Prophylaxis of Ventilator-Associated Pneumonia

mass. such such as training in in addition to caloric caloric mass. as exercise exercise training addition to restriction, for for the the primary primary and and secondary secondary prevention of restriction, prevention of CV diseases. diseases. CV Carl Lavie, MD, MD, FCCP FCCP Carl j. j. Lavie, Hector O. MD O. Ventura, MD Richard V. V. Milani, MD MD New Orleans, LA LA Dr. Lavie Lavie is Dr. is Medical Medical Director, Director, Cardiac Cardiac Rehabilitation Rehabilitation and and PrePreCenvention, vention, Director, Director, Exercise Exercise Laboratories, Laboratories, Ochsner Ochsner Medical Medical Center. Dr. Dr. Ventura Ventura is Chairman of of Graduate Graduate Medical is Chairman Medical Education, Education, ter. and of Advanced Heart Failure Failure and and Transplantation, Transplantation, Advanced Healt and Director Director of Vice Chairman, Chairman, DepartDepartOchsner Medical Center. Center. Dr. Dr. Milani Milani is is Vice Ochsner Medical ment of of Cardiovascular Cardiovascular Diseases, Diseases, Ochsner Ochsner Medical Medical Center. Center. ment reported to to the the ACCP ACCP that that no no signiflcant signiflcant The authors authors have have reported The conflicts of interest exist with any any companies/organizations of interest exist with companies/organizations whose whose conflicts products products or or services selvices may may be be discussed discussed in in this this article. artie,le. written pennission pennission Reproduction of this this article article is prohibited without without written Reproduction of is prohibited from the the American American College College of of Chest Chest Physicians Physicians (www.chestjoumal. (www.cliestjoumal, from orglmisc!reprints.shtml). orglmisc!reprints.shtml). Correspondence J. Lavie, Lavie, MD, MD, FCCP, FCCP, Medical Medical Director, Director, to: Carl Carl J. Correspondence to: Cardiac Rehabilitation Rehabilitation and and Prevention, Prevention, Director, Director, Exercise Exercise LaboLaboCardiac ratories, Ochsner Ochsner Medical Medical Center, Center, 1514 1514 Jefferson Jefferson Hwy, Hwy, New New ratories, Orleans, LA LA 70121-2483; 70121-2483; e-mail: e-mail: [email protected] [email protected] Orleans, DOl: 10.1378/chest.08-1673 10.1378/chest.08-1673 DOl:

