Prevention of Intensive Care Unit-acquired Pneumonia

Michael Klompas, MD, MPH

Disclosures

Semin Respir Crit Care Med. 2019;40(4):548-557. 

In This Article

Summary and Practical Recommendations

Much still remains unclear about how best to prevent pneumonia in critically ill patients. Recent studies have challenged many favored interventions without clearly identifying a bundle of interventions that does work. Head-of-bed elevation is widely practiced but there are very little randomized controlled trial data supporting its use. Novel endotracheal tube cuff shapes and materials do not lower VAP rates and continuous control of cuff pressure remains understudied. An updated meta-analysis of subglottic secretion drainage reported no impact on duration of mechanical ventilation, ICU length of stay, or mortality. Selective digestive decontamination has historically been the one pneumonia prevention strategy repeatedly associated with lower mortality rates, but a recent cluster randomized trial in ICUs with a high baseline prevalence of resistant organisms did not find a mortality benefit. Oral care with chlorhexidine has a limited effect on VAP and may increase mortality rates. Stress ulcer prophylaxis is associated with higher pneumonia risk in some studies. Probiotics are associated with lower VAP rates but sometimes cause bloodstream infections and do not clearly impact more objective outcomes.

Large multicenter studies on stress ulcer prophylaxis, probiotics, and oral care with chlorhexidine are underway, so more clarity may be forthcoming. In the interim, a practical way forward is to prioritize interventions with the best safety records and the most convincing (albeit still imperfect) data suggesting a favorable impact on objective outcomes. These might include avoiding intubation whenever possible using high flow oxygen or noninvasive mechanical ventilation as appropriate, minimizing sedation, implementing daily spontaneous breathing trials, mobilizing patients early, providing oral care with sterile water alone, and elevating the head of the bed. Other strategies such as digestive decontamination, continuous monitoring of endotracheal tube cuff pressures, and probiotics may prove beneficial but more data on their safety and effectiveness are needed before advocating widespread adoption.

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