Best Practice in the Best Practice in the Prevention of Prevention of VentilatorVentilator--Associated PneumoniaAssociated Pneumonia

SomchaiSomchai SuntornlohanakulSuntornlohanakul, MD., MD.

somchai.su@psu.ac.th

26 March 200826 March 2008

NosocomialNosocomial PneumoniaPneumonia

HAP : HospitalHAP : Hospital--Acquired PneumoniaAcquired PneumoniaVAP : VentilatorVAP : Ventilator--Associated PneumoniaAssociated PneumoniaHCAP : HealthcareHCAP : Healthcare--AssociatedAssociated PneumoniaPneumonia

HospitalHospital--Acquired Pneumonia (HAP)Acquired Pneumonia (HAP)

HAPHAP is defined as pneumonia that occurs is defined as pneumonia that occurs 48 hours or more after admission, which was 48 hours or more after admission, which was not incubating at the time of admission.not incubating at the time of admission.

Healthcare Infection Control Practices Advisory Committee, CDC CHealthcare Infection Control Practices Advisory Committee, CDC Control and Prevention ontrol and Prevention MMWR MMWR RecommRecomm Rep 2004;53:1Rep 2004;53:1--3636

VentilatorVentilator--Associated Pneumonia (VAP)Associated Pneumonia (VAP)

VAPVAP refers to pneumonia that arises more than refers to pneumonia that arises more than 4848--72 hours after 72 hours after endotrachealendotracheal intubation. intubation.

EarlyEarly--onsetonset : VAP arising in the first 4 days : VAP arising in the first 4 days after ET intubation after ET intubation

LateLate--onset onset : VAP which occurs 5 days : VAP which occurs 5 days or more after ET intubationor more after ET intubation

Healthcare Infection Control Practices Advisory Committee, CDC CHealthcare Infection Control Practices Advisory Committee, CDC Control and Prevention ontrol and Prevention MMWR MMWR RecommRecomm Rep 2004;53:1Rep 2004;53:1--3636

HealthcareHealthcare--Associated Pneumonia (HCAP)Associated Pneumonia (HCAP)

HCAPHCAP includes any patient who was hospitalized includes any patient who was hospitalized in acute care hospital for two or more days within in acute care hospital for two or more days within 90 days of the infection90 days of the infection

-- a nursing homea nursing home-- longlong--term care facilityterm care facility-- received recent IV antibiotic therapy chemotherapy, received recent IV antibiotic therapy chemotherapy, wound carewound care within 30 days of the current infection within 30 days of the current infection

Healthcare Infection Control Practices Advisory Committee, CDC CHealthcare Infection Control Practices Advisory Committee, CDC Control and Prevention ontrol and Prevention MMWR MMWR RecommRecomm Rep 2004;53:1Rep 2004;53:1--3636

EpidemiologyEpidemiology

Patient with HAP, VAP and HCAP are at Patient with HAP, VAP and HCAP are at increased risk colonization and infection with increased risk colonization and infection with MDR pathogensMDR pathogensIt is difficult to define the exact incidence of It is difficult to define the exact incidence of HAP, VAPHAP, VAP

EpidemiologyEpidemiology

HAP occurs at a rate of 5HAP occurs at a rate of 5--10 case per 1,000 hospital 10 case per 1,000 hospital admissionsadmissionsHAP accounts for up to 25% of all ICU infections HAP accounts for up to 25% of all ICU infections VAP occurs in 9VAP occurs in 9--27% of all 27% of all intubatedintubated patientspatientsRisk of VAP is highest early in the course of hospital stay.Risk of VAP is highest early in the course of hospital stay.Approximate half of all episodes of VAP occur within the Approximate half of all episodes of VAP occur within the first 4 days of mechanical ventilationfirst 4 days of mechanical ventilation..

