Strategies for preventing ventilator-associated pneumonia: an integrative review

Alecrim, Raimunda Xavier; Taminato, Mônica; Belasco, Angélica; Longo, Maria Cristina Barbosa; Kusahara, Denise Miyuki; Fram, Dayana

doi:10.1590/0034-7167-2018-0473

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Revista Brasileira de Enfermagem

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Sumário

REVIEW • Rev. Bras. Enferm. 72 (2) • Mar-Apr 2019 • https://doi.org/10.1590/0034-7167-2018-0473 copy

Strategies for preventing ventilator-associated pneumonia: an integrative review

Estrategias para la prevención de la neumonía asociada a la ventilación mecánica: revisión integrativa

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

to identify studies about strategies for prevention of ventilator-associated pneumonia deployed in health services and classify their level of evidence.

Method:

integrative review of the literature, in 7 databases, which included the following descriptors: Prevention and Control AND Pneumonia Ventilator-Associated AND Intensive Care Units AND Bundle AND Patient Care.

Results:

twenty-three scientific productions were included. Of the preventive measures identified, 9 (39.1%) correspond from three to five strategies. The most frequent were: 22 (95.6%) lying with head elevated, 19 (82.6%) oral hygiene with chlorhexidine and 14 (60.8%) reduction of sedation whenever possible.

Final Consideration:

the application of measures based on scientific evidence is proven to be effective when carried out in conjunction, impacting the reduction of the incidence of ventilator-associated pneumonia.

Descriptors:
Disease Prevention; Ventilator-Associated Pneumonia; Patient Care Bundles; Intensive Care Unit; Nursing

