(1):91–97.
20.
KollefMH, ShorrA, TabakYP, GuptaV, LiuLZ, JohannesRS. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest, 2005; 128(6):3854–3862.
21.
BercaultN, BoulainT. Mortality rate attributable to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective case-control study. Crit Care Med, 2001; 29(12):2303–2309.
22.
CraigCP, ConnellyS. Effect of intensive care unit nosocomial pneumonia on duration of stay and mortality. Am J Infect Control, 1984; 12(4):233–238.
23.
KappsteinI, SchulgenG, BeyerU, GeigerK, SchumacherM, DaschnerFD. Prolongation of hospital stay and extra costs due to ventilator-associated pneumonia in an intensive care unit. Eur J Clin Microbiol Infect Dis, 1992; 11(6):504–508.
24.
BakerAM, MeredithJW, HaponikEF. Pneumonia in intubated trauma patients. Microbiology and outcomes. Am J Respir Crit Care Med, 1996; 153(1):343–349.
25.
CollardHR, SaintS, MatthayMA. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med, 2003; 138(6):494–501.
26.
KollefMH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med, 2004; 32(6):1396–1405.
27.
D'AmicoR, PifferiS, LeonettiC, TorriV, TinazziA, LiberatiA. Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials. BMJ, 1998; 316(7140):1275–1285.
28.
DeRisoAJ2nd, LadowskiJS, DillonTA, JusticeJW, PetersonAC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest, 1996; 109(6):1556–1561.
29.
NathensAB, MarshallJC. Selective decontamination of the digestive tract in surgical patients: a systematic review of the evidence. Arch Surg, 1999; 134(2):170–176.
30.
CookDJ, LaineLA, GuyattGH, RaffinTA. Nosocomial pneumonia and the role of gastric pH. A meta-analysis. Chest, 1991; 100(1):7–13.
31.
ChlebickiMP, SafdarN. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med, 2007; 35(2):595–602.
32.
KollefMH, AfessaB, AnzuetoA, VeremakisC, KerrKM, MargolisBD, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA, 2008; 300(7):805–813.
33.
AhrensT, KollefM, StewartJ, ShannonW. Effect of kinetic therapy on pulmonary complications. Am J Crit Care, 2004; 13(5):376–383.
34.
Orozco-LeviM, TorresA, FerrerM, PieraC, el-EbiaryM, de la BellacasaJP, Rodriguez-RoisinR. Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med, 1995; 152(4 Pt 1):1387–1390.
35.
TorresA, Serra-BatllesJ, RosE, PieraC, Puig de la BellacasaJ, CobosA, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med, 1992; 116(7):540–543.
36.
DrakulovicMB, TorresA, BauerTT, NicolasJM, NogueS, FerrerM. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet, 1999; 354(9193):1851–1858.
37.
PneumatikosIA, DragoumanisCK, BourosDE. Ventilator-associated pneumonia or endotracheal tube-associated pneumonia? An approach to the pathogenesis and preventive strategies emphasizing the importance of endotracheal tube. Anesthesiology, 2009; 110(3):673–680.
38.
BouzaE, PerezMJ, MunozP, RinconC, BarrioJM, HortalJ. Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest, 2008; 134(5):938–946.
39.
TorresA, GatellJM, AznarE, el-EbiaryM, Puig de la BellacasaJ, GonzalezJ, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med, 1995; 152(1):137–141.
40.
JohansonWGJr, PierceAK, SanfordJP, ThomasGD. Nosocomial respiratory infections with gram-negative bacilli. The significance of colonization of the respiratory tract. Ann Intern Med, 1972; 77(5):701–706.
41.
Cardenosa CendreroJA, Sole-ViolanJ, Bordes BenitezA, Noguera CatalanJ, Arroyo FernandezJ, Saavedra SantanaP, Rodriguez de CastroF. Role of different routes of tracheal colonization in the development of pneumonia in patients receiving mechanical ventilation. Chest, 1999; 116(2):462–470.