EpidemiologyEpidemiology

In the NNIS, rate of VAP in pediatric patient: 5 In the NNIS, rate of VAP in pediatric patient: 5 cases/1000 vcases/1000 v--daysdays

In thermal injury VAP rate: 35 cases/1000 vIn thermal injury VAP rate: 35 cases/1000 v--daysdays

Overall rates 10Overall rates 10--15 cases/1000 v15 cases/1000 v--days days for ICU patientsfor ICU patients

VAP is a complication of intubation and mechanical VAP is a complication of intubation and mechanical ventilator supportventilator support..

อัตราการตดิเชื้อปอดอกัเสบในผูปวยที่ใสเครื่องชวยหายใจอัตราการตดิเชื้อปอดอกัเสบในผูปวยที่ใสเครื่องชวยหายใจ

อัตราการติดเชื้ออัตราการติดเชื้อ == จํานวนครั้งรวมที่ผูปวยตดิเชื้อปอดอักเสบจํานวนครั้งรวมที่ผูปวยตดิเชื้อปอดอักเสบ x x 10001000

จํานวนวันรวมที่ผูปวยใสเครื่องชวยหายใจจํานวนวันรวมที่ผูปวยใสเครื่องชวยหายใจ

VentilatorVentilator--daysdays หมายถึงหมายถึง จาํนวนวันรวมจาํนวนวันรวม ที่ผูปวยใสเครื่องชวยหายใจที่ผูปวยใสเครื่องชวยหายใจ

Pneumonia Pneumonia หมายถึงหมายถึง จํานวนครั้งรวมจํานวนครั้งรวม ที่ผูปวยตดิเชือ้ปอดอักเสบที่ผูปวยตดิเชือ้ปอดอักเสบ

VAP/1000 ventilatorVAP/1000 ventilator--daysdays หมายถึงอัตราการติดเชื้อปอดอักเสบคดิเปนหมายถึงอัตราการติดเชื้อปอดอักเสบคดิเปน

ครั้งตอจํานวนครั้งตอจํานวน 1000 1000 วันที่ใสเครื่องชวยหายใจวันที่ใสเครื่องชวยหายใจ

Incidence of VAP in Incidence of VAP in SongklanagarindSongklanagarind HospitalHospital

Infection Control Report 2007 ; Infection Control Report 2007 ; SongklanagarindSongklanagarind Hospital Hospital

25452545 5.95.9

25462546 5.15.1

2547 3.92547 3.9

2548 1246 3.212548 1246 3.21 48144814 2.082.08

2549 1485 3.37 4108 3.42549 1485 3.37 4108 3.411

2550 809 1.13 4574 1.2550 809 1.13 4574 1.9797

YearYear vv--daysdays VAPVAP vv--days days VAPVAP--ICUICU

NNIS 25 percentile VAP = 2.6 NNIS 25 percentile VAP = 2.6 ครั้งครั้ง v v--daysdays

Incidence and crude mortality rates of VAPIncidence and crude mortality rates of VAP

Author Year No. of Pt. Incidence(%) Diag Criteria MR(%)Patients in ICUPatients in ICUSalataSalata 1987 1987 5151 41 41 ClinicalClinical––autopsy autopsy 7676Craven Craven 19861986 233 233 21 21 Clinical Clinical 5555Langer Langer 1989 1989 724 724 23 23 Clinical Clinical 4444FagonFagon 1989 1989 567 567 9 9 PSB PSB 77KerverKerver 1987 1987 39 39 6767 Clinical Clinical 3030DriksDriks 1987 1987 130 130 18 18 Clinical Clinical 5656Torres Torres 1990 1990 322 322 24 24 ClinicalClinical––PSB PSB 3333Baker Baker 1996 1996 514514 55 PSB/BAL PSB/BAL 2424KollefKollef 1993 1993 277 277 16 16 Clinical Clinical 3737FagonFagon 1996 1996 1,118 1,118 28 28 PSB/BAL PSB/BAL 5353TimsitTimsit 1996 1996 387 387 15 15 PSB/BAL PSB/BAL 5757Cook Cook 1998 1998 1,014 1,014 18 18 ClinicalClinical––PSB/BAL PSB/BAL 2424TejadaTejada 20012001 103 103 22 22 PSB PSB 4444Patients with ARDSPatients with ARDSSutherland Sutherland 1995 1995 105 105 15 15 PSB/BAL PSB/BAL 3838DelclauxDelclaux 1997 1997 30 30 60 60 PTC/BAL PTC/BAL 6363ChastreChastre 1998 1998 56 56 55 55 PSB/BALPSB/BAL 7878MeduriMeduri 19981998 9494 4343 PSB/BAL PSB/BAL 5252MarkowiczMarkowicz 2000 2000 134 134 37 37 PSB/BALPSB/BAL 5757

Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867-903

Mortality Mortality

In ICU, risk of mortality appears to be In ICU, risk of mortality appears to be 2 to102 to10--fold higherfold higher in in patients with patients with nosocomialnosocomial pneumonia than in those without.pneumonia than in those without.

Crude mortality rates are Crude mortality rates are higher in patients with VAPhigher in patients with VAP than in than in those withoutthose without

Risk factors: Risk factors: Pseudomonas Pseudomonas aeruginosaaeruginosa, bacteria resistant strain, , bacteria resistant strain, secondary secondary bacteremiabacteremia

Mean length of stay; Mean length of stay; 34 days for patient with VAP34 days for patient with VAP and and 21 days 21 days for those matched withoutfor those matched without

Mortality rates according to initial Mortality rates according to initial antibiotic therapyantibiotic therapy

Crude Mortality Rates of Patients Receiving antibiotic therapyCrude Mortality Rates of Patients Receiving antibiotic therapy

AuthorAuthor Inadequate Inadequate AdequateAdequate p Valuep Value

Luna Luna 92.2% (n 34) 92.2% (n 34) 37.5% (n 15) 37.5% (n 15) <<0.0010.001AlvarezAlvarez--LermaLerma 34.9% (n 146) 34.9% (n 146) 32.5% (n 284) 32.5% (n 284) NSNSRelloRello 63.0% (n 27) 63.0% (n 27) 41.5% (n 58) 41.5% (n 58) 0.060.06KollefKollef 60.8% (n 51) 60.8% (n 51) 26.6% (n 79) 26.6% (n 79) 0.0010.001SanchezSanchez--Nieto Nieto 42.9% (n 14) 42.9% (n 14) 25.0% (n 24) 25.0% (n 24) NSNSRuiz Ruiz 50.0% (n 18) 50.0% (n 18) 39.3% (n 28) 39.3% (n 28) NSNSDupont Dupont 60.7% (n 56) 60.7% (n 56) 47.3% (n 55) 47.3% (n 55) NSNS

Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867-903

VAP in VAP in SongklanagarindSongklanagarind Hospital Hospital

เริ่มเริ่มทําการเฝาระวังตั้งแตปทําการเฝาระวังตั้งแตป พพ..ศศ.. 2543 (VAP:16.74)2543 (VAP:16.74)VAP in the year 2545VAP in the year 2545

High mortalityHigh mortalityHigh rate of VAP (esp. in ICU)High rate of VAP (esp. in ICU)75% of ICU patients were 75% of ICU patients were intubatedintubatedExcellence centerExcellence center

คณะกรรมการดําเนนิการคณะกรรมการดําเนนิการ สิงหาคมสิงหาคม 25452545

ภาควิชาภาควิชาอายุรอายุรศาสตรศาสตร ภาควิชาวิสญัญีวิทยาภาควิชาวิสญัญีวิทยา ภาควิชาเวชศาสตรชมุชนภาควิชาเวชศาสตรชมุชน หนวยระบาดวิทยาหนวยระบาดวิทยา หนวยควบคุมโรคติดเชือ้หนวยควบคุมโรคติดเชือ้ หนวยเครื่องชวยหายใจหนวยเครื่องชวยหายใจ หออภิบาลผูปวยหนักหออภิบาลผูปวยหนัก

