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Keywords:
Abstract
Evidence-based clinical
Background: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality
practice guidelines;
in ventilated critically ill patients.
Ventilator-associated
Purpose: To develop evidence-based guidelines for the prevention of VAP.
pneumonia;
Data Sources: MEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews and
Prevention
Register of Controlled Trials.
Study Selection: The authors systematically searched for all relevant randomized, controlled trials and
systematic reviews on the topic of prevention of VAP in adults that were published from 1980 to
October 1, 2006.
Data Extraction: Independently and in duplicate, the panel scored the internal validity of each trial.
Effect size, confidence intervals, and homogeneity of the results were scored using predefined
definitions. Scores for the safety, feasibility, and economic issues were assigned based on consensus of
the guideline panel.
Levels of Evidence: The following statements were used: recommend, consider, do not recommend, and
no recommendation due to insufficient or conflicting evidence.
Data Synthesis: To prevent VAP:
We recommend: that the orotracheal route of intubation should be used for intubation; a new ventilator
circuit for each patient; circuit changes if the circuit becomes soiled or damaged, but no scheduled
changes; change of heat and moisture exchangers every 5 to 7 days or as clinically indicated; the use of a
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.
Corresponding author. Tel.: +1 613 549 6666#3339; fax: +1 613 548 2428.
E-mail address: dkh2@queensu.ca (D. Heyland).
1
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.
0883-9441/$ see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jcrc.2007.11.014
Comprehensive evidence-based clinical practice guidelines for VAP 127
closed endotracheal suctioning system changed for each patient and as clinically indicated; subglottic
secretion drainage in patients expected to be mechanically ventilated for more than 72 hours; head of
bed elevation to 45 (when impossible, as near to 45 as possible should be considered).
Consider: the use of rotating beds; oral antiseptic rinses.
We do not recommend: use of bacterial filters; the use of iseganan
We make no recommendations regarding: the use of a systematic search for sinusitis; type of airway
humidification; timing of tracheostomy; prone positioning; aerosolized antibiotics; intranasal mupirocin;
topical and/or intravenous antibiotics.
Conclusion: There are a growing number of evidence-based strategies for VAP prevention, which, if
applied in practice, may reduce the incidence of this serious nosocomial infection.
2008 Elsevier Inc. All rights reserved.
because this strategy is not designed to prevent VAP, results, homogeneity assessment, VAP definition, pooled
although it may indirectly influence the incidence of VAP. event rates, and other outcomes. Panel members read all
We graded trials as level 1 if they demonstrated concealed circulated documents and evidence tables in advance of an
randomization, blinded outcome adjudication, an intention- in-person panel meeting. By abiding by a specified group
to-treat analysis, and an explicit definition of VAP. Trials process, using levels of evidence and consensus methods, a
were graded as level 2 if any one of these characteristics draft recommendation was generated for each intervention
was unfulfilled and as level 3 if allocation was not strictly reviewed [29]. At the panel meeting, each member disclosed
randomized. Level 3 trials were excluded from inclusion any potential conflicts of interest [30].
into this guideline. Because of the large size of the panel (29) and the large
In duplicate and independently, a pair of panel members number of RCTs to appraise, the evidence was first reviewed
critically appraised each trial [26,27] and systematic review by a small working group and then by the whole panel. The
[28]. Differences were resolved by consensus or independent pair of panel members responsible for critical appraisal of
adjudication by the chair of the panel. For each trial, we each intervention provided a structured written and oral
abstracted the outcomes of interest and for each intervention; presentation of the evidence to the working group. The
we summarized the risk differences and calculated a pooled working group members assigned levels of evidence,
risk difference. For each systematic review, we abstracted semiquantitative scores to summarize the evidence, and
number of trials, population, intervention, selection criteria, drafted a recommendation statement. The working group
search strategy, validity assessment, method of pooling chair (PD) was responsible for ensuring it achieved its
Comprehensive evidence-based clinical practice guidelines for VAP 129
objectives through group process. Once the evidence there was potential for harm or increased healthcare costs
summaries and recommendations were drafted, they were from the intervention.
