Essential practices
Confer minimal risk of harm and some data suggest that they may lower VAP rates, PedVAE rates, and/or duration of mechanical ventilation.
Avoid intubation.
1	Use noninvasive positive pressure ventilation (NIPPV) or high-flow oxygen by nasal cannula whenever safe and feasible. (Quality of evidence: MODERATE)
Minimize duration of mechanical ventilation.
1	Assess readiness to extubate daily using spontaneous breathing trials in patients without contraindications. (Quality of evidence: MODERATE)
2	Take steps to minimize unplanned extubations and reintubations. (Quality of evidence: LOW)
3	Avoid fluid overload. (Quality of evidence: MODERATE)
Provide regular oral care (ie, toothbrushing or gauze if no teeth). (Quality of evidence: LOW)
Elevate the head of the bed unless medically contraindicated. (Quality of evidence: LOW)
Maintain ventilator circuits.
1	Change ventilator circuits only when visibly soiled or malfunctioning (or per manufacturer’s instructions). (Quality of evidence: MODERATE)
2	Remove condensate from the ventilator circuit frequently and avoid draining the condensate toward the patient. (Quality of evidence: LOW)
Endotracheal tube selection and management
1	Use cuffed endotracheal tubes. (Quality of evidence: LOW)
2	Maintain cuff pressure and volume at the minimal occlusive settings to prevent clinically significant air leaks around the endotracheal tube, typically 20-25cm H2O. This “minimal leak” approach is associated with lower rates of post-extubation stridor. (Quality of evidence: LOW)
3	Suction oral secretions before each position change. (Quality of evidence: LOW)