ลดอัตราการติดเชื้อปอดอักเสบจากการลดอัตราการติดเชื้อปอดอักเสบจากการใชเครื่องชวยหายใจในผูปวยใชเครื่องชวยหายใจในผูปวย ICUICU

พันธพันธกิจกิจ

การดําเนนิการการดําเนนิการ

เปาหมายเปาหมาย :: เดือนธันวาคมเดือนธันวาคม 2545 2545 ลดลด VAP VAP รอยละรอยละ 1010สิ้นสุดโครงการสิ้นสุดโครงการ 1 1 ปป ลดลด VAP VAP รอยละรอยละ 2020

กลยุทธกลยุทธ :: ใชใช Continuous Quality ImprovementContinuous Quality Improvement

วิธีการวิธีการ :: ใชใช cross functional team cross functional team พัฒนาพัฒนาคุณภาพอยางตอเนือ่งโดยใชคุณภาพอยางตอเนือ่งโดยใช CDC CDC GuidelineGuideline มาเปนแนวทางในการปฏบิัติมาเปนแนวทางในการปฏบิัติ แตละกลุมตองจัดแนวทางในการปฏิบัติแตละกลุมตองจัดแนวทางในการปฏิบัติ

Prevention strategyPrevention strategy

Interrupting transmission of microInterrupting transmission of micro--organismorganismStaff education and Infection Staff education and Infection surveillencesurveillence

การดําเนนิการการดําเนนิการ

คูมือคูมือ :: ดัดแปลงดัดแปลง CDCCDC guidelineguideline บุคลากรบุคลากร :: ใหความสําคัญเรื่องใหความสําคัญเรื่องการลางมอืการลางมอื ผูปวยผูปวย :: เฝาระวังเรื่องเฝาระวังเรื่อง atelectasisatelectasis; chest PT; chest PTEnvironment Environment : : ventilationventilationในใน ICU ICU; air exchange; air exchangeEducationEducation : : พยาบาลพยาบาล ผูชวยพยาบาลผูชวยพยาบาล

นกันกักากายยภาพบําบัดภาพบําบัด เจาหนาที่หนวยเครื่องชวยหายใจเจาหนาที่หนวยเครื่องชวยหายใจ แพทยใชทนุแพทยใชทนุ แพทยประจําบานแพทยประจําบาน

การประเมินการประเมิน :: การควบคุมคุณภาพการพยาบาลการควบคุมคุณภาพการพยาบาล

การปองกันการปองกัน VAP VAP ในใน PICU PICU

ลางมือกอนและหลังใหการดแูลเด็กลางมือกอนและหลังใหการดแูลเด็กการปลดสายเครื่องชวยหายใจออกจากทอชวยหายใจการปลดสายเครื่องชวยหายใจออกจากทอชวยหายใจการใชการใช alcohol alcohol เช็ดขอตอของทอชวยหายใจเช็ดขอตอของทอชวยหายใจดูดเสมหะโดยใชดูดเสมหะโดยใช sterile techniquesterile techniqueOral hygieneOral hygieneการเปลี่ยนการเปลี่ยน finger tip finger tip ขวดรองรบัเสมหะขวดรองรบัเสมหะเปลี่ยนชุดกระบอกเปลี่ยนชุดกระบอก forcepsforcepsน้ําในกระบอกทําความชืน้น้ําในกระบอกทําความชืน้ การเตมิน้ําการเตมิน้ํา :: closed systemclosed systemการเปลี่ยนสายและอุปกรณของเครื่องชวยหายใจการเปลี่ยนสายและอุปกรณของเครื่องชวยหายใจCondensateCondensate ในสายตอเครื่องชวยหายใจในสายตอเครื่องชวยหายใจกรณีตองใชน้ํากรณีตองใชน้ํา dilute dilute ใหใชแบบใหใชแบบ single dosesingle dose