presented to a plenary session of the whole panel for After the working group meeting and plenary panel
discussion and modifications until consensus was reached. meeting, the evidence summaries and draft recommendations
For each intervention, we used a predefined semiquanti- were sent to all panel members to check for accuracy and
tative scoring system for effect size, confidence intervals clarity. The guideline chair (JM) organized the background
around the estimate of effect, validity, and homogeneity of documents, the evidence summaries, and a table of the
trial results (Appendix B). Similar scores for safety, evidence scores. In addition, a structured abstract was
feasibility, and economic consequences of the interventions constructed [31].
were developed based on consensus of the panel members. After approval by the panel members, the draft guideline
The language of the draft recommendation for each item was document was externally reviewed by the Boards of the
keyed to the level of evidence and the semiquantitative Canadian Critical Care Society, the Canadian Critical Care
scores. We used the term recommend if there were no Trials Group, the Canadian Association of Critical Care
reservations about endorsing an intervention, and the term Nurses, the Canadian Society of Respiratory Therapists, the
consider if the evidence supported an intervention but Canadian Association of Medical Microbiology and Infec-
there were minor uncertainties about the benefits, harms, or tious Disease, and the Canadian Thoracic Society. In
costs. No recommendation was made if evidence regarding addition, expert external international reviewers (Dr Andrew
an intervention was inadequate or if there were major Shorr and Dr Christian Bruin-Bruisson) were asked to
uncertainties about the benefits, harms, and costs. Do not review the guideline. Each of the external societies and
recommend was used if there was no evidence of benefit and reviewers was asked to assess the guideline for logic,
130 J. Muscedere et al.
that less frequent HME changes may be associated with a ventilation but is associated with a trend toward an increase
slightly decreased incidence of VAP. Reduction in the in mortality.
frequency of humidifier changes might be considered as a Recommendation: We do not recommend the use of
cost-reduction measure. bacterial filters.
Recommendation: We recommend changes of HMEs
every 5 to 7 days or as clinically indicated.
4.2. Positional strategies
4.1.6. Endotracheal suctioning system: closed vs open 4.2.1. Kinetic bed therapy
On the basis of 6 level 2 trials [55-61], we conclude
Based on 7 level 2 trials [75-81], we conclude that the use
that the type of suctioning system has no effect on the
of rotating beds is associated with a decreased incidence of
incidence of VAP. Safety considerations (patient and
VAP. However, feasibility, safety, and cost concerns may be
healthcare worker exposure to aerosolized secretions) favor
barriers to implementation.
the use of closed systems.
Recommendation: The use of rotating beds should be
Recommendation: We recommend the use of closed
considered.
endotracheal suctioning system.
4.2.2. Semirecumbent positioning
4.1.7. Endotracheal suctioning system: frequency
On the basis of 1 level 1 [82] and 1 level 2 trial [83], we
of change
conclude that semirecumbent positioning may be associated
On the basis of 1 level 2 trial [62], we conclude that
with a decreased incidence of VAP. The absence of a
scheduled daily changes and unscheduled changes of closed
treatment effect observed in the trial by van Nieuwenhoven
systems have no effect on VAP. Cost considerations favor
et al [82] may have been due to an inability to achieve the
less frequent changes.
intended elevation of 45, raising concerns about the
Recommendation: We recommend that closed endotra-
feasibility of achieving this degree of semirecumbency.
cheal suctioning systems be changed for each patient and as Semirecumbent positioning may be unsafe for some patients.
clinically indicated.
Recommendation: We recommend that the head of the
bed be elevated to 45. When this is not possible, attempts to
4.1.8. Subglottic secretion drainage
raise the head of the bed as near to 45 as possible should
Based on 5 level 2 trials [63-68], we conclude that
be considered.
subglottic secretion drainage is associated with a
decreased incidence of VAP. The incremental cost of
4.2.3. Prone positioning
these tubes was considered to be reasonable given the
Based on 2 level 2 trials [84,85], we conclude that the use
burden of illness associated with VAP. To increase their of prone positioning may be associated with a reduction in
utility and cost-effectiveness, these tubes should only be
the incidence of VAP. However, feasibility and safety issues
placed in patients expected to require prolonged mechan-
may be barriers to implementation.
ical ventilation. Given the increased availability of these
Recommendation: We make no recommendation.
tubes compared to when our first guideline was devel-
oped, this recommendation was now considered to be
more feasible. 4.3. Pharmacologic strategies
Recommendation: We recommend the use of subglottic
secretion drainage in patients expected to be mechanically 4.3.1. Prophylactic antibiotics: aerosolized antibiotics
ventilated for more than 72 hours. Based on 2 level 2 trials [86,87], we conclude that the use
of aerosolized antibiotics may decrease the incidence of VAP.
