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Vanishing VAE
Introduction
Mechanical ventilation is an essential, life-saving therapy for patients in the modern intensive care unit (ICU).
Unfortunately, mechanical ventilation can increase patients’ risk of developing ventilator-associated events (VAE)
such as ventilator-associated pneumonia (VAP). It is estimated that 10-20 percent of ventilated patients develop
VAP [1]. VAP is associated with increased lengths of ICU and hospital stay, extended duration of mechanical
ventilation, increased mortality rates, increased use of antimicrobials, and increased costs [1-3]. VAP is the most
common and associated with the highest mortality among hospital-onset infections that occur in the ICU setting
[2,3].
VAP develops as a result of microorganisms reaching the normally-sterile lower respiratory tract. A major risk
factor for developing VAP is oropharyngeal colonization by the patient’s flora or by microorganisms acquired from
the environment – in particular the hands of healthcare personnel, in addition to contaminated respiratory
equipment, water, fomites, and air [3]. The greatest risk for developing VAP occurs early on during ventilation and
then decreases over time.
Evidence-based interventions can reduce the risk of complications and the occurrence of VAE. Examples of
essential prevention measures include excellent hand hygiene, patient positioning and mobilization, oral care,
managing oropharyngeal and tracheal secretions, and sedation vacation.
The Minnesota Vanishing VAE Bundle
The Vanishing VAE bundle is a succinct approach to VAE prevention for hospitals of all sizes. The bundle
elements are supported by the Society for Healthcare Epidemiology of America (SHEA) [1], Infectious Diseases
Society of America (IDSA) [1], Association for Professionals in Infection Control and Epidemiology (APIC) [1],
American Hospital Association [1], the Joint Commission [1], American Association of Critical-Care Nurses,
American Thoracic Society [6], Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control
Advisory Committee (HICPAC) [7], and Institute for Healthcare Improvement (IHI) [8] guidance documents. The
Vanishing VAE tool kit is a collection of resources and tools to assist hospitals in implementing VAE prevention
strategies.
See the accompanying MHA Gap Analysis for the development of a comprehensive HAI prevention and control
program.
Vanishing VAE Bundle
•
Use low tidal volume ventilation [1,4-5].
o Consider use of tidal volume of less than 8 ml/kg [4-5].
•
Early progressive mobilization and ambulation [1,4-5,7].
•
Elevate the head of the bed 30-45 degrees including during patient transport [1,6,8,9].
•
Daily assessment of readiness to extubate with the use of sedation vacation and spontaneous breathing
trial.
o Conduct sedation vacation at least daily [1,6].
 Consider sedation vacation once per staffed shift.
o
Conduct spontaneous breathing trial [7] at least daily [1,9].
 Conduct immediately following sedation vacation [1].
 Consider spontaneous breathing trial once per staffed shift.
•
Daily oral care [1,5, 8-9] with chlorhexidine [5,9-14] or other comparable approved, evidence-based
antiseptic agent [15-20].
o Conduct oral care every 4 hours [5].
 Use antiseptic agent per manufacturer instructions.
•
Subglottic suctioning – use subglottic suctioning, continuous or intermittent, in patients expected to be
mechanically ventilated for >72 hours to prevent aspiration and the risk of ventilator-associated
pneumonia [1,5-6,8].
o Use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage by
continuous suctioning of tracheal secretions that accumulate in the subglottic area [1,5-6,8].
o If using intermittent suctioning, conduct regularly to achieve a continuous-like system [8].
•
Consider managing ventilated patients without sedation or with intermittent or minimal sedation whenever
possible [1,6,9,21].
References
1. Klompas M, Branson R, Eichenwald EC, et al. Strategies to Prevent Ventilator-Associated Pneumonia in
Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology. 2014;35:915-936.
Available at http://www.shea-online.org/PriorityTopics/CompendiumofStrategiestoPreventHAIs.aspx
2. Bonten MJM, Kollef MH, Hall JB. Risk Factors for Ventilator-Associated Pneumonia: From Epidemiology
to Patient Management. Clinical Infectious Diseases. 2004;38:1141-1149.
3. Sadfar N, Crnich CJ, Maki DG. The Pathogenesis of Ventilator-Associated Pneumonia: Its Relevance to
Developing Effective Strategies for Prevention. Respiratory Care. 2005;50:725-741.