REFERENCES REFERENCES Lavie CJ, CJ, Milani Obesity and and cardiovascular Lavie Milani RV. RV. ObeSity cardiovascular disease: disease: the Hippocrates Hippocrates paradox? Am ColI ColI Cardiol2003; Cardiol2003; 42:67742:677the paradox? JJ Am 679 679 Lavie CJ, CJ, Milani Milani RV, et a!. effects of of 22 Lavie RV, Ventura Ventura HO, HO, et a!. Disparate Disparate effects left ventricular geometry and obesity on on mortality left ventricular geometry and obesity mortality in in patients patients with Am JJ Cardiol Cardiol with preserved preserved left left ventricular ventricular ejection ejection fraction. fraction. Am 2007; 100:1460-1464 100:1460-1464 2007; Lavie CJ, CJ, Morshedi-Meibodi Morshedi-Meibodi A, Milani RV. Impact of of cardiac cardiac A, Milani RV. Impact 33 Lavie rehabilitation on coronary rehabilitation on coronary risk risk factors, factors, inflammation, inflammation, and and the the metabolic in obese coronmy patients. patients. JJ CardiomCardiommetabolic syndrome syndrome in obese coronmy 3:136-140 etab Syndr Syndr 2008; 2008; 3:136-140 etab Lavie CJ, CJ, Mehra Mehra MR, Milani RV. Obesity and and heart heart failnre failure 44 Lavie MR, Milani RV. Obesity prognosis: paradox paradox of of reverse epidemiology? Eur Eur Heart Heart JJ prognosis: reverse epidemiology? 200,5; 26:5-7 26:5-7 200,5; 55 Lavie Lavie CJ, CJ, Artham Artham SM, SM, Milani Milani RV, RV, et et a!. a!. The The obesity obesity paradox: paradox: impact of obesity on the the prevalence and prognosis prognosis of obeSity on prevalence and of cardiocardioimpact of vascular 120:34-41 vascular diseases. diseases. Postgrad Postgrad Med Med 2008; 2008; 120:34-41 Lavie CJ, CJ, Milani Milani RV, Ventura HO. 66 Lavie RV, Ventura HO. Obesity, Obesity, heart heart disease, disease, and and favorable or paradox? Am JJ Med 2007; 2007; favorable prognosis: prognosis: truth truth or paradox? Am 120:82.5- 826 120:82.5826 77 Romero Corral A, A, Lopez-Jimenez Lopez-Jimenez F, F, Sierra-Johnson Sierra-Johnson J, J, et et al, a!. Romero Corral DifIerentiating between and lean lean mass: mass: how how should should DifIerentiating between body body hit hit and we measure measure obesity? obesity? Nat Nat Clin Clin Pract Pract Endocrinol Endocrinol Metab Metab 2008; 2008; we 4:322-333 4:322-333 Lavie CJ, CJ, Osman Osman AF, AF, Milani Milani RV, 88 Lavie RV, et et a!. a!. Body Body composition composition and and prognosis heart failure: failure: the the obesity obesity paradox. paradox. prognosis in in chronic chronic systolic systolic heart Am 91:891-894 Am JJ Cardiel Cardiol 2003; 2003; 91:891-894 Galal W, van Gestel Gestel Y, Hoeks SE, The obeSity obesity paradox W, van Y, Hoeks SE, et et a!. a!. The paradox 99 Galal in peripheral artelial arterial (lisease. disease, Chest 2(Xl8; 134: in patients patients with with peripheral Chest 2(Xl8; 134: 925-930 925-930 Allison DB, DB, Zannolli R, Faith Faith MS, MS, et et a!. a!. Weight Weight loss loss increases increases 10 Allison Zannolli R, and fat fat loss loss decreases decreases all-cause all-cause mortality mortality rates: rates: results results from from and two independent independent cohort cohort shl(hes. studies, 1nt 1nt JObes JObes Relat Relat Metab Metab two Disord 1999; 1999; 23:603-611 23:603-611 Disord 11 Eldar M, Goldbourt U. U. Association Association of of inteninten11 Eilat-Adar Eilat-Adar S, S, Eldar M, Go!dbourt heart disease disease tional changes changes in in body weight with with coronary coronary heart tional body weight event rates rates in in overweight overweight subjects subjects who event who have have an an additional additional coronary 161:3.52-3.58 coronary risk risk factor. factor. Am Am JJ Epidemiol 200.5; 200.5; 161:3.52-3.58

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12 Blair Blair SN, SN, Church Church TS. TS. The The fitness, fitness, obesity, obesity, and health equaequa12 and health tion: is is physical physical activity activity the the common common denominator? denominator? JAM JAMA tion: A 2004; 292:1232-12:34 2004; 292:1232-12:34

Prophylaxis of of VentilatorVentilatorProphylaxis Associated Pneumonia Pneumonia Associated Changing Culture Culture and and Strategies Strategies to to Changing Trump Disease Disease Trump "Failure is success if you learn learn from from it." it." "Failure is success if you Malcolm Forbes Forbes Malcolm

lacement of an endotracheal tube (ETT) inP creases P a patient's risk of pneumonia 6-fold to

