PREVENTION AND MANAGEMENT OF VAP IN INTUBATED AND VENTILATED PATIENTS
RECOMMENDATIONS
Preventative strategies
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Routine twice daily CPT physiotherapy to all patients in ICU to prevent VAP is NOT RECOMMENDED at this time
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Motivation: Two studies investigated the effect of a routine twice daily physiotherapy package (position; suction; MHI
or vibrations) on the incidence of VAP (Ntoumenopolous et al 1998; Ntoumenopolous et al 2002) with conflicting
results. The physiotherapeutic package of care provided in two RCT’s (Ntoumenopolous et al 1998; Ntoumenopolous
et al 2002) did not affect TOV; ICU LOS or mortality. It showed a tendency to reduce the incidence of VAP (diagnosed
by CPIS) in one study. The quality of evidence is downgraded to low due to imprecision of sample and poor
methodological quality (refer to table 2). Furthermore, patients only entered into the study after two days of intubation
and positioned on a side to drain a segment where there was already radiographic evidence of infiltrates (refer to
management)
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Recommendation 1
 All intubated patients (that do not present with contra indications) should be nursed in a semi-recumbent position
with the goal of 45O head up to prevent the development of VAP.
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Strong recommendation This positioning resulted in a decrease in the incidence of VAP in one clinical guideline
(Dodek et al 2004) and one systematc review (Gastmeier et al (2007). The cost and burden of implementing a basic
nursing position for all intubated patients in ICU is very low compared to the possibility of preventing the development
of VAP
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based on moderate quality evidence: One well developed clinical guideline (Dodek et al 2004) scoring above 75 for
all the domains of the AGREE instrument and a systematic review updating the evidence (Gastmeier et al 2007).
Evidence is downgraded due to imprecision of data
Recommendation 2
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 No suction system (open or closed) is superior in the prevention of VAP in intubated patients. The choice of which
system to use must be based on availability.
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Strong recommendation None of the systems (OSS or CSS) reported a decrease in the incidence of VAP. Intubated
patients are suctioned regularly in ICU and claims have been made to the effectiveness of CSS over OSS. It is
therefore important to recognize that no system is superior
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based on high quality evidence from one meta analysis evaluating 9 RCT’s.
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Management strategy
Recommendation 3
 When infiltrates are visible on CxR a CPT package including a gravity assisted drainage position; MHI and
suctioning should be initiated with a frequency of two treatment sessions per day.
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Weak recommendation significant improvement in static lung compliance and inspiratory resistance was
documented in one randomized cross over design study (Choi et al 2005). Although significant improvement was
documented in the respiratory mechanics the impact of these changes on long term outcome is not clear.
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based on low quality evidence: one randomized crossover RCT (Choi et al 2005). Evidence was downgraded
because of methodological quality and imprecision.
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NOTE In the study by Ntoumenopelous et al (2002) subjects only entered into the study after 48 hours of intubation
and with infiltrates visible on CxR. The mean CPIS score was measured daily for the duration of ICU stay and the
diagnosis was based on a combination of clinical diagnosis and CPIS score. Because the provision of physiotherapy
to patients diagnosed with VAP is regarded as a standard of care; and no studies to date have evaluated the optimal
package of care it is recommended that the package of care investigated by Ntoumenopolous et al (2002) to
prevent VAP be used as the basis for the physiotherapeutic management of patients where VAP has been
diagnosed. This package also includes the techniques (MHI and suction) investigated by Choi et al (2005).
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Review question: Is CPT effective in the prevention and management of ventilator associated pneumonia
(VAP) in intubated and ventilated patients compared with no intervention?
Following a systematic review of the literature; critical appraisal of identified studies; the following conclusions were
reached:
SEARCH RESULTS
 Six studies were included in this review. This includes three experimental studies (Ntoumenopoulos et al 1998;
Ntoumenopoulos et al 2002; Choi et al 2005); one clinical guideline (Dodek et al 2004) and two systematic reviews
(Gastmeier et al 2007; Von Bergh et al 2006).
 Five studies into strategies to prevent VAP were pubished (Ntoumenopoulos et al 1998; Ntoumenopoulos et al 2002;
Dodek et al 2004; Gastmeier et al 2007; Von Bergh et al 2006) and one study (Choi et al 2005) investigated the
effect of CPT techniques on the pulmonary dynamics in patients diagnosed with VAP.
 The preventative strategies include patient positioning; optimal suction system and routine CPT.
Experimental studies
 Two experimental studies (RCT) evaluated the effect of CPT techniques in the prevention of VAP (Ntoumenopoulos
et al 1998; Ntoumenopoulos et al 2002) and one crossover RCT was done to investigate the effect of these
techniques on the respiratory mechanics in patients already diagnosed with VAP (Choi et al 2005).
