Prevention and management of ventilator-associated pneumonia - the Care Bundle approach

Abstract

Ventilator-associated pneumonia (VAP), defined as pneumonia occurring >48 - 72 hours after endotracheal intubation, is the most common and fatal nosocomial infection of intensive care. Risk factors include both impaired host immunity and the introduction of an endotracheal tube, which contributes to the development of VAP in the critically ill patient. VAP is associated with increased mortality and morbidity, increased duration of mechanical ventilation, prolonged intensive care unit and hospital stay, and increased cost of hospitalisation. Both the Centers for Disease Control Guidelines and Pugin’s Clinical Pulmonary Infection Score (CPIS) criteria note that diagnosing VAP requires a combination of clinical signs, impaired gas exchange, radiological changes and positive microscopy to differentiate an episode of VAP from mere colonisation. In a resource-strapped environment, semi-quantitative analysis of specimens obtained utilising a non-invasive sampling technique is an acceptable option. Specific guidelines have been developed to both prevent VAP and treat it appropriately as soon as possible. The guidelines provide targeted strategies, while additional management of VAP includes the provision of essential care, psychosocial support, ventilatory support, enteral feeding and relevant medication including deep-vein thrombosis prophylaxis, and the prevention of complications. The Care Bundle approach offers an interventional tool to implement strategies specifically directed to the prevention of VAP and the facilitation of a team approach to improving its clinical management. The evidence available presents a strong argument to consider a team approach to reducing the incidence of VAP in our own critical care units.