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

Avoiding Intubation and Minimizing Duration of Mechanical Ventilation

Invasive mechanical ventilation is the single greatest risk factor for hospital-acquired pneumonia. Pneumonia occurs 5 to 10 times more frequently in ventilated patients compared with nonventilated patients.[1,8] It stands to reason then that avoiding invasive ventilation whenever safe and feasible to do so should lower ICU-acquired pneumonia rates. There are three primary strategies for minimizing exposure to invasive mechanical ventilation: high flow oxygen without intubation for patients with hypoxemic respiratory failure, noninvasive mechanical ventilation for patients with hypercapnic respiratory failure, and spontaneous breathing trials to identify the earliest possible moment when patients are likely to tolerate extubation. High flow oxygen via nasal cannula versus invasive mechanical ventilation was associated with lower mortality and a trend toward less nosocomial pneumonia in one prominent study,[21] but a subsequent meta-analysis only found nonsignificant trends toward lower mortality rates and less intubation.[22] Initial use of noninvasive ventilation has been associated with lower pneumonia and lower mortality rates when used in suitable populations, particularly patients with chronic obstructive lung disease exacerbations.[23–25] Early liberation from invasive mechanical ventilation by extubating to noninvasive mechanical ventilation also appears beneficial in reducing total exposure to invasive ventilation, preventing ICU-acquired pneumonia and shortening length of stay, but is not associated with lower mortality rates.[26,27] Finally, spontaneous breathing trials have long been associated with shortening duration of mechanical ventilation, fewer ventilator-associated events, and perhaps with lower mortality rates, particularly when performed in conjunction with sedative interruptions.[28–31]

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