 The internal validity of the studies is compromised, scoring between 3 and 6/11 on PEDRO scale (refer to table 1).
Clinical guideline
 One evidenced based clinical guideline for the prevention of VAP in intubated and ventilated patients was identified
(Dodek et al 2004).
 The clinical guideline developed by Dodek et al (2004) scored above 70% in all the domains of the AGREE
instrument (refer to table 3 for domain scores).
Systematic Review
 Three systematic reviews were included in this review (Gastmeier et al 2007; Von Bergh et al 2006; Subraiana et al
2007).
 Gastmeier et al (2007) review was an update of the Dodek et al (2004) guideline evaluating multidisciplinary
strategies to prevent VAP. Even though a number of primary research papers were published between 2004 and
2007 – they concluded that no additions could be made to the 2004 guideline.
 Von Bergh et al (2006) and Subriana et al (2008) reviewed the evidence to decide between closed and open suction
systems in the prevention of VAP.
SUMMARY OF EVIDENCE
 It remains unclear whether the routine twice daily application of a CPT package will prevent the development of VAP
(Ntoumenopolous et al 1998; Ntoumenopoulos et al 2002; Dodek et al 2004 )
 CPT techniques including MHI and suctioning into the management of patients diagnosed with VAP may improve
lung compliance (Choi et al 2005).
 When infiltrates are visible on CxR a CPT package including gravity assisted positioning; MHI and suction does not
have adverse effects and could prevent the progression of pathology (Ntoumenopoulos et al 2002 and
Ntoumenopoulos et al 1998).
Table 1 Summary of experimental studies
Experimental
Studies
Ntoumenopo
ulos et al
1998
Internal
validity
Pedro
6
Ntoumenopo
ulos et al
2002
4
Choi et al
2005
3
Sampl
e size
Population
Intervention and
comparison
46
Intubated and ventilated
patients admitted to a trauma
unit
MHI; gravity assisted
position; suction; twice
daily compared to
passive/active movements
once daily
Gravity assisted position;
shakings and suction
compared to “sham
therapy” (occasional
musculo-skeletal)
MHI and suction
compared to suction
alone
46
15
Intubated and ventilated for at
least 48 hours
Intubated and ventilated
patients diagnosed with VAP
Study
structure
Outcome measured
Incidence of VAP (CPIS
diagnosed)
RCT
RCT
Crossover
RCT
LOS; mortality; TOV;
Incidence of VAP (CPIS
diagnosed)
Static pulmonary
compliance and inspiratory
resistance
 Patients must be nursed in semi recumbent position with the goal of 45O head up position (Dodek et al 2004;
Gastmeier et al 2007).
 There is no difference in open and closed suction systems in the prevention of VAP, but open systems could be more
cost effective (Von Bergh et al 2006; Subriana et al 2008).
Table 2 Summary of reviews / metanalysis
Review
AMSTAR Studies
Score
included
Population
Intervention
and
comparison
Outcome
measured
Conclusion
At a given pneumonia
prevalence of 20% in ICU
patients there was no
significant advantage for
the use of either
suctioning system in this
meta-analysis.
Despite a number of
studies published after
2004 the
recommendations made
by Dodek et al 2004
remain
Von Berg et
al 2006
7
9 RCT’s
including data for
1292 patients
(644 OSS and
648 CSS)
Adult
intubated
population
Open suction
system
compared to
closed suction
system
Incidence of
VAP
Gastmeier et
al 2007
5
15 RCT’s and 7
meta analyses
Adult
intubated
population
Variety of
preventative
strategies
Incidence of
VAP
Subriana et al
2008
11
11 RCT’s
Adult
intubated
population
Open suction
system
compared to
closed suction
system
Incidence of
VAP; LOS;
mortality
suctioning with either
closed or open tracheal
suction systems did not
have an effect on the risk
of ventilator-associated
pneumonia or mortality
Table 3: Levels of guideline recommendations Dodek et al 2004
Strategy
Prophylactic physiotherapy
for the prevention of VAP
Recommendation
We make no recommendation
Motivation
On the basis of evidence from one trial,chest physiotherapy
may be associated with decreased incidence of VAP.
However, methodologic limitations of this trial and the lack of
feasibility of universal application preclude widespread use of
this intervention.
Routine semi-recumbent
positioning
We recommend the use of semirecumbent positioning, with a goal
of 45 degrees, in patients without
contraindications.
On the basis of evidence from one trial with minimal
methodological limitations, we conclude that semi-recumbent
positioning (caring for patients positioned at 45 degrees from
horizontal) is associated with decreased incidence of VAP.