42.
FeldmanC, KasselM, CantrellJ, KakaS, MorarR, Goolam MahomedA, PhilipsJI. The presence and sequence of endotracheal tube colonization in patients undergoing mechanical ventilation. Eur Respir J, 1999; 13(3):546–551.
43.
BontenMJ, GaillardCA, van TielFH, SmeetsHG, van der GeestS, StobberinghEE. The stomach is not a source for colonization of the upper respiratory tract and pneumonia in ICU patients. Chest, 1994; 105(3):878–884.
44.
BluntMC, YoungPJ, PatilA, HaddockA. Gel lubrication of the tracheal tube cuff reduces pulmonary aspiration. Anesthesiology, 2001; 95(2):377–381.
45.
PavlinEG, VanNimweganD, HornbeinTF. Failure of a high-compliance low-pressure cuff to prevent aspiration. Anesthesiology, 1975; 42(2):216–219.
46.
SeegobinRD, van HasseltGL. Aspiration beyond endotracheal cuffs. Can Anaesth Soc J, 1986; 33(3 Pt 1):273–279.
47.
TorresA, el-EbiaryM, GonzalezJ, FerrerM, Puig de la BellacasaJ, GeneA, et al. Gastric and pharyngeal flora in nosocomial pneumonia acquired during mechanical ventilation. Am Rev Respir Dis, 1993; 148(2):352–357.
48.
Garrouste-OrgeasM, ChevretS, ArletG, MarieO, RouveauM, PopoffN, SchlemmerB. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med, 1997; 156(5):1647–1655.
49.
SottileFD, MarrieTJ, ProughDS, HobgoodCD, GowerDJ, WebbLX, et al. Nosocomial pulmonary infection: possible etiologic significance of bacterial adhesion to endotracheal tubes. Crit Care Med, 1986; 14(4):265–270.
50.
AdairCG, GormanSP, FeronBM, ByersLM, JonesDS, GoldsmithCE, et al. Implications of endotracheal tube biofilm for ventilator-associated pneumonia. Intensive Care Med, 1999; 25(10):1072–1076.
51.
CostertonJW, StewartPS, GreenbergEP. Bacterial biofilms: a common cause of persistent infections. Science, 1999; 284(5418):1318–1322.
52.
StewartPS, CostertonJW. Antibiotic resistance of bacteria in biofilms. Lancet, 2001; 358(9276):135–138.
53.
HessDR. Noninvasive positive-pressure ventilation and ventilator-associated pneumonia. Respir Care, 2005; 50(7):924–931.
54.
KohlenbergA, SchwabF, BehnkeM, GeffersC, GastmeierP. Pneumonia associated with invasive and noninvasive ventilation: an analysis of the German nosocomial infection surveillance system database. Intensive Care Med, 2010; 36(6):971–978.
55.
AlexiouVG, IerodiakonouV, DimopoulosG, FalagasME. Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. J Crit Care, 2009; 24(4):515–522.
56.
van NieuwenhovenCA, Vandenbroucke-GraulsC, van TielFH, JooreHC, van SchijndelRJ, van der TweelI, RamsayG, BontenMJ. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med, 2006; 34(2):396–402.
57.
DezfulianC, ShojaniaK, CollardHR, KimHM, MatthayMA, SaintS. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med, 2005; 118(1):11–18.
58.
DullenkopfA, GerberA, WeissM. Fluid leakage past tracheal tube cuffs: evaluation of the new Microcuff endotracheal tube. Intensive Care Med, 2003; 29(10):1849–1853.
59.
PoelaertJ, DepuydtP, De WolfA, Van de VeldeS, HerckI, BlotS. Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: a pilot study. J Thorac Cardiovasc Surg, 2008; 135(4):771–776.
60.