Incidence of VAP in Incidence of VAP in SongklanagarindSongklanagarind HospitalHospital

Infection Control Report 2007 ; Infection Control Report 2007 ; SongklanagarindSongklanagarind Hospital Hospital

25452545 5.95.9

25462546 5.15.1

2547 3.92547 3.9

2548 1246 3.212548 1246 3.21 48144814 2.082.08

2549 1485 3.37 4108 3.42549 1485 3.37 4108 3.411

2550 809 1.13 4574 1.2550 809 1.13 4574 1.9797

YearYear vv--daysdays VAPVAP vv--days days VAPVAP--ICUICU

NNIS 25 percentile VAP = 2.6 NNIS 25 percentile VAP = 2.6 ครั้งครั้ง v v--daysdays

ICU Policy for the Prevention of VAPICU Policy for the Prevention of VAP1. Assure adequate intensive care unit staffing levels1. Assure adequate intensive care unit staffing levels

2. Immunize health care workers for influenza2. Immunize health care workers for influenza

3. Implement hand hygiene with alcohol rubs3. Implement hand hygiene with alcohol rubs

4. Adopt an antibiotic policy 4. Adopt an antibiotic policy restricting the prescription of restricting the prescription of broadbroad--spectrum agents and useless antibioticsspectrum agents and useless antibiotics by by implementing strict guidelines, avoiding treating patients implementing strict guidelines, avoiding treating patients without bacterial infection, without bacterial infection, using narrowusing narrow--spectrum spectrum antibiotics whenever possibleantibiotics whenever possible, and , and reducing the duration of reducing the duration of treatmenttreatment

5. Follow a restrictive transfusion trigger policy5. Follow a restrictive transfusion trigger policy

6. Reduce as much as possible the duration of mechanical 6. Reduce as much as possible the duration of mechanical ventilation (a major risk factor for VAP), using:ventilation (a major risk factor for VAP), using:-- Improved methods of sedation and avoidance of paralytic agentsImproved methods of sedation and avoidance of paralytic agents-- Protocols to facilitate and accelerate weaningProtocols to facilitate and accelerate weaning-- Intensive insulin therapy, with tight control of blood glucose Intensive insulin therapy, with tight control of blood glucose levellevel

-- Noninvasive mechanical ventilation whenever possibleNoninvasive mechanical ventilation whenever possible

7. 7. Avoid nasal insertion of Avoid nasal insertion of endotrachealendotracheal and gastric tubes to and gastric tubes to minimize the risk of minimize the risk of nosocomialnosocomial sinusitissinusitis

8. 8. Maintain Maintain endotrachealendotracheal tube cuff pressure above 20 cm Htube cuff pressure above 20 cm H22O, O, to prevent leakage of bacteria around the cuff into the to prevent leakage of bacteria around the cuff into the lower respiratory tractlower respiratory tract

ICU Policy for the Prevention of VAPICU Policy for the Prevention of VAP

9. 9. ReintubateReintubate promptlypromptly patients who would inexorably fail patients who would inexorably fail extubationextubation

10. Keep patients in the 10. Keep patients in the semirecumbentsemirecumbent positionposition, especially , especially in case of in case of enteralenteral nutritionnutrition

11. Provide 11. Provide adequate oral hygieneadequate oral hygiene with an antiseptic such with an antiseptic such as as chlorhexidinechlorhexidine

12. Use a 12. Use a heatheat--andand--moisture exchangermoisture exchanger or heatedor heated--wire wire circuit instead of a conventional active humidifier to circuit instead of a conventional active humidifier to prevent formation of contaminated tubing condensates prevent formation of contaminated tubing condensates and their inadvertent flushing into the lower airwaysand their inadvertent flushing into the lower airways

ICU Policy for the Prevention of VAPICU Policy for the Prevention of VAP

Strategy for Conducting Antimicrobial Therapy in VAPStrategy for Conducting Antimicrobial Therapy in VAP