Semi-recumbent positioning may be unsafe for some patients
but is a feasible and low-cost intervention.
SUMMARY OF THE QUALITY OF THE EVIDENCE
 Two studies investigated the effect of a routine twice daily physiotherapy package (position; suction; MHI or
vibrations) on the incidence of VAP (Ntoumenopolous et al 1998; Ntoumenopolous et al 2002) with conflicting results.
The physiotherapeutic package of care provided in two RCT’s (Ntoumenopolous et al 1998; Ntoumenopolous et al
2002) did not affect TOV; ICU LOS or mortality. It showed a tendency to reduce the incidence of VAP (diagnosed by
CPIS) in one study. The quality of evidence is downgraded to low due to imprecision of sample and poor
methodological quality (refer to table 2). Furthermore, patients only entered into the study after two days of intubation
and positioned on a side to drain a segment where there was already radiographic evidence of infiltrates.
Table 4 Factors considered in determining the quality of the evidence for RCT’s
Risk of bias
Experimental
Studies
Ntoumenopou
los et al 1998
Ntoumenopou
los et al 2002
Directness of evidence
Heterogeneity
Precision
Concealed
allocation
LTFO
Lost to
follow up
ITT
Intervention
investigated
Sample
investigated
Publication Bias
Data
Sample
Yes
No
No
Yes
Yes
NA
No
No
Yes
No
Yes
Yes
NA
No OR 0.72
(0.18 -2.76)
Yes OR 0.14
(CI 0.02 – 0.7)
No
A well developed clinical guideline on strategies to prevent VAP in intubated patients (Dodek et al 2004) scoring 95%
in (refer to table 3) the rigor of development domain of the AGREE instrument also failed to recommend the routine
application of a physiotherapy package of care to all patients in ICU (refer to table 4). It is unsure whether increasing
the burden of providing twice daily physiotherapy package of care to all patients admitted to the ICU to prevent VAP is
a cost effective strategy and is thus not recommended.
Table 5 AGREE domains for Clinical guideline
Clinical
guideline
Dodek et
al 2004
Subject
Evidence based
clinical practice
guideline for the
prevention of ventilator
asociated pneuonia
Scope And
Purpose
100%
Stakeholder
Involvement
75%
Rigor Of
Development
95%
Clarity And
Presentation
92%
Applicabilit
y
67%
Editorial
Independence
100%
 The quality of evidence available for chosing between an OSS or CSS remains high as it is provided by two well
conducted systematic reviews reaching the same conclusion (Van Berg et al 2006 and Subriana et al 2008) refer to
table 6.
 Only one study investigated the immediate effect of MHI and suction on the pulmonary dynamics of patients
diagnosed with VAP (Choi et al 2005) and reported a significant improvement in pulmonary compliance compared to
baseline. Quality of the evidence was downgraded to low due to methodological quality and imprecision (refer to
table 5).
NOTE In the study by Ntoumenopelous et al (2002) subjects only entered into the study after 48 hours of intubation
and with infiltrates visible on CxR. The mean CPIS score was measured daily for the duration of ICU stay and
diagnosed with VAP combining clinical diagnosis and CPIS score. Because the provision of physiotherapy to patients
diagnosed with VAP is regarded as a standard of care; and no studies to date have evaluated the optimal package of
care it is recommended that the package of care investigated by Ntoumenopolous et al (2002) to prevent VAP be used
as the basis for the physiotherapeutic management of patients where VAP has been diagnosed. This package also
includes the techniques (MHI and suction) investigated by Choi et al (2005).
Table 6 Quality of evidence from systematic review
Directness of evidence
Review
Methodological
quality assessed
Heterogeneity
Precision
Intervention
investigated
Sample
investigated
Publication
Bias
Data
Sample
No (p = 0.46)
Pooled RR for closed suctioning
systems is 0.95 (95% CI
0.76–1.18)
No did not
assess
No (p=0.26)
Did not assess
Von Berg et al
2006
None described
Yes
Gastmeier et
al 2007
Subriana et al
2008
None described
yes
No: Various ICU
populations (neuro;
medical; trauma;
surgical)
yes
yes
yes
yes
Pooled RR 0.88; (95% CI 0.70 to
1.12)
Table 7 Factors considered in determining the quality of the evidence for the crossover design study
Experimental
Studies
Choi et al
2005
Risk of bias
Study
design
Yes:
Appropriat
e
Washout
period
Yes: Baseline
comparisons
not
significantly
different
Directness of evidence
Sample
selected
No: did
not
include
APACHE;
TOV
Intervention
investigated
Yes
Sample
investigated
Yes
Heteroge
neity
Precision
Publicatio
n Bias
Data
Sample
NA
Insufficient
data to
calculate
mean
difference
No