LorenteL, LecuonaM, JimenezA, MoraML, SierraA. Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am J Respir Crit Care Med, 2007; 176(11):1079–1083.
61.
FletcherAJ, RuffellAJ, YoungPJ. The LoTrach system: its role in the prevention of ventilator-associated pneumonia. Nurs Crit Care, 2008; 13(5):260–268.
62.
KolobowT, Li BassiG, CurtoF, ZanellaA. The Mucus Slurper: a novel tracheal tube that requires no tracheal tube suctioning. A preliminary report. Intensive Care Med, 2006; 32(9):1414–1418.
63.
Li BassiG, CurtoF, ZanellaA, StylianouM, KolobowT. A 72-hour study to test the efficacy and safety of the “Mucus Slurper” in mechanically ventilated sheep. Crit Care Med, 2007; 35(3):906–911.
64.
KolobowT, BerraL, Li BassiG, CurtoF. Novel system for complete removal of secretions within the endotracheal tube: the Mucus Shaver. Anesthesiology, 2005; 102(5):1063–1065.
65.
BerraL, CurtoF, Li BassiG, LaquerriereP, BaccarelliA, KolobowT. Antibacterial-coated tracheal tubes cleaned with the Mucus Shaver: a novel method to retain long-term bactericidal activity of coated tracheal tubes. Intensive Care Med, 2006; 32(6):888–893.
66.
BoH, HeL, QuJ. [Influence of the subglottic secretion drainage on the morbidity of ventilator associated pneumonia in mechanically ventilated patients]. Zhonghua Jie He He Hu Xi Za Zhi, 2000; 23(8):472–474. Article in Chinese.
67.
KollefMH, SkubasNJ, SundtTM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest, 1999; 116(5):1339–1346.
68.
MahulP, AuboyerC, JospeR, RosA, GuerinC, el KhouriZ, et al. Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Med, 1992; 18(1):20–25.
69.
SmuldersK, van der HoevenH, Weers-PothoffI, Vandenbroucke-GraulsC. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest, 2002; 121(3):858–862.
70.
VallesJ, ArtigasA, RelloJ, BonsomsN, FontanalsD, BlanchL, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med, 1995; 122(3):179–186.
71.
ZhengRQ, LinH, ShaoJ, ChenQH, LuNF, YuJQ. [A clinical study of subglottic secretion drainage for prevention of ventilation associated pneumonia]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue, 2008; 20(6):338–340. Article in Chinese.
72.
RelloJ, DiazE, RoqueM, VallesJ. Risk factors for developing pneumonia within 48 hours of intubation. Am J Respir Crit Care Med, 1999; 159(6):1742–1746.
73.
GirouE, Buu-HoiA, StephanF, NovaraA, GutmannL, SafarM, FagonJY. Airway colonisation in long-term mechanically ventilated patients. Effect of semi-recumbent position and continuous subglottic suctioning. Intensive Care Med, 2004; 30(2):225–233.
74.
SeneffMG, ZimmermanJE, KnausWA, WagnerDP, DraperEA. Predicting the duration of mechanical ventilation. The importance of disease and patient characteristics. Chest, 1996; 110(2):469–479.
75.
BerraL, De MarchiL, PanigadaM, YuZX, BaccarelliA, KolobowT. Evaluation of continuous aspiration of subglottic secretion in an in vivo study. Crit Care Med, 2004; 32(10):2071–2078.
76.
DragoumanisCK, VretzakisGI, PapaioannouVE, DidilisVN, VogiatzakiTD, PneumatikosIA. Investigating the failure to aspirate subglottic secretions with the Evac endotracheal tube. Anesth Analg, 2007; 105(4):1083–1085.
77.
SantosPM, AfrassiabiA, WeymullerEAJr. Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngol Head Neck Surg, 1994; 111(4):453–459.
78.
JaenssonM, OlowssonLL, NilssonU. Endotracheal tube size and sore throat following surgery: a randomized-controlled study. Acta Anaesthesiol Scand, 2010; 54(2):147–153.