4.1.9. Timing of tracheostomy The use of aerosolized antibiotics has no effect on ICU
Based on 4 level 2 trials [69-72], we conclude that there is mortality, ICU length of stay, or duration of mechanical
no difference in the incidence of VAP between early and late ventilation. In addition, the panel considered the potential
tracheostomy. The methodological limitations of these trials emergence of resistance to antibiotics in arriving at
(the unclear definition of VAP [69], numerous crossovers a recommendation.
[70]) and the higher cost of an earlier tracheostomy were also Recommendation: We make no recommendation.
noted by the committee [71-73].
Recommendation: We make no recommendation. 4.3.2. Prophylactic antibiotics: nasal antibiotics
Based on 1 level 1 trial [88], we conclude that the use of
4.1.10. Bacterial filters nasal mupirocin may decrease the incidence of VAP due to
On the basis of 1 level 2 trial [74], we conclude that the methicillin-resistant Staphylococcus aureus but has no effect
use of bacterial filters does not influence the incidence of on the overall incidence of VAP. Concerns about the
VAP. In addition, the use of bacterial filters does not emergence of resistance to antibiotics were raised by the panel.
influence ICU length of stay or duration of mechanical Recommendation: We make no recommendation.
132 J. Muscedere et al.
aspects of VAP prevention, clinicians will need to rely upon Search Strategy:
judgment and expert opinion to guide clinical practice.
This guideline has several limitations. First, our reliance 1. exp Pneumonia/
on high-quality RCT evidence for VAP prevention means 2. Cross Infection/
that we did not generate recommendations for certain 3. exp Ventilation, Mechanical/
fundamental practices about which observational data exist 4. Ventilators, Mechanical/
(eg, hand hygiene). Second, the safety, feasibility, and costs 5. 1 and 2 and (3 or 4)
of each intervention were graded qualitatively by the panel 6. (vap and pneumonia$).mp. [mp=title, cinahl subject
using their values and judgment; panels with different headings, abstract, instrumentation] (79)
compositions and values may generate different recommen- 7. "ventilator associated pneumonia$".mp. [mp=title,
dations. Our panel was formed predominantly by Canadian cinahl subject headings, abstract, instrumentation]
members, who work chiefly within the Canadian critical care 8. "ventilator acquired pneumonia$".mp. [mp=title,
context. Therefore, although these recommendations were cinahl subject headings, abstract, instrumentation]
based upon a rigorous and transparent evaluation of the 9. 5 or 6 or 7 or 8
international literature, these recommendations reflect our 10. limit 9 to (yr=1980-2006 and journal article)
target audience and practice setting. In keeping with the trend
toward one universal system to generate clinical recommen-
dations, we plan to use the recently proposed GRADE Search Strategy for MEDLINE database
approach for our next guideline update [107].
Although there is abundant research evidence that VAP is 1. exp PNEUMONIA/
preventable, at least in part, gaps in our understanding exist, 2. Cross Infection/
as exemplified by our inability to make recommendations 3. Respiration, Artificial/
related to some interventions. More research is required in 4. exp Ventilators, Mechanical/
areas in which there is a paucity of high-level research 5. 1 and 2 and (3 or 4)
evidence. For example, the long-term impact of VAP 6. (vap and pneumonia$).mp. [mp=title, original title,
prevention practices on the microbial ecology of ICUs and abstract, name of substance, mesh subject heading]
antibiotic resistance patterns needs to be further delineated. 7. ventilator associated pneumonia$".mp. [mp=title,
In addition, even with high-grade evidence and strong original title, abstract, name of substance, mesh subject
recommendations, the challenge is to apply best research heading]
evidence into clinical practice. Prior Canadian studies have 8. ventilator acquired pneumonia$".mp. [mp=title, ori-
demonstrated deficiencies in the adoption of strategies ginal title, abstract, name of substance, mesh subject
shown to decrease the incidence of VAP, underscoring heading]
important opportunities to improve VAP prevention practices 9. 5 or 6 or 7 or 8
[108,109]. Further knowledge translation efforts and original 10. limit 9 to (human and yr=1980-2006 and journal
research are required to reduce the morbidity and mortality of article)
VAP in the complex environment of the ICU setting.
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