Authors, place and date of publication	Objective	Type of study/Level of evidence	Preventive measures and interventions	Outcome/Conclusions
Landrum ML, et al. USA 2007⁽¹¹11 Landrum ML, Murray CK. Ventilator associated pneumonia in a military deployed setting: the impact of an aggressive infection control program. J Trauma [Internet]. 2008 [cited 2018 Sep 6];64(Suppl):S123-8. Available from: https://pdfs.semanticscholar.org/6a7e/0cecd348f16a01cf4b4e6ebbbcd94edc5f37.pdf https://pdfs.semanticscholar.org/6a7e/0c... ⁾.	To analyze the impact of a VAP prevention program in the ICU of an Iraqi Hospital.	Observational study/ III	Hand hygiene. Oral hygiene with chlorhexidine. Reduction in the duration and range of action of surgical prophylaxis. Cohort of patients in contact precaution and professionals. Periodically barring beds for cleaning and disinfection. Daily inspections of procedures related to VAP prevention.	Reduction in VAP rate from 60.6/1000 MV-day to 9.7/1000 MV-day.
BlamounJ, et al. USA 2008⁽¹²12 Blamoun J, Alfakir M, Rella ME, Wojcik JM, Solis RA, Anees Khan M, et al. Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit. Am J Infect Control [Internet]. 2009 [cited 2018 Sep 6];37(2):172-5. Available from: https://sci-hub.tw/10.1016/j.ajic.2008.05.010 https://sci-hub.tw/10.1016/j.ajic.2008.0... ⁾.	To assess the reduction in VAP incidence, after implementation of a prevention protocol in the ICU of a university hospital.	Observational study/ III	Elevated headboard. Daily awakening. Prophylaxis for deep vein thrombosis. Prophylaxis for stress ulcer.	Reduction in VAP rate from 14.1/1000 MV-day to near-zero VAP rate for 30 months.
Marra AR, et al.Brazil, 2009⁽¹³13 Marra AR, Cal RGR, Silva CV, Caserta RA, Paes AT, Moura Jr DF, et al. Successful prevention of ventilator-associated pneumonia in an intensive care setting. Am J Infection Control [Internet]. 2009 [cited 2018 Sep 8];12(1). Available from: https://sci-hub.tw/10.1016/j.ajic.2009.03.009 https://sci-hub.tw/10.1016/j.ajic.2009.0... ⁾.	To evaluate the effect of the implementation of a VAP prevention bundle on the reduction of its occurrence.	Quasi-experimental study/ II	Elevation of the headboard. Reduction of sedation and evaluation for extubation. Prophylaxis for peptic ulcer. Prophylaxis for deep vein thrombosis. Replacement of circuits and humidifiers when necessary. Proper drainage and disposal of the circuits' condensate. Use of heat and moisture filter Oral hygiene with 0.12% chlorhexidine. Continuous aspiration of subglottic secretions.	The density of VAP incidence ranged from 1.3/1000 MV-day to zero when adherence to the measures was greater than 95%. Mortality ranged from 83.3% to 100% for patients with VAP and the rate of use of MV decreased from 28% to 27%
ZaydfudimV, et al. USA 2009⁽¹⁴14 Zaydfudim V, Dossett LA, Starmer JM, Arbogast PG, Feurer ID, Ray WA, et al. Implementation of a real-time compliance dashboard to help reduce SICU ventilator-associated pneumonia with the ventilator bundle. Arch Surg [Internet]. 2009 [cited 2018 Sep 6];144(7):656-62. Available from: https://sci-hub.tw/10.1001/archsurg.2009.117 https://sci-hub.tw/10.1001/archsurg.2009... ⁾.	To implement electronic monitoring and assess the impact on adherence to preventive measures and VAP rate in a surgical ICU.	Observational study/ III	Implementation of the electronic panel. Spontaneous breathing test. Titration of sedation and analgesia. Elevation of the bed's headboard. Oral hygiene and hypopharyngeal aspiration. Prophylaxis for stress ulcer. Prophylaxis for deep vein thrombosis.	The average adherence to the VAP prevention bundle went from 39% to 89% and VAP incidence decreased from 15.2 to 9.3/1000 MV-day.
