Ventilator-associated pneumonia (VAP) is a common and serious complication of mechanical ventilation via an artificial airway. As with all nosocomial infections, VAP increases costs, morbidity, and mortality in the intensive care unit (ICU). VAP prevention is a multifaceted priority of the intensive care team, and can include the use of specialized artificial airways and heat-and-moisture exchangers (HME). Substantial evidence supports the use of endotracheal tubes (ETTs) that allow subglottic suctioning; silver-coated and antiseptic-impregnated ETTs; ETTs with thin-walled polyurethane cuffs; and HMEs, but these devices also can have adverse effects. Controversy still exists regarding the evidence, cost-effectiveness, and disadvantages and risks of these devices.
KollefMH. What is ventilator-associated pneumonia and why is it important?. Respir Care, 2005; 50(6):714–721.
2.
CookDJ, WalterSD, CookRJ, GriffithLE, GuyattGH, LeasaD, et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med, 1998; 129(6):433–440.
3.
PneumatikosIA, DragoumanisCK, BourosDE. Ventilator-associated pneumonia or endotracheal tube-associated pneumonia? An approach to the pathogenesis and preventive strategies emphasizing the importance of endotracheal tube. Anesthesiology, 2009; 110(3):673–680.
4.
SafdarN, DezfulianC, CollardHR, SaintS. Clinical and economic consequences of ventilator- associated pneumonia: a systematic review. Crit Care Med, 2005; 33(10):2184–2193.
5.
RelloJ, OllendorfDA, OsterG, Vera-LlonchM, BellmL, RedmanR, KollefMH; VAP Outcomes Scientific Advisory Group. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest, 2002; 122(6):2115–2121.
6.
CravenDE. Preventing ventilator associated pneumonia in adults. Chest, 2006; 130(1):251–260.
7.
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med, 2005; 171(4):388–416.
8.
CoffinSE, KlompasM, ClassenD, AriasKM, PodgornyK, AndersonDJ, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol, 2008; 29(1):S31–S40.
9.
DodekP, KeenanS, CookD, HeylandD, JackaM, HandL, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med, 2004; 141(4):305–313.
10.
GreeneR, ThompsonS, JantschHS, TeplickR, CullenDJ, GreeneEM, et al. Detection of pooled secretions above endotracheal-tube cuffs: value of plain radiographs in sheep cadavers and patients. AJR Am J Roentgenol, 1994; 163(6):1333–1337.
11.
PetringOU, AdelhojB, JensenBN, PedersenNO, LomholtN. Prevention of silent aspiration due to leaks around cuffs of endotracheal tubes. Anesth Analg, 1986; 65(7):777–780.
12.
TorresA, Serra-BatllesJ, RosE, PieraC, Puig de la BellacasaJ, CobosA, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med, 1992; 116(7):540–543.
13.
MahulP, AuboyerC, JospeR, RosA, GuerinC, el KhouriZ, et al. Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Med, 1992; 18(1):20–25.
14.
VallesJ, ArtigasA, RelloJ, BonsomsN, FontanalsD, BlanchL, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med, 1995; 122(3):179–186.
15.
KollefMH, SkubasNJ, SundtTM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest, 1999; 116(5):1339–1346.
16.
BoH, HeL, QuJ. Influence of the subglottic secretion drainage on the morbidity of ventilator associated pneumonia in mechanically ventilated patients. Zhonghua Jie He He Hu Xi Za Zhi, 2000; 23(8):472–474.
17.
SmuldersK, van den HoevenH, Weers-PothoffJ, Vandenbroucke-GraulsC. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest, 2002; 121(3):858–862.
18.
BouzaE, PerezMJ, MunozP, RinconC, BarrioJM, HortalJ. Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest, 2008; 134(5):938–946.
19.
DezfulianC, ShojaniaK, CollardHR, KimHM, MatthayMA, SaintS. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med, 2005; 118(1):11–18.
20.
ShorrAF, O'MalleyPG. Continuous subglottic suctioning for the prevention of ventilator-associated pneumonia: potential economic implications. Chest, 2001; 119(1):228–235.
21.
SeegobinRD, van HasseltGL. Aspiration beyond endotracheal cuffs. Can Anaesth Soc J, 1986; 33(3):273–279.
22.
PavlinEG, VanNimweganD, HornbeinTF. Failure of a high-compliance low-pressure cuff to prevent aspiration. Anesthesiology, 1975; 42(2):216–219.
23.
