Reduction in Oropharyngeal Colonization

Peptic Ulcer Disease (PUD) Prophylaxis

Both H2 antagonists and antacids have been identified as risk factors for VAP because they decrease intragastric acidity, which can result in greater colonization of pathogenic bacteria.([FOOTNOTE=American Thoracic Society, Infectious Diseases Society of America. 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.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805217]) However, trials investigating alternative therapies have been inconclusive regarding the prevention of VAP.1 The American Thoracic Society suggests that the risks and benefits of PUD prophylaxis regimens should be weighed before prescribing.1

Daily Oral Care with Chlorhexidine

Oral care is designed to reduce VAP by reducing oropharyngeal bacterial colonization.([FOOTNOTE=Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis. 2011;11(11):845-854.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805233])

Selective Decontamination of the Digestive Tract

Gram-negative bacterial colonization of the stomach during critical illness is considered to be the source of microorganisms isolated from sputum cultures of patients with VAP.([FOOTNOTE= Liberati A, D'Amico R, Pifferi S, Torri V, Brazzi L, Parmelli E. Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev. 2009(4):CD000022.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805230]) Selective decontamination of the digestive track (SDD) uses prophylactic antibiotic therapy to reduce bacterial colonization.3

Silver-Coated Endotracheal Tubes

Biofilm on the endotracheal tube is considered to be a source of reinfection in patients with VAP.([FOOTNOTE=Gil-Perotin S, Ramirez P, Marti V, et al. Implications of endotracheal tube biofilm in ventilator-associated pneumonia response: a state of concept. Crit Care. 2012;23;16(3):R93. [Epub ahead of print]],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=412902]) Silver has a very effective broad-spectrum antimicrobial effect and is believed to reduce biofilm on endotracheal tubes.([FOOTNOTE=Kollef MH, Afessa B, Anzueto A, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300(7):805-813.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=231680])

Semirecumbent Position

This method is typically defined as raising the head of the bed to an angle of 30-45 degrees, and is thought to reduce VAP by decreasing the migration of gastric pathogens into the subglottic space.([FOOTNOTE=Niël-Weise BS, Gastmeier P, Kola A, Vonberg RP, Wille JC, van den Broek PJ. An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Crit Care. 2011;15(2):R111.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805232])

Efficacy of VAP Interventions that Target Oropharyngeal Colonization

1. Meta-analysis (14 studies, 2,481 participants) (P= 0.004)2

2. Randomized controlled trial (1,200 participants) (P=0.19)([FOOTNOTE=Cook D, Guyatt G, Marshall J, 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; 19;338(12):791-797.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=97565])

3. Meta-analysis (33 studies, 5,697 participants) 3

4. Randomized controlled trial (1,509 participants) (P=0.03)5

View the Efficacy of VAP Interventions that Target Oropharyngeal Colonization table

Microaspiration Prevention

Cuff Pressure Monitoring

ETT cuffs that are not frequently monitored are often inflated to a pressure that is outside recommended cuff pressure range. It has been proposed that maintaining the ETT cuff pressure to the appropriate level may prevent secretions from aspirating through the microchannels on the cuff.([FOOTNOTE=Valencia M, Ferrer M, Farre R, et al. Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trial. Crit Care Med. 2007;35(6):1543-1549. ],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805228])

Subglottic Secretion Drainage

Subglottic secretion drainage removes oral and gastric secretions from the subglottic space, preventing microaspiration that could lead to VAP.([FOOTNOTE=Wang F, Bo L, Tang L, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: an updated meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2012;72(5):1276-1285.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805236]) Continuous or intermittent aspiration of subglottic secretions is done with a specialized endotracheal tube with a separate dorsal lumen.

Ultrathin Cuff

An ultrathin cuff membrane may reduce the formation of channels within the ETT cuff through which pathogens may leak compared to conventional thickness cuffs.([FOOTNOTE=Fernandez JF, Levine SM, Restrepo MI. Technologic advances in endotracheal tubes for prevention of ventilator-associated pneumonia. Chest. 2012;142(1):231-238.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805220])

Taper-Shaped Cuff

The unique design of some ETT tapered-shaped cuffs may reduce the formation of channels within the ETT cuff through which pathogens may leak compared to barrel-shaped cuffs.([FOOTNOTE=Zanella A, Scaravilli V, Isgrò S, et al. Fluid leakage across tracheal tube cuff, effect of different cuff material, shape, and positive expiratory pressure: a bench-top study. Intensive Care Med. 2011;37(2):343-347.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805218])

Efficacy of VAP Interventions that Target Microaspiration

5. Randomized controlled trial (142 participants) (P=0.89)8

6. Randomized controlled trial (122 participants) (P=0.03)([FOOTNOTE=Nseir S, Zerimech F, Fournier C, et al. Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am J Respir Crit Care Med. 2011;184(9):1041-1047.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805234])

7. Meta-analysis (3 studies, 337 participants) (P=0.16)6

8. Meta-analysis (10 studies, 2,213 participants) (P<0.00001)9

9. Randomized controlled trial (134 participants) (P=0.026)([FOOTNOTE=Poelaert J, Depuydt P, De Wolf A, Van de Velde S, Herck I, Blot S. Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: a pilot study. J Thorac Cardiovasc Surg. 2008 ;135(4):771-776.],[ANCHOR=View Abstract],[LINK=/content/covidien/websites/medtronic/com/en/covidien/support/clinical-evidence.html?id=805229])

View the Efficacy of VAP Interventions that Target Microaspiration table