Bouadma L,et al. France 2010⁽¹⁵15 Bouadma L, Deslandes E, Lolom I, Le Corre B, Mourvillier B, Regnier B, et al. Long term impact of a multifaceted prevention program on ventilator associated pneumonia in a medical intensive care unit. Clin Infect Dis [Internet]. 2010 [cited 2018 Sep 6];51(10):1115-22. Available from: https://sci-hub.tw/10.1086/656737 https://sci-hub.tw/10.1086/656737... ⁾.	To describe the long-term impact of a multifaceted program to reduce VAP incidence.	Experimental study/ II	Hand hygiene. Proper use of gloves. Elevation of the headboard between 30-45° Keeping cuff pressure > 20 cm H₂O Using an orotracheal tube rather than a nasotracheal one Preventing gastric distension Oral hygiene with 0.12% chlorhexidine 4 times a day; Not using a continuous suction tube routinely.	Reduction in VAP rate from 22.6 to 13.1 cases/1000 MV-day, representing a 43% reduction.
Tawfiq AAJ,et al. Asia 2010⁽¹⁶16 Al-Tawfiq JA, Abed MS. Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle. Am J Infect Control [Internet]. 2010 [cited 2018 Sep 6];38(7):552-6. Available from: https://sci-hub.tw/10.1016/j.ajic.2010.01.008 https://sci-hub.tw/10.1016/j.ajic.2010.0... ⁾.	To deploy the intervention bundle, with the goal of reducing VAP incidence in an adult ICU.	Observational study/ III	Elevation of the bed's headboard Daily interruption of sedation. Assessment of readiness for extubation. Prophylaxis for peptic ulcer. Prophylaxis for deep vein thrombosis.	Reduction in VAP rate from 9.3/1000 MV-day to 2.2/1000 MV-day.
Mona B, et al. USA 2010⁽¹⁷17 Bingham M, Ashley J, De Jong M, Swift C. Implementing a unit-level intervention to reduce the probability of ventilator-associated pneumonia. Nurs Res [Internet]. 2010 [cited 2018 Sep 6];59(Suppl):S40-7. Available from: https://scihub.tw/10.1097/NNR.0b013e3181c3bffc https://scihub.tw/10.1097/NNR.0b013e3181... ⁾.	To evaluate the effectiveness of specific interventions for VAP prevention in five ICUs, improving adherence to preventive measures and decreasing VAP incidence and number of MV days.	Observational study/ III	Hand hygiene. Elevated headboard. Oral hygiene. Educational interventions	There was no significant reduction in the following indicators: VAP rate, MV time and adherence to preventive measures
Stone P, et al. New York 2011⁽¹⁸18 Pogorzelska M, Stone PW, Furuya EY, Perencevich EN, Larson EL, Goldmann D, et al. Impact of the ventilator bundle on ventilator-associated pneumonia in intensive care unit. Int J Qual Health Care [Internet]. 2011 [cited 2018 Sep 6];23(5):538-44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168266/pdf/mzr049.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾.	To determine the effectiveness of isolated interventions in VAP incidence;To determine the effectiveness of at least two interventions for reduction of the VAP rates.	Observational study/ III	Elevation of the headboard. Daily awakening from sedation. Prevention of stress ulcer. Prevention of deep vein thrombosis	The average VAP rate was 2.7 cases/1000 MV-day. Among the units, 39% reported adequate adherence to the intervention bundle.
Tao L, et al. China 2012⁽¹⁹19 Tao L, Hu B, Rosenthal VD, Zhang Y, Gao X, He L. Impact of a multidimensional approach on ventilator-associated pneumonia rates in a hospital of Shanghai: findings of the International Nosocomial Infection Control Consortium. J Crit Care [Internet]. 2012 [cited 2018 Sep 6];27(5):440-6. Available from: https://sci-hub.tw/10.1016/j.jcrc.2011.12.018 https://sci-hub.tw/10.1016/j.jcrc.2011.1... ⁾.	To analyze the impact of a multimodal approach for reduction of VAP in 3 ICUs of a Chinese hospital.	Observational study/ III	Education, surveillance of outcomes and process, feedback on the VAP rates and practices for evaluation of infection control. Elevated headboard; Oral hygiene with chlorhexidine. Hand hygiene.	The VAP rate in the 1st phase of the study was 24.1 cases/1000 MV-day, and decreased to 5.7, which represents a 79% cumulative reduction which was maintained for the 3 following years. Significant reduction of the average mortality rate.