GacouinA, BarbarotN, CamusC, SalomonS, IsslameS, MarqueS, et al. Late-onset ventilator-associated pneumonia in nontrauma intensive care unit patients. Anesth Analg, 2009; 109(5):1584–1590.
24.
DullenkopfA, GerberA, WeissM. Fluid leakage past tracheal tube cuffs: evaluation of the new Microcuff endotracheal tube. Intensive Care Med, 2003; 29(10):1849–1853.
25.
LucangeloU, ZinWA, AntonagliaV, PetrucciL, VivianiM, BuscemaG, et al. Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. Crit Care Med, 2008; 36(2):409–413.
26.
PoelaertJ, DepuydtP, De WolfA, Van de VeldeS, HerckI, BlotS. Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: a pilot study. J Thorac Cardiovasc Surg, 2008; 135(4):771–776.
YoungPJ, PakeerathanS, BluntMC, SubramanyaS. A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med, 2006; 34(3):632–639.
29.
YoungPJ, BluntMC. Improving the shape and compliance characteristics of a high-volume, low-pressure cuff improves tracheal seal. Br J Anaesth, 1999; 83(6):887–889.
30.
LorenteL, LecuonaM, JimenezA, MoraML, SierraA. Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am J Respir Crit Care Med, 2007; 176(11):1079–1081.
31.
BerraL, De MarchiL, YuZX, LaquerriereP, BaccarelliA, KolobowT. Endotracheal tubes coated with antiseptics decrease bacterial colonization of the ventilator circuits, lungs, and endotracheal tube. Anesthesiology, 2004; 100(6):1446–1456.
32.
BerraL, KolobowT, LaquerriereP, PittsB, BramatiS, PohlmannJ, et al. Internally coated endotracheal tubes with silver sulfadiazine in polyurethane to prevent bacterial colonization: a clinical trial. Intensive Care Med, 2008; 34(6):1030–1037.
33.
KollefMH, AfessaB, AnzuetoA, VeremakisC, KerrKM, MargolisBD, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA, 2008; 300(7):805–813.
34.
ShorrAF, ZilberbergMD, KollefM. Cost-effectiveness analysis of a silver-coated endotracheal tube to reduce the incidence of ventilator-associated pneumonia. Infect Control Hosp Epidemiol, 2009; 30(8):759–763.
35.
BransonR, DavisK, CampbellRS, JohnsonDJ, PorembkaDT. Humidification in the intensive care unit: prospective study of a new protocol utilizing heated humidification and a hygroscopic condenser humidifier. Chest, 1993; 104(6):1800–1805.
36.
MarkowiczP, RicardJD, DreyfussD, MierL, BrunP, CosteF, et al. Safety, efficacy, and cost-effectiveness of mechanical ventilation with humidifying filters changed every 48 hours: a prospective, randomized study. Crit Care Med, 2000; 28(3):665–671.
37.
BoissonC, ViviandX, ArnaudS, ThomachotL, MilianiY, MartinC. Changing a hydrophobic heat and moisture exchanger after 48 hours rather than 24 hours: a clinical and microbiological evaluation. Intensive Care Med, 1999; 25(11):1237–1243.
38.
BransonRD. The ventilator circuit and ventilator-associated pneumonia. Respir Care, 2005; 50(6):774–785; discussion 785-787. Review.
39.
HessDR, KallstromTJ, MottramCD, MyersTR, SorensonHM, VinesDL. Care of the ventilator circuit and its relation to ventilator-associated pneumonia. Respir Care, 2003; 48(9):869–879.
40.
HessD. Prolonged use of heat and moisture exchangers: why do we keep changing things?. Crit Care Med, 2000; 28(5):1667–1668.
41.
KirtonOC, DeHavenB, MorganJ, MorejonO, CivettaJ. 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; 112(4):1055–1059.
42.
BootsRJ, GeorgeN, FaoagaliJL, DrueryJ, DeanK, HellerRF. Double-heater-wire circuits and heat-and-moisture exchangers and the risk of ventilator-associated pneumonia. Crit Care Med, 2006; 34(3):687–693.
43.
KollefMH, ShapiroSD, BoydV, SilverP, Von HarzB, TrovillionE, PrenticeD. A randomized clinical trial comparing an extended-use hygroscopic condenser humidifier with heated-water humidification in mechanically ventilated patients. Chest, 1998; 113(3):759–767.
44.
HurniJM, FeihlF, LazorR, LeuenbergerP, PerretC. Safety of combined heat and moisture exchanger filters in long-term mechanical ventilation. Chest, 1997; 111(3):686–691.