Step 1: Start therapy using broadStep 1: Start therapy using broad--spectrum antibiotics spectrum antibiotics

Step 2: Stop therapy if the diagnosis of infection becomesStep 2: Stop therapy if the diagnosis of infection becomesunlikelyunlikely

Step 3: Use narrowerStep 3: Use narrower--spectrum drugs once the agent of spectrum drugs once the agent of infection is identifiedinfection is identified

Step 4: Use pharmacokineticStep 4: Use pharmacokinetic--pharmacodynamicpharmacodynamic data to data to optimize treatmentoptimize treatment

Step 5: Switch to Step 5: Switch to monotherapymonotherapy on days 3on days 3––55

Step 6: Shorten the duration of therapyStep 6: Shorten the duration of therapy

HAP, VAP or HCAP HAP, VAP or HCAP SuspectedSuspected

Obtain Lower Respiratory Tract Sample for CultureObtain Lower Respiratory Tract Sample for Culture(Quantitative or Semi(Quantitative or Semi--quantitative) & Microscopyquantitative) & Microscopy

Days 2&3 : Check cultures & Assess clinical response: Temp, WBC,Days 2&3 : Check cultures & Assess clinical response: Temp, WBC, CXR, Oxygenation, CXR, Oxygenation, Purulent sputum, Hemodynamic changes & Organ function)Purulent sputum, Hemodynamic changes & Organ function)

Unless there is both a low clinical suspicion for pneumonia & neUnless there is both a low clinical suspicion for pneumonia & negative gative microscopy of LRT sample, begin empiric antimicrobial therapymicroscopy of LRT sample, begin empiric antimicrobial therapy

Clinical improvement at 48Clinical improvement at 48--72 hours72 hours

NoNo

Search for other Search for other pathogens, pathogens,

complications, other complications, other diagnoses or other diagnoses or other

sites of infectionsites of infection

YesYes

Consider Consider stopping stopping

antibioticsantibiotics

Management strategies for a patient with Management strategies for a patient with suspecetedsuspeceted HAP, VAP, HCAP. ATS. Am J HAP, VAP, HCAP. ATS. Am J RespirRespir CritCrit Care Med Care Med 2005; 171 :3882005; 171 :388--416416

Culture Culture -- Culture +Culture + Culture Culture -- Culture +Culture +

Adjust antibiotic therapy, Adjust antibiotic therapy, Search for other Search for other

pathogens, complications, pathogens, complications, other diagnoses or other other diagnoses or other

sites of infectionsites of infection

DeDe--escalate escalate antibiotics, if antibiotics, if

possible. Treat possible. Treat selected patients for selected patients for

77--8 d & reassess8 d & reassess

EvidenceEvidence--Based Clinical Practice Guideline Based Clinical Practice Guideline for the Prevention of VAPfor the Prevention of VAP

Physical strategiesPhysical strategiesPositional strategiesPositional strategiesPharmacologic strategiesPharmacologic strategies

EvidenceEvidence--Based Clinical Practice Guideline Based Clinical Practice Guideline for the Prevention of VAPfor the Prevention of VAP

Physical strategiesPhysical strategies

Route of Route of endotrachealendotracheal intubationintubationSystematic search for sinusitisSystematic search for sinusitisFrequency of ventilator circuit changesFrequency of ventilator circuit changesAirway humidificationAirway humidificationEndotrachealEndotracheal suctioning systemsuctioning systemSubglotticSubglottic secretion drainagesecretion drainageChest physiotherapyChest physiotherapyTiming of Timing of tracheostomytracheostomy

Route of Route of endotrachealendotracheal intubationintubation

Status: Status: We recommend that the We recommend that the orotrachealorotrachealroute of intubationroute of intubation should be used when should be used when intubation is necessary.intubation is necessary.

Systematic search for sinusitisSystematic search for sinusitis

Status: Status: We make no recommendation because We make no recommendation because of insufficient evidence.of insufficient evidence.