Caserta RA, et al. Brazil 2012⁽²⁰20 Caserta RA, Marra AR, Durão MS, Silva CV, Pavão SOF, Neves HSS, et al. A program for sustained improvement in preventing ventilator associated pneumonia in an intensive care setting. BMC Infect Dis [Internet]. 2012 [cited 2018 Sep 6];12:234. Available from: https://doi.org/10.1186/1471-2334-12-234 https://doi.org/10.1186/1471-2334-12-234... ⁾.	To evaluate the VAP rates after application of multiple interventions.	Quasi-experimental study/ II	Active surveillance of VAP.Surveillance of adherence to hand hygiene. Elevated headboard Weaning protocols. Oral hygiene with antiseptic solution. Use of non-invasive ventilation whenever possible. Preferred use of orotracheal tube. Keeping cuff pressure at 20 cm H₂O. Removal of condensate from the circuits. Replacement of the fan's circuit and humidifier only when visiblydirty or malfunctioning. Prevention of gastric overdistention. Use of gastric protectors. Use of sterile water for rinsing respiratory equipment.	VAP rates ranged from 1.3 to 2.0/1000 MVday, reaching zero VAP incidence whenever adherence to the bundle was greater than 90%.
Gonçalves FAF, et al. Brazil 2012⁽²¹21 Gonçalves FAF, Brasil VV, Ribeiro LCM, Tipple AFV. Nursing actions for the prevention of ventilator-associated pneumonia. Acta Paul Enferm [Internet]. 2012 [cited 2018 Sep 6];25(Spec):101-07. Available from: http://www.scielo.br/pdf/ape/v25nspe1/16.pdf http://www.scielo.br/pdf/ape/v25nspe1/16... ⁾.	To determine the effectiveness of educational strategies to improve the performance of the nursing staff in carrying out selected procedures for VAP prevention.	Experimental study/ II	Cleaning, disinfection, assembly and testing of fan. Proper handling of ventilation circuits. Replacement and handling of humidifiers. Verification of cuff pressure. Positioning on the bed. Bronchial hygiene. Oral hygiene. Proper handling of enteral probe. Hand hygiene.	The intervention was effective for some measures evaluated. The team members did not carry out all selected interventions for VAP prevention.
Ajenjo MC, et al. Chile 2013⁽²²22 Ajenjo MC, Zambrano A, Eugenin ML, Achurra P, Zalaquett R, Irarrázaval MJ, et al . Reducción de incidencia de neumonía asociada a ventilación mecánica post cirugía cardíaca: experiencia de 13 años de vigilancia epidemiológica en un hospital universitario. Rev Chil Infectol [Internet]. 2013 [cited 2018 Sep 5];30(2):129-34. Available from: https://scielo.conicyt.cl/pdf/rci/v30n2/art02.pdf https://scielo.conicyt.cl/pdf/rci/v30n2/... ⁾.	Evaluate general and specific interventions implemented to reduce the incidence of VAP in cardiac surgery postoperative ICUs.	Observational study/ III	Use of hand sanitizer for hand hygiene. Contact precaution for patients colonized and/or infected by multidrug-resistant bacteria. Periodic supervision of the measures implemented by the HICC nurses. Training of nurses in the sector to carry out the cleaning, disinfection and sterilization of the MV equipment, replacing the service that was provided by an external company. Early extubation. Proper handling of secretions, transportation and maintenance of ventilation devices Elevated headboard. Periodic meetings with the healthcare team about surveillance of process and outcomes for creation of a VAP prevention plan.	Significant reduction in VAP rates from 56.7 cases/1000 MV-day to 4.7 cases/1000 MV-day.