79.
SiobalM, KalletRH, KraemerR, JonsonE, LemonsD, YoungD, et al. Tracheal-innominate artery fistula caused by the endotracheal tube tip: case report and investigation of a fatal complication of prolonged intubation. Respir Care, 2001; 46(10):1012–1018.
80.
DeemS. Limited value of the cuff-leak test. Respir Care, 2005; 50(12):1617–1618.
81.
FrancoisB, BellissantE, GissotV, DesachyA, NormandS, BoulainT, et al. 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet, 2007; 369(9567):1083–1089.
82.
TablanOC, AndersonLJ, BesserR, BridgesC, HajjehR. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep, 2004; 53(RR-3):1–36.
83.
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med, 2005; 171(4):388–416.
84.
LucangeloU, ZinWA, AntonagliaV, PetrucciL, VivianiM, BuscemaG, et al. Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. Crit Care Med, 2008; 36(2):409–413.
85.
YoungPJ, PakeerathanS, BluntMC, SubramanyaS. A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med, 2006; 34(3):632–639.
86.
YoungPJ, BurchettK, HarveyI, BluntMC. The prevention of pulmonary aspiration with control of tracheal wall pressure using a silicone cuff. Anaesth Intensive Care, 2000; 28(6):660–665.
87.
MillerMA, ArndtJL, KonkleM, ChenowethCE, FlahertyKR, HyzyRC. Polyurethane cuff endotracheal tube to prevent ventilator-associated pneumonia in an academic hospital (abstract). Am J Respir Crit Care Med, 2009:179; A1731. http://ajrccm.atsjournals.org/cgi/reprint/179/1meetingabstracts/a1731.pdf. Accessed May 21, 2010.
88.
BerraL, CurtoF, Li BassiG, LaquerriereP, PittsB, BaccarelliA, KolobowT. Antimicrobial-coated endotracheal tubes: an experimental study. Intensive Care Med, 2008; 34(6):1020–1029.
89.
BerraL, De MarchiL, YuZX, LaquerriereP, BaccarelliA, KolobowT. Endotracheal tubes coated with antiseptics decrease bacterial colonization of the ventilator circuits, lungs, and endotracheal tube. Anesthesiology, 2004; 100(6):1446–1456.
90.
BerraL, KolobowT, LaquerriereP, PittsB, BramatiS, PohlmannJ, et al. Internally coated endotracheal tubes with silver sulfadiazine in polyurethane to prevent bacterial colonization: a clinical trial. Intensive Care Med, 2008; 34(6):1030–1037.
RelloJ, AfessaB, AnzuetoA, ArroligaAC, OlsonME, RestrepoMI, et al. Activity of a silver-coated endotracheal tube in preclinical models of ventilator-associated pneumonia and a study after extubation. Crit Care Med, 2010; 38(4):1135–1140.
93.
RelloJ, KollefM, DiazE, SandiumengeA, del CastilloY, CorbellaX, ZachskornR. Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study. Crit Care Med, 2006; 34(11):2766–2772.
94.
YoungPJ, BassonC, HamiltonD, RidleySA. Prevention of tracheal aspiration using the pressure-limited tracheal tube cuff. Anaesthesia, 1999; 54(6):559–563.
95.
ShorrAF, O'MalleyPG. Continuous subglottic suctioning for the prevention of ventilator-associated pneumonia: potential economic implications. Chest, 2001; 119(1):228–235.
96.
ShorrAF, ZilberbergMD, KollefM. Cost-effectiveness analysis of a silver-coated endotracheal tube to reduce the incidence of ventilator-associated pneumonia. Infect Control Hosp Epidemiol, 2009; 30(8):759–763.
97.
WarrenDK, ShuklaSJ, OlsenMA, KollefMH, HollenbeakCS, CoxMJ, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med, 2003; 31(5):1312–1317.
