Theme Issue EditorialComprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Prevention☆
Introduction
Ventilator associated pneumonia (VAP) is a healthcare-associated infection that commonly causes morbidity and mortality in mechanically ventilated patients [1]. For example, VAP is associated with an increased duration of mechanical ventilation, crude death rates of 5% to 65% [2], [3], [4], [5], and increased healthcare costs [6], [7], [8]. However, VAP is preventable and many practices have been demonstrated to reduce the incidence of VAP and its associated burden of illness [9], [10]. Because the body of literature on VAP is extensive and in some cases, conflicting, it has become increasingly difficult for critical care practitioners to assimilate and apply best evidence into clinical practice [11]. The synthesis of large bodies of knowledge into clinical practice guidelines (CPGs) is one method of improving the accessibility and utility of medical literature to clinicians [12]. For the management of critically ill patients, guidelines can improve the processes, outcomes, and costs of critical care [13], [14], [15], [16]. The optimal method to implement guidelines is uncertain, but active strategies are superior to passive ones, periodic updates are necessary, and continued efforts to effect behavior change are required [17].
The guidelines committee of the Canadian Critical Care Society and Canadian Critical Care Trials Group developed evidence-based CPGs for the prevention of VAP in 2004 [18]. However, only research evidence published before April 1, 2003, was incorporated into those guidelines. Since then, new randomized controlled trials (RCTs) of strategies to prevent VAP have been published, and updating is necessary [19]. Therefore, the Canadian Critical Care Trials Group commissioned the development of up-to-date and comprehensive evidence-based CPGs for the prevention, diagnosis, and treatment of VAP. Herein, we report on the guidelines for the prevention of VAP. The guidelines for the diagnosis and treatment of VAP are reported in a companion manuscript in this issue [20].
Section snippets
Methods
A multispecialty and multidisciplinary panel was created to develop the comprehensive VAP CPGs. This group was composed of 20 intensivists from university-affiliated and community hospitals, 4 infectious disease specialists, 3 intensive care unit (ICU) nurses, an infection control nurse, an ICU pharmacist, an ICU respiratory therapist, and a representative from the Canadian Patient Safety Institute [21]. Panel members were experts in critical care medicine (n = 20), infectious diseases (n = 5),
Results
The final evidence summaries and recommendations for each of the interventions are reported. The results are divided into physical strategies, positional strategies, and pharmacologic strategies, and are summarized in Table 1. The semiquantitative scores for each intervention are reported in Table 2 and the agreement scores are reported in Table 3.
Route of endotracheal intubation
On the basis of 1 level 2 trial [33], we conclude that orotracheal intubation is associated with a trend toward a reduction in VAP compared to nasotracheal intubation.
Furthermore, this trial and 4 other level 2 trials have found that orotracheal intubation is associated with a decreased incidence of sinusitis and that incidence of VAP is lower in patients who do not develop sinusitis [34], [35], [36], [37].
Recommendation: We recommend that the orotracheal route of intubation should be used when
Discussion
Ventilator associated pneumonia continues to be a cause of significant morbidity and mortality in critically ill patients [99], and the literature on VAP prevention continues to evolve. To synthesize the growing research evidence on VAP prevention, thereby aiding in knowledge transfer, we developed this CPG. Guidelines require periodic updates to reflect current knowledge [19]; accordingly, the recommendations in this article reflect an update of our prior work [18] after reviewing evidence
Acknowledgments
The authors thank the Canadian Critical Care Trials Group and Canadian Critical Care Society for their support of this initiative and the professional societies, which reviewed and critiqued this guideline. We are grateful to Drs Christian Brun-Buisson and Andrew Shorr for constructive criticisms on this document.
References (109)
- et al.
Why do physicians not follow evidence-based guidelines for preventing ventilator associated pneumonia? A survey based on the opinions of an international panel of intensivists
Chest
(2002) - et al.
Guidelines in the intensive care unit
Clin Chest Med
(2003) - et al.
Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine
Chest
(2001) - et al.
Heat and moisture exchangers and vaporizing humidifiers in the intensive care unit
Chest
(1990) - et al.
Safety of combined heat and moisture exchanger filters in long-term mechanical ventilation
Chest
(1997) - et al.
A randomized clinical trial comparing an extended-use hygroscopic condenser humidifier with heated-water humidification in mechanically ventilated patients
Chest
(1998) - et al.
A prospective, randomized comparison of an in-line heat moisture exchange filter and heated wire humidifiers: rates of ventilator-associated early-onset (community-acquired) or late-onset (hospital-acquired) pneumonia and incidence of endotracheal tube occlusion
Chest
(1997) - et al.
A randomized clinical trial to compare the effects of a heat and moisture exchanger with a heated humidifying system on the occurrence rate of ventilator-associated pneumonia
Am J Infect Control
(2001) - et al.