Garcell HG, et al. Cuba 2013⁽²³23 Guanche-Garcell H, Morales-Pérez C, Rosenthal VD. Effectiveness of a multidimensional approach for the prevention of ventilator-associated pneumonia in an adult intensive care unit in Cuba: Findings of the International Nosocomial Infection Control Consortium (INICC). J Infect Public Health [Internet]. 2013 [cited 2018 Sep 6];6(2):98-107. Available from: https://sci-hub.tw/10.1016/j.jiph.2012.11.009 https://sci-hub.tw/10.1016/j.jiph.2012.1... ⁾.	To evaluate the effect of preventive measures on the VAP rates in microorganisms isolated from a Cuban ICU.	Observational study/ III	Education, surveillance of process and outcome, active VAP surveillance, feedback on VAP rates. Adherence to hand hygiene Sedation weaning protocols. Oral hygiene with antiseptic solution. Use of non-invasive ventilation. Use of an orotracheal tube rather than a nasotracheal one. Keeping cuff pressure at 20 cm H₂O. Proper removal of condensate from the circuit and replacement only if necessary. Prevention of gastric distension with medicines. Use of sterile water in the reprocessing of respiratory materials.	The VAP rates were reduced from 53.4 cases/1000 MV-day to 5.4 cases/1000 MV-day, which corresponds to a 90% reduction over time. The isolated bacteria included Acinetobacter spp. and Pseudomonas aeruginosana in phase 1 and Klebsiella spp in phase 2.
Souza AF, et al. Brazil 2013⁽²⁴24 Souza AF, Guimarães AC, Ferreira EF. Evaluation of the implementation of new protocol of oral hygiene in an intensive care center for prevention of pneumonia associated with mechanical ventilation. Rev Min Enferm [Internet]. 2013 [cited 2018 Sep 6];17(1):177-84. Available from: http://reme.org.br/artigo/detalhes/588 http://reme.org.br/artigo/detalhes/588... ⁾.	To include oral hygiene and dental care in the standardized bundle and evaluate the outcomes associated with VAP prevention.	Observational study/ III	Elevated headboard. Evaluation for sedation and extubation. Prophylaxis for stress ulcer. Prophylaxis for deep vein thrombosis. Oral hygiene and dental care.	Reduction of VAP from 33.3% to 3.5%.
RelloJ, et al. Spain 2013⁽²⁵25 Rello J, Afonso E, Lisboa T, Ricart M, Balsera B, Rovira A, FADO Project Investigators: a care bundle approach for prevention of ventilator-associated pneumonia. Clin Microbiol Infect [Internet]. 2013 [cited 2018 Sep 6];19(4):363-9. Available from: https://sci-hub.tw/10.1111/j.1469-0691.2012.03808.x https://sci-hub.tw/10.1111/j.1469-0691.2... ⁾.	To evaluate the impact of the care bundle on VAP incidence, MV time, rate of stay in five Spanish ICUs and adherence to isolated preventive measures.	Observational study/ III	Replacement of the fan's circuit only if dirty. Daily sedation control. Hand hygiene with an antiseptic solution before handling the airways. Oral hygiene with 0.12% chlorhexidine every 8 hours. Cuff pressure control.	Reduction in VAP incidence from 12.9/1000 MV-day to 9.28/1 MV-day. Decrease of MV days from 8.0 to 4.0 days. Decrease of length of stay in the ICU from 10 to 6 days. The isolated measures with the highest rate of compliance were: replacement of the ventilatory circuit when necessary (34%), sedation control (27%), oral hygiene (21%) and hand hygiene (19%). Cuff pressure control was carried out in only 18%. For cases where there was no adherence to the complete bundle, VAP incidence was 19.5/1000 MV-day.
Mehta Y, et al. India 2013⁽²⁶26 Mehta Y, Jaggi N, Rosenthal VD, Rodrigues C, Todi SK, Saini N, et al. Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC). Epidemiol Infect [Internet]. 2013 [cited 2018 Sep 6];141(12):2483-91. Available from: https://sci-hub.tw/10.1017/S0950268813000381 https://sci-hub.tw/10.1017/S095026881300... ⁾.	To evaluate the effectiveness of a multimodal approach for VAP prevention in 21 ICUs of 10 Indian cities and the profile of isolated microorganisms.	Observational study/ III	Intervention bundle for infection control,education and surveillance of process and outcome. Feedback on VAP rates and performance of infection control practices. Adherence to hand hygiene guidelines and direct observation of hand hygiene. Headboard elevated to 30-45°. Daily assessment of sedation for extubation and oral hygiene with antiseptic solution. Use of non-invasive ventilation and minimization of MV time. Preferred use of orotracheal tube. Maintenance of cuff pressure at 20 cm H₂O. Proper removal of condensate from the ventilation circuits. Replacement of the fan's circuit only when visibly dirty or malfunctioning. Prevention of gastric overdistention. Use of gastric protectors. Use of sterile water for rinsing in the reprocessing of articles.	The VAP rate went from 17.43/MV-1000 day to 10.8/MV-1000 day, totaling a 38% reduction. Pseudomonas aeruginosa, Acinetobacter spp. and Klebsiella spp. accounted for 80% of isolated bacteria.
