Friday May 30, 2008
An update on VAP (Ventilator Associated Pneumonia)

There have been several studies recently published in the journal of critical care medicine on Ventilator Associated Pneumonia (VAP). The VAP Guidelines Committee and the Canadian Critical Care Trials Group has made evidence based recommendations for the prevention, diagnosis and treatment of VAP.

• For VAP prevention, the group recommend that the orotracheal route of intubation should be used for intubation
• a new ventilator circuit for each patient
• circuit changes if the circuit becomes soiled or damaged, but no scheduled changes
• change of heat and moisture exchangers every 5 to 7 days or as clinically indicated
• the use of a closed endotracheal suctioning system changed for each patient and as clinically indicated
• subglottic secretion drainage in patients expected to be mechanically ventilated for more than 72 hours
• head of bed elevation to 45 degrees (when impossible, as near to 45 degrees as possible should be considered)

Consider:

• the use of rotating beds;
• oral antiseptic rinses.

The group do not recommend:

• use of bacterial filters;
• the use of iseganan,

make no recommendations regarding:

• the use of a systematic search for sinusitis;
• type of airway humidification;
• timing of tracheostomy;
• prone positioning;
• aerosolized antibiotics;
• intranasal mupirocin;
• topical and/or intravenous antibiotics.
  

For the diagnosis and treatment of VAP, the group recommends that

• endotracheal aspirates with nonquantitative cultures be used as the initial diagnostic strategy.
• When there is a suspicion of VAP, they recommend empiric antimicrobial therapy (in contrast to delayed or culture directed therapy) and appropriate single agent antimicrobial therapy for each potential pathogen as empiric therapy for VAP.
• Choice of antibiotics should be based on patient factors and local resistance patterns.
• They recommend that an antibiotic discontinuation strategy be used in patients who are treated of suspected VAP.
• For patients who receive adequate initial antibiotic therapy, they recommend 8 days of antibiotic therapy.
• The group does not recommend nebulized endotracheal tobramycin or intratracheal instillation of tobramycin for the treatment of VAP.
  
  

Click here to get VAP prevention getting started kit from IHI

Reference: Click to article

1. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention. - J Crit Care. 2008 Mar;23(1):126-37.

2. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and treatment. - J Crit Care. 2008 Mar;23(1):138-47