4. Saguil A, Fargo M. Acute Respiratory Distress Syndrome: Diagnosis and Management. Am Fam
Physician. 2012;15:352-358. Available at http://www.aafp.org/afp/2012/0215/p352.html
5. Johns Hopkins Armstrong Institute for Patient Safety and Quality. CUSP for Mechanically Ventilated
Patients - Ventilator Associated Pneumonia (CUSP 4 MVP-VAP). Available at
https://armstrongresearch.hopkinsmedicine.org/vap/vap/resources.aspx
6. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of
adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Resp
Crit Care Med. 2005;171:388-416. Available at http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/HAP.pdf
7. Girard TD, Alhazzani W, Kress JP, et al. An Official American Thoracic Society/American College of
Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults.
Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J Respir Crit Care Med.
2016 Oct 20. [Epub ahead of print]
8. Tablan O. Guidelines for preventing health care-associated pneumonia, 2003: recommendations of CDC
and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep.
2004;53(RR03):1–36. Available at http://www.cdc.gov/hicpac/pdf/guidelines/HApneu2003guidelines.pdf
9. How-to Guide: Prevent Ventilator-Associated Pneumonia. Cambridge, MA: Institute for Healthcare
Improvement; 2012. Available at www.ihi.org
10. Chlebicki MP, Safdar N. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a metaanalysis. Crit Care Med. 2007;35(2):595-602.
11. Silvestri L, Weir I, Gregori D, et al. Effectiveness of oral chlorhexidine on nosocomial pneumonia,
causative microorganisms and mortality in critically ill patients: a systematic review and meta-analysis.
Minerva Anestesiol. 2014;80(7):805-20.
12. Klompas M, Speck K, Howell MD, et al. Reappraisal of routine oral care with chlorhexidine gluconate for
patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med.
2014;174(5):751-761.
13. DeRiso AJ 2nd, Ladowski JS, Dillon TA, et al. Chlorhexidine gluconate 0.12% oral rinse reduces the
incidence of total nosocomial respiratory infection and nonpro- phylactic systemic antibiotic use in
patients undergoing heart surgery. Chest. 1996;109(6):1556-1561.
14. Segers P, Speekenbrink RG, Ubbink DT, et al. Prevention of nosocomial infection in cardiac surgery by
decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized
controlled trial. JAMA. 2006;296(20):2460-2466.
15. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in
mechanically ventilated adults: systematic review and meta-analysis. BMJ. 2007;334(7599):889-993.
16. Pileggi C, Bianco A, Flotta D, et al. Prevention of ventilator-associated pneumonia, mortality and all
intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a metaanalysis of randomized controlled trials in intensive care units. Crit Care. 2011;15(3):R155.
17. Labeau SO, Van de Vyver K, Brusselaers N, et al. Prevention of ventilator-associated pneumonia with
oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis. 2011;11(11):845-854.
18. Tantipong H, Morkchareonpong C, Jaiyindee S, Thamlikitkul V. Randomized controlled trial and metaanalysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated
pneumonia. Infect Control Hosp Epidemiol. 2008;29(2):131-136.
19. Li J, Xie D, Li A, Yue J. Oral topical decontamination for preventing ventilator-associated pneumonia: a
systematic review and meta-analysis of randomized controlled trials. J Hosp Infect. 2013;84(4):283-293.
20. Shi Z, Xie H, Wang P, et al. Oral hygiene care for critically ill patients to prevent ventilator-associated
pneumonia. Cochrane Database Syst Rev. 2013;8:CD008367.
21. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and
delirium in adult patients in the ICU. Critical Care Medicine. 2013;41:263-306.
VAE Prevention Bundle Resources
American Association of Critical-Care Nurses. PracticeAlert. Ventilator-associated Pneumonia.
http://www.aacn.org/wd/practice/docs/practicealerts/vap.pdf
Health Research & Educational Trust, American Hospital Association, Partnership for Patients Ventilator
Associated Events (VAE) Change Package: Preventing Harm from VAE 2014 Update
http://www.hret-hen.org/index.php?option=com_content&view=article&id=10&Itemid=134
Health Research & Educational Trust. Ventilator Associated Events (VAE) Change Package: 2016 Update.
http://www.hret-hen.org/topics/vae/HRETHEN_ChangePackage_VAE.pdf
IHI How-to Guide: Prevent Ventilator-Associated Pneumonia
http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventVAP.aspx
AHRQ Safe Critical Care Project: Testing Improvement Strategies
Hospital Corporation of America (HCA) and Vanderbilt University collaborative to compare the effectiveness of
two approaches to implementing evidence-based medicine practices in Critical Care.
https://innovations.ahrq.gov/qualitytools/safe-critical-care-project-testing-improvement-strategies
Centers for Medicare & Medicaid Services Partnership for Patients Resources: Ventilator-associated
Pneumonia (VAP)
http://partnershipforpatients.cms.gov/p4p_resources/tsp-ventilator-associatedpneumonia/toolventilatorassociatedpneumoniavap.html