Ongstad SB , et al. USA 2013⁽²⁷27 Ongstad SB, Frederickson TA, Peno SM, Jackson JA, Renner CH, Sahr SM. Assessment of the implementation of a protocol to reduce ventilator-associated pneumonia in intensive care unit trauma patients. J Trauma Nurs [Internet]. 2013 [cited 2018 Sep 6];20(3):133-8. Available from: https://sci-hub.tw/10.1097/JTN.0b013e3182a171e3 https://sci-hub.tw/10.1097/JTN.0b013e318... ⁾.	To assess the implementation of a protocol to reduce VAP incidence in trauma patients and days of stay in the ICU	Observational study/ III	Elevated headboard. Daily spontaneous breathing test. Daily awakening and evaluation of readiness for extubation. Prophylaxis for deep vein thrombosis and peptic ulcer. Hand hygiene before and after contact with the patient. Oral hygiene with antiseptic solution. Individual breathing equipment, new or sterilized.	Decrease in VAP incidence, even with increased rates of MV use. Reduction in days of stay in the ICU from 8.28 to 6.21 days.
Sachetti A, et al. Brazil 2014⁽²⁸28 Sachetti A, Rech V, Dias AS, Fontana C, Barbosa GL, Schlichting D. Adesão às medidas de um bundle para prevenção de pneumonia associada à ventilação mecânica. Rev Bras Ter Intensiva [Internet]. 2014 [cited 2018 Sep 5];26(4):355-9. Available from: http://www.scielo.br/pdf/rbti/v26n4/0103-507X-rbti-26-04-0355.pdf http://www.scielo.br/pdf/rbti/v26n4/0103... ⁾.	To assess adherence to the MV bundle in an ICU, and the impact on the VAP rates, after an educational intervention.	Experimental study/ II	Educational intervention. Elevated headboard Positioning of the humidifier above the trachea. Control of presence of liquid in the circuit and humidifier. Oral hygiene three times a day, with chlorhexidine. Daily maintenance ofcuff pressure between 20 and 30cm H₂O. Respiratory physical therapy three times a day.	Increased adherence to individual measures and to the bundle. There was no impact onVAP incidence.
Granda MJP, et al. Spain 2014⁽²⁹29 Pérez-Granda MJ, Barrio J, Muñoz P, Hortal J, Rincón C, Bouza E. Impact of four sequential measures on the prevention of ventilator-associated pneumonia in cardiac surgery patients. Critical Care [Internet]. 2014 [cited 2018 Sep 6];18(2):R53. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056787/pdf/cc13799.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾.	To evaluate the impact of deployment of four VAP prevention measures in a cardiac surgery ICU, on VAP rates, MV days, costs and use of antimicrobials	Observational study/ III	Specific training program. Aspiration of subglottic secretions. Positioning of the patient. Oral hygiene with chlorhexidine.	41% reduction in VAP incidence.Reduction in the VAP-related mortality rate from 13.0% to 10.2%.Reduction in expenditure on antimicrobials from 70.612/1000 days of stay to 52.775/1000 days of stay in the ICU.
Eom JS, et al. Korea 2014⁽³⁰30 Eom JS, Lee MS, Chun HK, Choi HJ, Jung SY, Kim YS, et al. The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study. Am J Infect Control [Internet]. 2014 [cited 2018 Sep 6];42(1):34-7. Available from: https://sci-hub.tw/10.1016/j.ajic.2013.06.023 https://sci-hub.tw/10.1016/j.ajic.2013.0... ⁾.	To assess the impact of some preventive measures that were already part of the routine of ICUs in 6 Korean hospitals.	Experimental Study/ II	Educational training on the bundle. Elevation of the bed's headboard. Prophylaxis for peptic ulcer. Prophylaxis for deep vein thrombosis. Oral hygiene with 0.12% chlorhexidine. Continuous aspiration of subglottic secretions, when available.	Reduction in VAP incidence from 4.08 cases/1000 MV-dayto 1.16 cases/1000 MV-day. Incidence density decreased 0.28 times.
