Running head: METHODS TO PREVENT VENTILATOR ASSOCIATED PNEUMONIA

A Comparison of Methods to Prevent Ventilator Associated Pneumonia

Kristine Martin
University of South Florida

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Abstract
Clinical Problem: Patients receiving mechanical ventilation are at risk of developing ventilator
associated pneumonia (VAP), which has been associated with longer duration of mechanical
ventilation and longer stay in the intensive care unit (Allen et al., 2005).
Objective: To determine if the use of endotracheal tubes that allow for secretion drainage reduces
the incidence of ventilator associated pneumonia.
Search Engine & Key Words Used: PubMed, CINHAL, and National Guideline Clearinghouse
were used to obtain randomized controlled trials and clinical guidelines regarding secretion
suctioning. The key search terms used were ventilator associated pneumonia, VAP prevention
bundle, VAP economic impact, subglottic secretion suctioning, and VAP prevention guidelines.
Results: Appere de Vecchi et al. (2010) found that the incidence of ventilator associated
pneumonia was decreased when patients were intubated with an endotracheal tube that allowed
for secretion drainage (p=0.02). Belafsky et al. (2013) demonstrated that the use of above-thecuff secretion suctioning decreased the incidence of VAP (p= 0.02). Additionally, Smulders et al.
(2002) found that intermittent subglottic secretion drainage reduced the incidence of ventilator
associated pneumonia (p= 0.01). The Centers for Disease Control and Prevention recommend the
use of an endotracheal tube capable of allowing drainage of tracheal secretions by continuous or
frequent intermittent suctioning (2003).
Conclusion: Patients receiving mechanical ventilation who receive secretion suctioning have a
lower incidence of ventilator associated pneumonia. Measurements of length of ICU stay,
duration of mechanical ventilation and mortality did not produce statistically significant results.

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A Comparison of Methods to Prevent Ventilator Associated Pneumonia
Ventilator associated pneumonia (VAP) is the second most common hospital acquired
infection (Centers for Disease Control and Prevention, n.d.). In the intensive care unit (ICU),
VAP is the most frequently occurring infection (Bonten, 2011). VAP has been shown to increase
length of ICU stay by 15.2 days and number of days on a ventilator by 11.9 days (Allen et al.,
2005). The implementation of the VAP prevention bundle, which includes maintaining
endotracheal cuff pressure above 20 cm H2O, elevating the head of the bed to 30-45, performing
oral care every 2-4 hours and adhering to hand-hygiene protocols, has been shown to decrease
the incidence of VAP (Munro & Ruggiero, 2014). Bacterial pathogens entering the lower airway
as a result of aspiration of secretions was found to be the main cause of VAP (Heyland et al.,
2011). The Centers for Disease Control and Prevention have established VAP prevention
guidelines that include using an endotracheal tube with inline or subglottic suctioning to drain
secretions (Centers for Disease Control and Prevention, 2003). The addition of secretion
suctioning to the VAP bundle may further decrease the incidence of VAP and enhance patient
outcomes. This paper serves to distinguish the effectiveness of secretion suctioning in reducing
incidence of VAP in mechanically ventilated patients. In hospitalized adult patients on a
ventilator, how does secretion suctioning compare to the standard VAP prevention bundle in the
prevention of VAP over a three month period?
Literature Search
PubMed, CINHAL, and National Guideline Clearinghouse were used to obtain
randomized controlled trials and clinical guidelines regarding secretion suctioning. The key
search terms used were ventilator associated pneumonia, VAP prevention bundle, VAP economic
impact, subglottic secretion suctioning, and VAP prevention guidelines.

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Literature Review
To determine the effectiveness of secretion suctioning, three randomized controlled trials
and one clinical guideline were used. A randomized controlled trial by Appere de Vecchi et al.
(2010) aimed to determine if subglottic secretion drainage (SSD) reduces the incidence of
ventilator associated pneumonia, including early- and late-onset, as well as duration of
mechanical ventilation and hospital mortality. The study included 333 adult patients expected to
remain ventilated for at least 48 hours who were intubated with a tracheal tube allowing for
drainage of subglottic secretions. Of those patients, 169 patients received suctioning while 164
patients remained in the control group. Patients receiving treatment were suctioned once every
hour and the incidence of VAP was measured based on cultures from pulmonary samples.
Patients in the experimental group had a lower incidence of VAP than those in the control group
(p= 0.02). Additionally, the incidence of early- and late-onset VAP was lower in the experimental
group than the control group (p= 0.02 and p=0.01, respectively). Strengths of this study include
the randomization of assignment to experimental or control group and that patients were
evaluated in their assigned group, random assignment was concealed from the study participants,
exclusion criteria was provided, adequate follow-up assessments were conducted, the control
group was appropriate, instruments used to measure outcomes were valid and reliable, and
patients in both groups were similar in regards to baseline variables. A weakness of this study, as
a result of the nature of the experiment, is that subjects and providers were not blind to study
group.
To determine the effectiveness of above-the-cuff suctioning in reducing the incidence of
VAP, Belafsky et al. (2013) conducted a randomized controlled trial on 18 patients who required
tracheostomy tube placement. Of those 18 patients, 9 patients were to receive a standard

