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CLINICAL GUIDELINES

Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia

Peter Dodek, MD, MHSc; Sean Keenan, MD, MSc(Epid); Deborah Cook, MD, MSc(Epid); Daren Heyland, MD, MSc(Epid); Michael Jacka, MD, MSc; Lori Hand, RRT; John Muscedere, MD; Debra Foster, RN; Nav Mehta, MD; Richard Hall, MD; Christian Brun-Buisson, MD, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society

17 August 2004 | Volume 141 Issue 4 | Pages 305-313

Background: Ventilator-associated pneumonia (VAP) is an important patient safety issue in critically ill patients.

Purpose: To develop an evidence-based guideline for the prevention of VAP.

Data Sources: MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews.

Study Selection: The authors systematically searched for relevant randomized, controlled trials and systematic reviews that involved mechanically ventilated adults and were published before 1 April 2003.

Data Extraction: Physical, positional, and pharmacologic interventions that may influence the development of VAP were considered. Independently and in duplicate, the authors scored the validity of trials; the effect size and confidence intervals; the homogeneity of results; and safety, feasibility, and economic issues.

Data Synthesis: Recommended: The orotracheal route of intubation, changes of ventilator circuits only for each new patient and if the circuits are soiled, use of closed endotracheal suction systems that are changed for each new patient and as clinically indicated, heat and moisture exchangers in the absence of contraindications, weekly changes of heat and moisture exchangers, and semi-recumbent positioning in the absence of contraindications. Consider subglottic secretion drainage and kinetic beds. Not recommended: Sucralfate to prevent VAP in patients at high risk for gastrointestinal bleeding and topical antibiotics to prevent VAP. Because of insufficient or conflicting evidence, no recommendations were made about systematically searching for maxillary sinusitis, chest physiotherapy, the timing of tracheostomy, prone positioning, prophylactic intravenous antibiotics, or intravenous plus topical antibiotics.

Limitations: No formal economic analysis was performed, and patient perspectives were not considered.

Conclusion: If effectively implemented, this guideline may decrease the morbidity, mortality, and costs of VAP in mechanically ventilated patients.

Author and Article Information

From University of British Columbia, Vancouver, British Columbia, Canada; McMaster University, Hamilton, Queen's University, Kingston, Hotel-Dieu Grace Hospital, Windsor, University of Toronto, Toronto, and Sudbury Regional Hospital, Sudbury, Ontario, Canada; University of Alberta Hospital, Edmonton, Alberta, Canada; Dalhousie University, Halifax, Nova Scotia, Canada; and Hopital Henri Mondor, Universite Paris-Val de Marne, Creteil, France.

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 who reviewed and critiqued this guideline. The VAP Prevention Guideline Panel thanks Dr. John Heffner for his advice during the development of this guideline.

Grant Support: By an unrestricted grant from Pfizer Canada Inc. Dr. Cook is a chair of the Canadian Institutes for Health Research. Dr. Heyland is a Career Scientist of the Ontario Ministry of Health and Long-Term Care.

Potential Financial Conflicts of Interest:Grants received: D. Cook (Hoechst Marion Roussel, Glaxo Wellcome), D. Heyland (Bayer Inc., AstraZeneca), C. Brun-Buisson (Wyeth-Lederle).

Requests for Single Reprints: Peter Dodek, MD, MHSc, Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada; e-mail, pedodek{at}interchange.ubc.ca.

Current Author Addresses: Dr. Dodek: St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.

Dr. Keenan: Suite 103, 250 Keary Street, New Westminster, British Columbia V3L 5E7, Canada.

Dr. Cook and Ms. Hand: McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.

Dr. Heyland: Kingston General Hospital, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada.

Dr. Jacka: University of Alberta, 1051 Falconer Road, Edmonton, Alberta T6R 2C9, Canada.

Dr. Muscedere: Hotel-Dieu Grace Hospital, 1030 Ouellette Avenue, Windsor, Ontario N91 1E1, Canada.

Ms. Foster: Department of Critical Care, University of Toronto, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.

Dr. Mehta: Sudbury Regional Hospital, 41 Ramsey Lake Road, Sudbury, Ontario P3E 5J1, Canada.

Dr. Hall: Queen Elizabeth II Health Sciences Center, 1796 Summer Street, Room 5452 HI, Halifax, Nova Scotia B3H 3A7, Canada.

Dr. Brun-Buisson: Department of Medical Intensive Care and Infection Control Unit, Hopital Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010 Creteil Cedex, France.

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