Prevention of Ventilator-Associated Pneumonia: An Evidence-Based Systematic Review
- Harold R. Collard, MD;
- Sanjay Saint, MD, MPH; and
- Michael A. Matthay, MD
- From University of Colorado Health Sciences Center, Denver, Colorado; Ann Arbor Veterans Affairs Medical Center and University of Michigan, Ann Arbor, Michigan; and University of California, San Francisco, San Francisco, California.
Abstract
Background: Ventilator-associated pneumonia is a common cause of morbidity in critically ill patients. Interventions beneficial to the prevention of ventilator-associated pneumonia would therefore have a significant impact on the care of these patients.
Purpose: To perform a literature review and synthesis of methods for prevention of ventilator-associated pneumonia.
Data Sources: MEDLINE (1966–2001), the Cochrane Library, and bibliographies of retrieved articles.
Study Selection: Studies were required to be prospective and controlled in design and to evaluate clinically important or surrogate outcomes. Surrogate outcomes were required to have a direct link to clinically important outcomes supported by the literature.
Data Extraction: Data on patients, definitions, study design, and outcomes were abstracted and graded by using preestablished criteria.
Data Synthesis: The preventive practices with the strongest supportive evidence were semi-recumbent positioning, sucralfate instead of H2-antagonists for stress ulcer prophylaxis, and selective digestive tract decontamination. Aspiration of subglottic secretions and oscillating beds may be useful in select populations. There is no evidence to support specific methods of enteral feeding or increased frequency of ventilator circuitry changes.
Conclusions: After evaluation of potential benefits and risks, the authors recommend considering several specific interventions to reduce the incidence of ventilator-associated pneumonia: semi-recumbent positioning in all eligible patients, sucralfate rather than H2-antagonists in patients at low to moderate risk for gastrointestinal tract bleeding, and aspiration of subglottic secretions and oscillating beds in select patient populations. Selective digestive tract decontamination is not recommended because routine use may increase antimicrobial resistance.
Article and Author Information
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Disclaimer: This article is based in part on work performed by the University of California, San Francisco–Stanford University Evidence-based Practice Center under contract with the U.S. Agency for Healthcare Research and Quality (contract no. 290-97-0013). The authors of this article are responsible for its contents, including the clinical and treatment recommendations. No statements in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
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Acknowledgments: The authors thank Drs. Kaveh Shojania and Robert Wachter for reviewing earlier versions of this manuscript.
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Grant Support: By a Career Development Award from the Health Services Research & Development Program of the Department of Veterans Affairs (Dr. Saint) and by the National Institutes of Health (NIH RO1HL51856) (Dr. Matthay).
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Potential Financial Conflicts of Interest: None disclosed.
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Requests for Single Reprints: Harold R. Collard, MD, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Campus Box C272, Denver, CO 80262; e-mail, hal.collard{at}uchsc.edu.
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Current Author Addresses: Dr. Collard: Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Campus Box C272, Denver, CO 80262.
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Dr. Saint: University of Michigan Health System, 300 North Ingalls, Box 0429, Room 7E-08, Ann Arbor, MI 48109-0429.
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Dr. Matthay: University of California, San Francisco, Moffitt-Long Hospital, M-917, 505 Parnassus Avenue, Box 0624, San Francisco, CA 94143-0624.
- Copyright ©2004 by the American College of Physicians
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