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tracheostomy tube and 9 were to receive suction-above-the-cuff tracheostomy tubes. While the
tracheostomy tube cuff was inflated patients received 10mmHg of continuous wall suction. The
incidence of VAP was lower in the experimental group than in the control group (p= 0.02) and
trends toward decreased length of stay and time on the ventilator were recorded, however the
results were statistically insignificant. Strengths of the study include random assignment of
patients to the control or experimental group, random assignment concealed from study
participants, provision of exclusion criteria, follow-up assessments conducted long enough to
fully study the effects of the intervention, patient evaluation in their assigned group, appropriate
control group, use of valid and reliable tools to measure outcomes and similar baseline variables
between patients included in the study. A weakness of the study is that nurses were not blind to
the study group and the small population of study participants.
A randomized controlled trial by Smulders, van der Hoeven, Vandenbroucke-Grauls, &
Weers-Pothoff (2002) aimed to determine the effect of subglottic secretion drainage on the
incidence of ventilator-associated pneumonia as well as its effect on length of hospital and ICU
stay, duration of mechanical ventilation and mortality. Of 150 patients, 75 were randomly
assigned to receive intermittent subglottic secretion drainage and 75 remained in the control
group. Intermittent suctioning was performed in 20-second intervals with a duration of 8
seconds. Tracheobronchial samples were obtained twice weekly to determine the presence of
VAP. Patients in the experimental group had a lower incidence of VAP than those in the control
group (p= 0.01). No statistically significant differences between the two groups in relation to
duration of mechanical ventilation, length of ICU stay, length of hospital stay or mortality were
found. Strengths of this study include the randomization of patients into the control and
experimental groups, exclusion criteria was provided, random assignment was concealed from

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the study participants, adequate follow-up assessments were performed, subjects were analyzed
in their assigned group, the control group was appropriate, instruments used to measure
outcomes were valid and reliable, and the patients baseline variables were similar between
groups. A weakness of this study is the nurses were unable to remain blind to the experimental
group.
The Centers for Disease Control and Prevention published guidelines for the prevention of
Healthcare-associated pneumonia, including ventilator associated pneumonia. The CDC
recommends the use of an endotracheal tube with a dorsal lumen above the endotracheal cuff to
allow tracheal secretion drainage by continuous or frequent intermittent suctioning (Centers for
Disease Control and Prevention [CDC], 2003). This recommendation is categorized as a category
II, indicating the suggestion of implementation is supported by clinical or epidemiological
studies or by strong theoretical rationale.
Synthesis
Appere de Vecchi et al. (2010) found that intubation with a tracheal tube allowing for
subglottic secretion drainage reduced the incidence of ventilator associated pneumonia (p= 0.02).
Belafsky et al. (2013) also demonstrated that the use of above-the-cuff secretion suctioning
decreased the incidence of VAP (p= 0.02). Additionally, Smulders et al. (2002) found that
intermittent subglottic secretion drainage in patients receiving mechanical ventilation reduced the
incidence of ventilator associated pneumonia (p= 0.01). While none of these studies produced
significantly significant results in regards to decreased duration of mechanical ventilation, length
of ICU stay, length of hospital stay or mortality, Appere de Vecchi et al. (2010) found that
secretion suctioning reduced the incidence of early- and late- onset VAP. Additionally, the Center
for Disease Control and Preventions (2003) guideline to reduce the incidence of hospital

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acquired infection suggests that patients who are receiving mechanical ventilation receive an
endotracheal tube with continuous or intermittent suctioning to drain tracheal secretions.
Research supports that the implementation endotracheal tubes allowing for secretion
drainage reduce the incidence of ventilator associated pneumonia. Further research on the effect
of secretion suctioning on length of ICU and hospital stay, time on a ventilator and mortality will
need to be conducted to produce significantly significant results.
Clinical Recommendations
The enactment of the VAP prevention bundle has been successful in reducing the incidence
of ventilator associated pneumonia as seen in research conducted by Ambrose et al. (2015).
Although the VAP bundle is a successful intervention, there is research to support that the
implementation of secretion suctioning in patients receiving mechanical ventilation significantly
reduces the incidence of VAP. The CDC (2003) guidelines encompass the interventions seen in
the VAP prevention bundle (maintaining of endotracheal cuff pressure above 20 cm H2O,
elevating the head of the bed to 30-45, performing oral care every 2-4 hours and adhering to
hand-hygiene protocols) as well as the utilization of an endotracheal tube capable of secretion
suctioning. The addition of secretion suctioning to the VAP prevention bundle may further
decrease the incidence of VAP and enhance patient outcomes.

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References
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Ambrose, A., Carr, D., Gray B., Lee-Parmley C., Martin B., Starmer J., & Talbot, T. (2015).
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