Frequency of ventilator circuit changesFrequency of ventilator circuit changes

Status: We recommend new circuits for each Status: We recommend new circuits for each patient, and patient, and changes if the circuits become changes if the circuits become soiledsoiled, but , but no scheduled ventilator circuit no scheduled ventilator circuit changes.changes.

Airway humidificationAirway humidification

Type of HumidifierType of HumidifierStatus: We recommend the Status: We recommend the use of heat and use of heat and moisture exchangersmoisture exchangers in patients who have no in patients who have no contraindications (such as contraindications (such as hemoptysishemoptysis or or requirement for high minute ventilation)requirement for high minute ventilation)

•• Frequency of Humidifier changesFrequency of Humidifier changesStatus: We recommend weekly changes of heatStatus: We recommend weekly changes of heatand moistureand moisture exchangers.exchangers.

EndotrachealEndotracheal suctioning systemsuctioning system

Status: We recommend the use of Status: We recommend the use of closed closed endotrachealendotracheal suction systemssuction systems that are changed for that are changed for each new patient and as clinically indicated.each new patient and as clinically indicated.

SubglotticSubglottic secretion drainagesecretion drainage

Status: Status: We recommend that clinicians We recommend that clinicians consider consider the use of the use of subglotticsubglottic secretion drainage.secretion drainage.

Chest physiotherapyChest physiotherapy

Status: We make no recommendation.Status: We make no recommendation.

Timing of Timing of tracheostomytracheostomy

Status: We make Status: We make no recommendationno recommendation because because of insufficient evidence.of insufficient evidence.

Positional strategiesPositional strategies

Kinetic bed therapyKinetic bed therapySemiSemi--recumbent positioningrecumbent positioningProne positioningProne positioning

Kinetic bed therapyKinetic bed therapy

Status: We recommend that clinicians Status: We recommend that clinicians consider consider the use of the use of kinetic beds.kinetic beds.

SemiSemi--recumbent positioningrecumbent positioning

Status: Status: We recommend the We recommend the use of semiuse of semi--recumbent positioning,recumbent positioning, with a goal of 45 degrees,with a goal of 45 degrees,in patients without contraindicationsin patients without contraindications..

Prone positioningProne positioning

Status: We make Status: We make no recommendationno recommendation..

Stress ulcer prophylaxisStress ulcer prophylaxisProphylactic Antibiotics, Including Selective Prophylactic Antibiotics, Including Selective Decontamination of the Digestive TractDecontamination of the Digestive Tract

Pharmacologic strategiesPharmacologic strategies

Stress ulcer prophylaxisStress ulcer prophylaxis

Status: Status: We recommend that We recommend that sucralfatesucralfate not be not be usedused to minimize the risk for VAP in patient at to minimize the risk for VAP in patient at high risk for stress ulcer bleeding.high risk for stress ulcer bleeding.

Prophylactic Antibiotics, Including Selective Prophylactic Antibiotics, Including Selective Decontamination of the Digestive TractDecontamination of the Digestive Tract

Status: Status: We recommend that We recommend that topical antibiotics alonetopical antibiotics alone not be usednot be used. . We make We make no recommendationsno recommendations regarding selectiveregarding selectivedigestive decontamination using intravenous and topical digestive decontamination using intravenous and topical antibiotics because of insufficient data about antibiotic antibiotics because of insufficient data about antibiotic resistance and costresistance and cost--effectiveness. effectiveness. We make We make no recommendationno recommendation regarding regarding intravenous intravenous antibiotics aloneantibiotics alone because of insufficient evidence.because of insufficient evidence.

DodekDodek P, Keenan S, Cook D, et al. EvidenceP, Keenan S, Cook D, et al. Evidence--based clinical practice guideline for the prevention of VAP based clinical practice guideline for the prevention of VAP Ann Intern Med. Ann Intern Med. 2004;141:3052004;141:305--313.313.

For every minute you angry you lose sixty seconds of happiness

Ralph Waldo Emerson 1803-1882