New Strategies to Prevent Ventilator-Associated Pneumonia: What to Do for Your Patients

The current rates of ventilator-associated pneumonia (VAP) are falling, in large part, as a result of effective prevention strategies. However, the application and efficacy of VAP prevention is being challenged by efforts to replace VAP surveillance with monitoring for ventilator-associated complications (VAC), which include many non-infectious processes. VAP prevention is based on interrupting pneumonia pathogenesis by avoiding the inoculation of contaminated oral secretions into the lower respiratory tract. This starts by using non-invasive ventilation in place of endotracheal intubation whenever possible, placing all tracheal and gastric tubes through the mouth and not the nose, and making daily efforts to liberate patients from mechanical ventilation. Intervention strategies to avoid microaspiration of oral contents to the lung have focused on the use of modified respiratory therapy equipment. This includes endotracheal tubes with subglottic secretion drainage channels, endotracheal tube cuffs made of special materials and of special shape, adaptation of endotracheal tube materials to prevent the development of biofilm, cleaning tubes with biofilm removal devices, and using devices to maintain endotracheal tube cuff pressure. Decontamination of oral secretions with chlorhexidine is commonly incorporated, as part of routine oral care, in many patients. The use of 24 h of prophylactic antibiotics after emergent intubation is also a valuable strategy, but controversy about selective digestive and selective oral decontamination persists, because of concerns about the emergence of antibiotic resistance, particularly in ICUs with high baseline rates of resistance. Other interventions are of less certain benefit, such as post-pyloric feeding, elevation of the head of the bed, and use of probiotics. This review makes recommendations about which current prevention strategies have the greatest potential to reduce the frequency of VAP.