Table 29.3.

Recommendations from the Society of Healthcare Epidemiology of America and the Infectious Disease Society of America’s 2014 updated recommendations for VAP prevention [39]

Recommendation	Level of recommendation
Minimizing sedation and assessing readiness to extubate daily through pairing spontaneous breathing trials and spontaneous awakening trials, which have been shown in two randomized control trials and one meta-analysis to reduce length of stay and duration of mechanical ventilation [47–50]	High
Instituting early mobilization and physical therapy, which has been shown to decrease length of stay and improve earlier return to independent function [51]	Moderate
Implementing strategies to reduce pooling of secretions above the endotracheal tube cuff, such as using endotracheal tubes with subglottic suctioning for patients requiring mechanical ventilation of 48 h or more [52–54]. A meta-analysis demonstrated reduction in VAP rates and length of mechanical ventilation [55]	Moderate
Changing ventilator circuits only when needed rather than on a schedule, which does little to decrease VAPs but does reduce costs [56]	High
Making use of noninvasive positive pressure ventilation (NIPPV) whenever possible, but only in the populations which have been shown to have some benefit (e.g. in chronic obstructive pulmonary disease or cardiogenic pulmonary edema) [57]. This recommendation, however, cautions use of NIPPV that may delay intubation, such as profound hypoxemia, acute respiratory distress syndrome or impaired consciousness [58]	High
Keeping the head of the bed elevated to at least 30°, which has only been shown to decrease VAP rates in one of three randomized control trials, but has little downside [59–61]	Low