Lim KP, et al. Taiwan 2015⁽³¹31 Lim KP, Kuo SW, Ko WJ, Sheng WH, Chang YY, Hong MC, et al. Efficacy of ventilator-associated pneumonia care bundle for prevention of ventilator-associated pneumonia in the surgical intensive care units of a medical center. J Microbiol Immunol Infect [Internet]. 2015 [cited 2018 Sep 6];48(3):316-21. Available from: https://sci-hub.tw/https://doi.org/10.1016/j.jmii.2013.09.007 https://sci-hub.tw/https://doi.org/10.10... ⁾.	To evaluate the effectiveness of a set of measures for reduction of the VAP rates, global compliance with measures, use of fan and stay in the ICU.	Observational study/ III	Bed's headboard elevated to 45°. Daily awakening or sedation weaning. Prophylaxis for stress ulcer. Prophylaxis for deep vein thrombosis. Oral hygiene with chlorhexidine. Hand hygiene before and after the procedures. Cuff pressure between 20-25cm H₂O. Oral hygiene before the change in decubitus. Sterilization of respiratory materials. Use of sterile water on respiratory devices. Well-defined indication for intubation.	VAP density decreased from 3.3 to 1.4 1000 MV-dayRates of global compliance with VAP prevention items for doctors, nurses and physical therapists were 97.9%, 80.3% and 73.7%, respectively. There was no difference in the length of stay in the ICU; however, the fan's use decreased from 1148.5 days to 956.1 days.
Rodrigues AN, et al. Brazil 2016⁽³²32 Rodrigues AN, Fragoso LVC, Beserra FM, Ramos IC. Determining impacts and factors in ventilator-associated pneumonia bundle. Rev Bras Enferm [Internet]. 2016 [cited 2018 Sep 5];69(6):1108-14. Available from: http://www.scielo.br/pdf/reben/v69n6/en_0034-7167-reben-69-06-1108.pdf http://www.scielo.br/pdf/reben/v69n6/en_... ⁾.	To assess the impact of the bundle, the determining factors that influence compliance with the VAP prevention measures in an ICU, the profile of microorganisms and mortality rate.	Observational study/ III	Daily interruption of sedation. Headboard elevated from 30° to 45°. Enteral nutrition care. Use of neuromuscular blockers. Maintaining cuff pressure between 25-35°. Oral hygiene with 0.12% aqueous chlorhexidine.	Increase in VAP incidence after implementation of the bundle from 11.53 to 16.42/1000MV-day. Prevalence of gram-negative bacteria Acinetobacter spp. and Pseudomonas spp. in the first phase and Klebsiella spp after implementation of the bundle. Mortality rate was 50%.
Ferreira CR, et al. Brazil 2016⁽³³33 Ferreira CR, Souza DF, Cunha TM, Tavares M, Reis SSA, Pedroso RS, et al. The effectiveness of a bundle in the prevention of ventilator-associated pneumonia. Braz J Infect Dis [Internet]. 2016 [cited 2018 Sep 6];20(3):267-71. Available from:http://www.scielo.br/pdf/bjid/v20n3/1413-8670-bjid-20-3-0267.pdf http://www.scielo.br/pdf/bjid/v20n3/1413... ⁾.	To assess the impact of a VAP prevention bundle called fasthug on costs and VAP-related mortality rates in an ICU.	Observational study/ III	Enteral nutrition care.Promotion of analgesia.Reduction of sedation. Elevated headboard. Prophylaxis for deep vein thrombosis. Prophylaxis for stress ulcer. Capillary glucose control. Oral hygiene with 0.12% chlorhexidine. Cuff pressure between 20-25cm H₂O. Subglottic aspiration every 6 hours and whenever necessary.	Considerable reduction in VAP incidence and 64% reduction in VAPrelated mortality. Significant reduction in hospital ICU costs and improvement in the quality of care.

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[1] Corresponding Author: Raimunda Xavier Alecrim E-mail: raimundaalecrim@bol.com.br