Strategies to prevent ventilator-associated pneumonia

Essential practices that should be provided whenever possible to all patients to prevent VAP

Use high-flow nasal oxygen or NIPPV, when appropriate, to avoid intubation, facilitate early extubation, and prevent reintubation
Provide enteral instead of parenteral nutrition, when possible
Avoid changing the ventilator circuit except in the following circumstances:
- The ventilator circuit is visibly soiled;
- The ventilator circuit is malfunctioning; or
- A ventilator circuit change is recommended after a fixed number of days by the manufacturer
Minimize sedation
Maintain and improve physical conditioning through active and passive exercises
Provide oral care, including toothbrushing (do not use chlorhexidine)
Set the head of the patient's bed to an elevation between 30 and 45 degrees

If VAP rates remain high despite implementing the preceding practices, the following additional practices can be considered:

Tracheostomy after 1 to 2 weeks of sustained invasive mechanical ventilation, taking into account patient trajectory and preferences*
Using endotracheal tubes with subglottic secretion drainage ports for patients expected to require more than 48 to 72 hours of mechanical ventilation*
Postpyloric feeding (instead of gastric feeding) for patients at high risk of aspiration or with gastric intolerance*
Using selective oral or digestive decontamination in ICUs with low antibiotic utilization and low prevalence of antibiotic-resistant organisms^¶

This list provides actions that can be taken as part of routine ICU care to prevent VAP in patients requiring mechanical ventilation.

VAP: ventilator-associated pneumonia; NIPPV: noninvasive positive pressure ventilation; ICU: intensive care unit.

* The intervention may lower VAP rates but there are insufficient data to determine its impact on duration of mechanical ventilation, length of stay, or mortality.

¶ The intervention has been shown to improve outcome in the population listed. However, it may confer increased risk in other populations.

Adapted from: Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687.

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Strategies to prevent ventilator-associated pneumonia