Comparison of the effect of closed versus open endotracheal suction systems on the development of ventilator-associated pneumonia
J Hosp Infect
(2004) - et al.
A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients
Chest
(1999)
A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation
Chest
The efficacy of an oscillating bed in the prevention of lower respiratory tract infection in critically ill victims of blunt trauma. A prospective study
Chest
Effect of air-supported, continuous, postural oscillation on the risk of early ICU pneumonia in nontraumatic critical illness
Chest
Continuous mechanical turning of intensive care unit patients shortens length of stay in some diagnostic-related groups
J Crit Care
Continuous oscillation: outcome in critically ill patients
J Crit Care
Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial
Lancet
Assessing the clinical effectiveness of preventive maneuvers: analytic principles and systematic methods in reviewing evidence and developing clinical practice recommendations. A report by the Canadian Task Force on the Periodic Health Examination
J Clin Epidemiol
National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004
Am J Infect Control
Pneumonia during mechanical ventilation
Anestiol Intenziv Med
The attributable morbidity and mortality of ventilator associated pneumonia in the critically ill patient. The Canadian Critical Care Trials Group
Am J Respir Crit Care Med
Risk factors and outcome of nosocomial infections: results of a matched case-control study of ICU patients
Am J Respir Crit Care Med
Influence of nosocomial infection on mortality rate in an intensive care unit
Crit Care Med
Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center
Crit Care Med
Ventilator-associated pneumonia
Am J Respir Crit Care Med
Clinical and economic consequences of ventilator-associated pneumonia: a systematic review
Crit Care Med
Impact of a program of intensive surveillance and interventions targeting ventilator associated pneumonia and its cost effectiveness
Infect Control Hosp Epidemiol
Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia
Crit Care Med
Users' guides to the medical literature: VIII. How to use clinical practice guidelines: A. Are the recommendations valid?
JAMA
Implementation of a clinical practice guideline for stress ulcer prophylaxis increases appropriateness and decreases cost of care
Intensive Care Med
Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilation patients: one-year outcomes and lessons learned
Crit Care Med
Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT)
CMAJ
Minimizing errors of omission: Behavioural Enforcement of Heparin to Avert Venous Emboli (BEHAVE)
Crit Care Med
Evidence based clinical based guideline for the prevention of ventilator associated pneumonia
Ann Intern Med
Validity of the agency for healthcare research and quality clinical practice guidelines. How quickly do guidelines become outdated?
JAMA
Comprehensive evidence based guidelines for ventilator associated pneumonia: diagnosis and treatment
J Crit Care
Centers for Disease Control and Prevention. Guidelines for preventing health-care–associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)
MMWR
Guidelines for the management of adults with hospital-acquired, ventilator-associated and healthcare associated pneumonia
Am J Respir Crit Care Med
Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients
JPEN JPEM JPEM J Parenter Enteral Nutr
Users' guides to the medical literature: II. How to use an article about therapy or prevention: B. What were the results and will they help me in caring for my patients? Evidence-Based Medicine Working Group
JAMA
Users' guides to the medical literature: II. How to use an article about therapy or prevention: A. Are the results of the study valid? Evidence- Based Medicine Working Group
JAMA
Users' guides to the medical literature: VI. How to use an overview. Evidence-Based Medicine Working Group
JAMA
Clinical guidelines: developing guidelines
BMJ
Relationships between authors of clinical practice guidelines and the pharmaceutical industry
JAMA
More informative abstracts of articles describing clinical practice guidelines
Ann Intern Med
When should clinical guidelines be updated?
BMJ
Influence of long-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective, randomized, clinical trial
Crit Care Med
Nosocomial maxillary sinusitis during mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal route for intubation
Intensive Care Med
Nosocomial sinusitis in ventilated patients. Nasotracheal versus orotracheal intubation
Anaesthesia
Risk factors and clinical relevance of nosocomial maxillary sinusitis in the critically ill
Am J Respir Crit Care Med
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Grant support: This project was supported by a research grant from the Department of Medicine, Queen's University, Kingston, Ontario, and an unrestricted grant from Pfizer Canada, Inc.
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VAP Guidelines committee was composed of Martin Albert, Clarence Chant, Sue Elliott, Richard Hall, Lori Hand, Rick Hodder, Carolyn Hoffman, Mike Jacka, Lynn Johnston, Jim Kutsogiannis, David Leasa, Kevin Laupland, Martin Legare, Claudio Martin, Mike Miletin, Brenda Morgan, Linda Nusdorfer, Juan Ronco, Taz Sinuff, Derek Townsend, Louis Valiquette, Christine Weir, Karl Weiss, and Dan Zuege.