Table 2.

Summary of Recommendations to Prevent VAP and/or VAE in Adult Patients

Category	Rationale	Intervention	Quality of Evidence
Essential practices	Good evidence that the intervention decreases the average duration of mechanical ventilation, length of stay, mortality, and /or costs. Benefits likely outweigh risks.	Avoid intubation and prevent reintubation • Use high-flow nasal oxygen or noninvasive positive pressure ventilation (NIPPV) as appropriate whenever safe and feasible91–93,96,99	HIGH
		Minimize sedation105,106 • Avoid benzodiazepines in favor of other agents106 • Use a protocol to minimize sedation110 • Implement a ventilator liberation protocol113	MODERATE
		Maintain and improve physical conditioning113,120–123	MODERATE
		Elevate the head of the bed to 30–45°125,388–390	LOWa
		Provide oral care with toothbrushing but without chlorhexidine126,127	MODERATE
		Provide early enteral vs. parenteral nutrition131	HIGH
		Change the ventilator circuit only if visibly soiled or malfunctioning (or per manufacturers’ instructions)391–394	HIGH
Additional approaches	Good evidence that the intervention improves outcomes in some populations, but may confer some risk in others.	Use selective oral or digestive decontamination in countries and ICUs with low prevalence of antibiotic-resistant organisms128,134,135	HIGHa
	May lower VAP rates but insufficient data to determine impact on duration of mechanical ventilation, length of stay, or mortality.	Utilize endotracheal tubes with subglottic secretion drainage ports for patients expected to require >48–72 hours of mechanical ventilation395	MODERATE
		Consider early tracheostomy144	MODERATE
		Consider postpyloric rather than gastric feeding for patients with gastric intolerance or at high risk for aspiration131,147	MODERATE
Generally not recommended	Inconsistently associated with lower VAP rates and no impact or negative impact on duration of mechanical ventilation, length of stay, or mortality.	Oral care with chlorhexidine75,128–130,150	MODERATE
		Probiotics153–156	MODERATE
		Ultrathin polyurethane endotracheal tube cuffs165–167	MODERATE
		Tapered endotracheal tube cuffs169	MODERATE
		Automated control of endotracheal tube cuff pressure170,171,174,175	MODERATE
		Frequent cuff-pressure monitoring176	MODERATE
		Silver-coated endotracheal tubes178	MODERATE
		Kinetic beds180	MODERATE
		Prone positioning181,183,a	MODERATE
		Chlorhexidine bathing184–186,a	MODERATE
	No impact on VAP rates, average duration of mechanical ventilation, length of stay, or mortality.a	Stress-ulcer prophylaxis190,191,193	MODERATE
		Monitoring residual gastric volumes194	MODERATE
		Early parenteral nutrition195	MODERATE
No recommendation	No impact on VAP rates or other patient outcomes, unclear impact on costs.	Closed endotracheal suctioning systems197–199	MODERATE

Note. VAP, ventilator-associated pneumonia.

^aMay be indicated for reasons other than VAP prevention.