Medicine of the Future in America

Preventing Ventilator-Associated Pneumonia in Adults: Sedation and Weaning

Preventing Ventilator-Associated Pneumonia in Adults: Sedation and WeaningThere have been conflicting reports on the use and benefits of heat/moisture exchangers (HMEs) compared to heated humidifiers for preventing VAP. A recent metaanalysis by Kola and cowork-ers demonstrated a reduction in the relative risk of developing VAP in the HME group (relative risk, 0.7; 95% CI, 0.5 to 0.04) but may have been affected by the large difference in the outcomes in one of the studies. For patients with a mean ventilation duration > 7 days, the relative risk for VAP fell to 0.57 in the HME group (95% CI, 0.38 to 0.83). A more recent, large, randomized study by Lacherade and coworkers found no benefit for the HME group. In another study of HMEs using historical control subjects, patients who received mechanical ventilation > 2 days reported a significant reduction in VAP (p = 0.01).
The focus on prevention is focused on ICU patients, but these patients are at increased risk for relapse or reinfection during their rehabilitation. Therefore, efforts should be directed at risk reduction at discharge, such as routine vaccinations and patient education (Table 1).
Despite rapid technological and treatment advances in medicine, dramatic reductions in rates of VAP and effective use of complex prevention and management guidelines remain elusive. Prevention outcomes are directly related to reducing risk (Fig 4, Table 1). Prevention involves planting a tree, nurturing it, pruning it, and watching it grow and spread seeds for more trees. Investing in prevention can pay great dividends in terms of improved quality of life, morbidity, and mortality. In addition, prevention can have a huge impact in reducing length of stay and health-care costs during acute care. Spreading the seeds of prevention into long-term care and rehabilitation facilities is also vitally needed.
As described in a recent commentary by Berwick et al, the laudable goal set forth by IHI to reduce deaths among hospitalized patients in the United States by 100,000 over 18 months by improving patient quality and safety set a very high bar. Each of the six “100,000 Lives Campaign Interventions,” which includes VAP, is conceptually simple and feasible; notably, each strategy in the “VAP bundle” is not new or expensive. The IHI 100,000 Lives Campaign may be the call to action that is needed to disseminate prevention and safety information, and implement prevention guidelines consistently and broadly. Even if the campaign falls short of its goal of saving 100,000 lives, the enrollment of over half of the hospitals in the nation in this effort can provide a valuable infrastructure for sowing seeds, planting trees, and measuring outcomes. This infrastructure, coupled with endorsements of government agencies (Joint Commission on Accreditation of Healthcare Organizations and Medicare), and medical, nursing, and public health groups, translates into powerful lobbies for the advancement of patient safety, quality care, and the necessary resources to incorporate prevention into practice.


Figure 4. VAP prevention program outcomes and targeted areas for intervention and risk reduction and improve patient outcomes.

This entry was posted in Pulmonary function and tagged antibiotics, evidence-based data, guidelines, infection control, Institute for Healthcare Improvement, intensive care, prevention of hospital-acquired pneumonia, ventilator-associated pneumonia.
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