45.
SiemposII, VardakasKZ, KopteridesP, FalagasME. Impact of passive humidification on clinical outcomes of mechanically ventilated patients: a meta-analysis of randomized controlled trials. Crit Care Med, 2007; 35(12):2843–2851.
46.
CollardHR, SaintS, MatthayMA. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med, 2003; 138(6):494–501.
47.
TablanOC, AndersonLJ, BesserR, BridgesC, HajjehR; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep, 2004; 53(RR-3):1–36.
48.
CookD, RicardJD, ReeveB, RandallJ, WiggM, BrochardL, DreyfussD. Ventilator circuit and secretion management strategies: a Franco-Canadian survey. Crit Care Med, 2000; 28(10):3547–3554.
49.
HeylandDK, CookDJ, DodekPM. Prevention of ventilator-associated pneumonia: current practice in Canadian intensive care units. J Crit Care, 2002; 17(3):161–167.
50.
SierraR, BenítezE, LeónC, RelloJ. Prevention and diagnosis of ventilator-associated pneumonia: a survey on current practices in Southern Spanish ICUs. Chest, 2005; 128(3):1667–1673.
51.
DepewCL, McCarthyMS. Subglottic secretion drainage: a literature review. AACN Adv Crit Care, 2007; 18(4):366–379.
52.
KreinSL, KowalskiCP, DamschroderL, FormanJ, KaufmanSR, SaintS. Preventing ventilator-associated pneumonia in the United States: a multicenter mixed-methods study. Infect Control Hosp Epidemiol, 2008; 29(10):933–940.
53.
WunderinkRG. Prevention of ventilator-associated pneumonia: does one size fit all?. Chest, 1999; 116(5):1155–1156.
54.
KlompasM, KulldorffM, PlattR. Risk of misleading ventilator-associated pneumonia rates with use of standard clinical and microbiological criteria. Clin Infect Dis, 2008; 46(9):1443–1446.
55.
TejerinaE, EstebanA, Fernández-SegovianoP, Frutos-VivarF, AramburuJ, BallesterosD, Rodríguez-BarberoJM. Accuracy of clinical definitions of ventilator-associated pneumonia: Comparison with autopsy findings. J Crit Care. 2009; Jul8. [Epub ahead of print].
56.
van SaeneHK, AshworthM, PetrosAJ, SanchezM, de la CalMA. Do not suction above the cuff. Crit Care Med, 2004; 32(10):2160–2162.
57.
CravenDE, HjalmarsonK. Prophylaxis of ventilator-associated pneumonia: changing culture and strategies to trump disease. Chest, 2008; 134(5):898–900.
58.
NseirS, FavoryR, JozefowiczE, DecampsF, DewavrinF, BruninG, et al. Antimicrobial treatment for ventilator-associated tracheobronchitis: a randomized, controlled, multicenter study. Crit Care, 2008; 12(3):R62.
59.
CravenDE. Ventilator-associated tracheobronchitis: questions, answers, and a new paradigm?. Crit Care, 2008; 12(3):157.
60.
MichelF, FranceschiniB, BergerP, ArnalJM, GainnierM, SaintyJM, PapazianL. Early antibiotic treatment for BAL-confirmed ventilator-associated pneumonia: a role for routine endotracheal aspirate cultures. Chest, 2005; 127(2):589–597.
61.
ChastreJ, FagonJY. Ventilator-associated pneumonia. Am J Respir Crit Care Med, 2002; 165(7):867–903.
62.
BerraL, De MarchiL, PanigadaM, YuZX, BaccarelliA, KolobowT. Evaluation of continuous aspiration of subglottic secretion in an in vivo study. Crit Care Med, 2004; 32(10):2071–2078.
63.
GirouE, Buu-HoiA, StephanF, NovaraA, GutmannL, SafarM, FagonJY. Airway colonisation in long-term mechanically ventilated patients: effect of semi-recumbent position and continuous subglottic suctioning. Intensive Care Med, 2004; 30(2):225–233.
64.
VallésJ, PoboA, García-EsquirolO, MariscalD, RealJ, FernándezR. Excess ICU mortality attributable to ventilator-associated pneumonia: the role of early vs late onset. Intensive Care Med, 2007; 33(8):1363–1368.
65.
RelloJ, SoñoraR, JubertP, ArtigasA, RuéM, VallésJ. Pneumonia in intubated patients: role of respiratory airway care. Am J Respir Crit Care Med, 1996; 154(1):111–115.
