| Landrum ML, et al. USA 2007(11). |
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(12). |
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(13). |
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(14). |
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(15). |
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(16). |
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(17). |
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(18). |
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(19). |
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(20). |
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(21). |
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(22). |
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(23). |
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(24). |
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(25). |
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(26). |
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(27). |
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(28). |
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(29). |
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(30). |
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(31). |
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(32). |
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(33). |
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. |
Strategies for preventing ventilator-associated pneumonia: an integrative review