66.
DragoumanisCK, VretzakisGI, PapaioannouVE, DidilisVN, VogiatzakiTD, PneumatikosIA. Investigating the failure to aspirate subglottic secretions with the Evac endotracheal tube. Anesth Analg, 2007; 105(4):1083–1085.
67.
SiobalM, KalletRH, KraemerR, JonsonE, LemonsD, YoungD, et al. Tracheal-innominate artery fistula caused by the endotracheal tube tip: case report and investigation of a fatal complication of prolonged intubation. Respir Care, 2001; 46(10):1012–1018.
68.
SantosPM, AfrassiabiA, WeymullerEAJr. Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngol Head Neck Surg, 1994; 111(4):453–459.
69.
DiazE, RodríguezAH, RelloJ. Ventilator-associated pneumonia: issues related to the artificial airway. Respir Care, 2005; 50(7):900–909.
ChaoYF, ChenYY, WangKW, LeeRP, TsaiH. Removal of oral secretion prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: a clinical controlled trial study. J Clin Nurs, 2009; 18(1):22–28.
72.
BabcockHM, ZackJE, GarrisonT, TrovillionE, JonesM, FraserVJ, KollefMH. An educational intervention to reduce ventilator-associated pneumonia in an integrated health system: a comparison of effects. Chest, 2004; 125(6):2224–2231.
73.
ZackJE, GarrisonT, TrovillionE, ClinkscaleD, CoopersmithCM, FraserVJ, KollefMH. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med, 2002; 30(11):2407–2412.
74.
ChastreJ. Conference summary: ventilator-associated pneumonia. Respir Care, 2005; 50(7):975–983.
75.
LorenteL, BlotS, RelloJ. Evidence on measures for the prevention of ventilator-associated pneumonia. Eur Respir J, 2007; 30(6):1193–1207.
76.
LansfordT, MoncureM, CarltonE, EndressR, ShikN, UdobiK, et al. Efficacy of a pneumonia prevention protocol in the reduction of ventilator-associated pneumonia in trauma patients. Surg Infect (Larchmt), 2007; 8(5):505–510.
77.
BurgerCD, ResarRK. “Ventilator bundle” approach to prevention of ventilator-associated pneumonia. Mayo Clin Proc, 2006; 81(6):849–850.
78.
WipC, NapolitanoL. Bundles to prevent ventilator-associated pneumonia: how valuable are they?. Curr Opin Infect Dis, 2009; 22(2):159–166.
79.
ZilberbergMD, ShorrAF, KollefMH. Implementing quality improvements in the intensive care unit: ventilator bundle as an example. Crit Care Med, 2009; 37(1):305–309.
80.
YoungquistP, CarrollM, FarberM, MacyD, MadridP, RonningJ, SusagA. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf, 2007; 33(4):219–225.
81.
UnahalekhakaA, JamulitratS, ChongsuvivatwongV, OvretveitJ. Using a collaborative to reduce ventilator-associated pneumonia in Thailand. Jt Comm J Qual Patient Saf, 2007; 33(7):387–394.
82.
Berriel-CassD, AdkinsFW, JonesP, FakihMG. Eliminating nosocomial infections at Ascension Health. Jt Comm J Qual Patient Saf, 2006; 32(11):612–620.
83.
ResarR, PronovostP, HaradenC, SimmondsT, RaineyT, NolanT. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf, 2005; 31(5):243–248.
84.
CocanourCS, PeningerM, DomonoskeBD, LiT, WrightB, ValdiviaA, LutherKM. Decreasing ventilator-associated pneumonia in a trauma ICU. J Trauma, 2006; 61(1):122–129.
85.
WhiteGC. Basic clinical lab competencies for respiratory care: an integrated approach. 4th edition. New York: Thompson, Delmar Learning, 2004:403.
JamilAK. Laryngotracheal toilet before extubation. Anaesthesia, 1974; 29(5):630–631.
90.
YoungPJ. The effect of positive expiratory pressure and tracheal tube cuff type on pulmonary aspiration (letter). Crit Care Med, 2008; 36(5)1691–1692.
91.
YoungPJ, BluntMC. Advances in translaryngeal tube technology. Yearbook of Intensive Care and Emergency Medicine. New York: Springer Science, 2007:337–347.
92.
YoungPJ, BluntMC. Novel therapies in the prevention of ventilator associated pneumonia. Intensive Care Medicine Annual Update 2008. New York: Springer Science. 2008:343–352.
93.
RelloJ, KollefM, DiazE, SandiumengeA, del CastilloY, CorbellaX, ZachskornR. Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study. Crit Care Med, 2006; 34(11):2766–2772.
94.
Li BassiG, BerraL, KolobowT. Silver-coated endotracheal tubes: is the bactericidal effect time limited?. Crit Care Med, 2007Mar; 35(3):986.
95.
OlsonME, HarmonBG, KollefMH. Silver-coated endotracheal tubes associated with reduced bacterial burden in the lungs of mechanically ventilated dogs. Chest, 2002; 121(3):863–870.
96.
KlompasM. Silver-coated endotracheal tubes and patient outcomes in ventilator-associated pneumonia. JAMA, 2008; 300(22):2605; author reply 2605-2606.
97.
ChastreJ. Preventing ventilator-associated pneumonia: could silver-coated endotracheal tubes be the answer?. JAMA, 2008; 300(7):842–844.
98.
LacheradeJC, AuburtinM, CerfC, Van de LouwA, SoufirL, RebufatY, et al. Impact of humidification systems on ventilator-associated pneumonia: a randomized multicenter trial. Am J Respir Crit Care Med, 2005; 172(10):1276–1282.
99.
MartinC, PerrinG, GevaudanMJ, SauxP, GouinF. Heat and moisture exchangers and vaporizing humidifiers in the intensive care unit. Chest, 1990; 97(1):144–149.
100.
RoustanJP, KienlenJ, AubasS, Du CailarJ. Comparison of hydrophobic heat and moisture exchangers with heated humidifier during prolonged mechanical ventilation. Intensive Care Med, 1992; 18(2):97–100.
101.
DreyfussD, DjedaïniK, GrosI, MierL, Le BourdellésG, CohenY, et al. Mechanical ventilation with heated humidifiers or heat and moisture exchangers: effects on patient colonization and incidence of nosocomial pneumonia. Am J Respir Crit Care Med, 1995; 151(4):986–992.
102.
MemishZA, OniGA, DjazmatiW, CunninghamG, MahMW. A randomized 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; 29(5):301–305.
103.
MissetB, EscudierB, RivaraD, LeclercqB, NitenbergG. Heat and moisture exchanger vs heated humidifier during long-term mechanical ventilation: a prospective randomized study. Chest, 1991; 100(1):160–163.
104.
LorenteL, LecuonaM, JimenezA, MoraML, SierraA. Ventilator-associated pneumonia using a heated humidifier or a heat and moisture exchanger-randomized controlled trial. Crit Care, 2006; 10(4):R116.
105.
BootsRJ, HoweS, GeorgeN, HarrisFM, FaoagaliJ. Clinical utility of hygroscopic heat and moisture exchangers in intensive care patients. Crit Care Med, 1997; 25(10):1707–1712.
106.
BransonRD, DavisKJr., BrownR, RashkinM. Comparison of three humidification techniques during mechanical ventilation: Pa-tient selection, cost, and infection considerations. Respir Care, 1996; 41(9):809–816.
107.
NakagawaNK, MacchioneM, PetrolinoHM, GuimarãesET, KingM, SaldivaPH, Lorenzi-FilhoG. Effects of a heat and moisture exchanger and a heated humidifier on respiratory mucus in patients undergoing mechanical ventilation. Crit Care Med, 2000; 28(2):312–317.
108.
FrenchCJ, BellomoR, BuckmasterJ. Effect of ventilation equipment on imposed work of breathing. Crit Care Resusc, 2001; 3(3):148–152.
109.
HinksonCR, BensonMS, StephensLM, DeemS. The effects of apparatus dead space on PaCO2 in patients receiving lung-protective ventilation. Respir Care, 2006; 51(10):1140–144.
110.
MoranI, BellapartJ, VariA, ManceboJ. Heat and moisture exchangers and heated humidifiers in acute lung injury/acute respiratory distress syndrome patients: effects on respiratory mechanics and gas exchange. Intensive Care Med, 2006; 32(4):524–531.
111.
PratG, RenaultA, TonnelierJM, GoetghebeurD, OgerE, BolesJM, L'HerE. Influence of the humidification device during acute respiratory distress syndrome. Intensive Care Med, 2003; 29(12):2211–2215.
112.
CampbellRS, DavisKJr., JohannigmanJA, BransonRD. The effects of passive humidifier dead space on respiratory variables in paralyzed and spontaneously breathing patients. Respir Care, 2000; 45(3):306–312.