lacement of an endotracheal tube (ETT) increases a patient's risk of pneumonia 6-fold to bacteria colonizing colonizing the the oropharorophar20-fold by by providing 20-fold providing bacteria ynx aa convenient, convenient, one-way one-way path path around around the the ETT ETT cuff cuff ynx I - ?4 Crude into the the lower lower respiratory respiratory tract. tract.Jr Crude mortality mortality into rates for for ventilator-associated ventilator-associated pneumonia pneumonia (VAP) (VAP) range range rates per from 60% with of $40,000 $40,000 per from 20 20 to to 60% with an an estimated estimated cost cost of episode.l-' Many Many of of these these poor poor outcomes outcomes result from episode.1.2 result from system failures failures that that are are preventable with changes changes in in system preventable with 2 ,.3.5 hospital culture. culture. 2 hospital A crucial crucial target target for for VAP A VAP prophylaxis prophylaxiS is is reducing reducing the number number of of pathogenic bacteria colonizing colonizing the the pathogenic bacteria the oropharynx and the lower lower respiratory oropharynx and entering entering the respiratory tract." tract.:3 One strategy strategy is is the the use of oropharyngeal oropharyngeal decontamdecontamOne use of ination with disinfectants, disinfectants, such ination with such as as chlorhexidine chlorhexidine or or of topically topically applied combinations combinations of applied antibiotics, antibiotics, with with 2-- 44 The and without without systemic systemic antibiotics. antibiotics. 2 The use use of of this this and approach been limited limited due due to to concerns concerns over over approach has has been inducing bacterial bacterial resistance.Pr' A second inducing resistance. 2 - 4 A second strategy, strategy, which shown in in Figure Figure 1, is to to prevent prevent the the entry entry of of which is is shown 1, is oropharyngeal bacteria trachea by by use use of of aa oropharyngeal bacteria into into the the trachea ETT having having aa suction port above above specially designed suction port specially designed ETT the cuff cuff for for continuous continuous aspiration aspiration of of subglottiC subglottic secresecrethe tions (CASS) (CASS) ..3,(i·7 ..3,(i·7 tions In this of CHEST CHEST (see (see page 938), Bouza In this issue issue of page 938), Bouza and and coworkers" coworkers(i present present data data from from aa large, large, well-executed well-executed clinical of 690 690 patients major cardiac cardiac clinical trial trial of patients undergoing undergoing major surgery who who were were randomized randomized to to use use an an ETT ETT capacapasurgery ble of of CASS CASS or or aa conventional conventional ETT. ETT. YAP YAP was was ble diagnosed by by clinical clinical and criteria, and and was was diagnosed and radiologic radiologiC criteria, 1044 confirmed by by endotracheal aspirates with with ~ 10 organisms per per milliliter. milliliter. This This is is the the largest largest study study to to organisms evaluate CASS, CASS, and and the the focus focus was was on on aa high-risk high-risk evaluate that was was more more homogeneous homogeneous than than most most population that population ICU patients. The greatest greatest benefit benefit of of CASS CASS was ICU patients. The was observed the 95 95 patients who received observed in in the patients who received ventilation ventilation for > > 48 48 h. h. In In these these patients, the use use of of CASS CASS for patients, the Significantly reduced the rates rates of of YAP YAP (27% (27% vs 48%, Significantly reduced the vs 48%, respectively; < 0.04), 0.04), espeCially especially YAP due to to HaeHaerespectively; pp < YAP due mophilus injlttenzae; infiuenzae; decreased decreased the the duration duration of of venvenmophiltts tilation (median duration, respectively; tilation (median duration, 33 vs vs 77 days, days, respectively; < 0.02); 0.02); shortened shortened the ofICU stay stay (median (median pp < the length length ofICU Editorials Editorials

Oropharynx 108 .10 10 cfu/ml

VAT orVAP: SQ-ETA (mod/heavy growth) Q-ETA ~ 1O·.e cfu/m I

VAP: BAL ~ 10·,cfu/ml PSB ~ 103 cfu/ml

Subglottic Secretions (Removed by CASS)

ETT Cuff ETT Biofllm

FIGURE 1. FIGURE 1. Schematic Schematic diagram diagram of of an an intubated intubated patient patient with with an an ETI ETI in in the the trachea, trachea, emphasizing emphasizing the the high high orophaI)'I.lx and and the presence of of bacteria bacteria above above the the ETI the presence ETI cuff cuff that that can can concentrations concentrations of of bacteria bacteria in in the the orophaI)'I.lx be CASSo Note Note the the number number of of bacteria bactelia isolated isolated by by semiquantiativc semiquantiative endotracheal endotracheal aspiration aspiration be removed removed by by CASSo (SQ-ETA) (SQ-ETA) and and quantitative quantitative endotracheal endotracheal aspiration aspiration (Q-ETA) (Q-ETA) aspirates aspirates needed needed for for aa microbiological microbiological Also shown shown are are the the quantitative quantitative levels levels of bacteria needed needed for for the the diagnosis of diagnosis of VAT VAT and and VAP. VAP. Also of bacteria microbiological diagnosis microbiological diagnosis ofVAP ofVAP by by distal distal lung lung samples samples obtained obtained by by BAL BAL or or protected protected specimen specimen brush. brush. NG == nasogastric NG nasogastric (tube). (rube).

duration, 7 duration, 7 vs vs 17 17 days, days, respectively; respectively; pp < < 0.01); 0.01); and and resulted in resulted in aa dramatic dramatic reduction reduction in in daily daily doses doses of of antibiotics (1,207 vs 1,878 doses, respectively; p < 0.001). There There were were no no complications complications with with CASS; CASS; although although CASS CASS was was more more expensive, expensive, substantial substantial overall overall cost cost savings savings were were documented. documented. These These data data add support add support to to the the findings findings of of aa metaanalysis metaanalysis?7 of of five five other randomized other randomized trials trials of of CASS, CASS, which which demondemonstrated strated aa 50% 50% reduction reduction in in VAP VAP incidence, incidence, aa shorter shorter length of length of ICU ICU stay stay (by (by 3 3 days), days), delayed delayed onset onset of of YAP (by YAP (by 66 days), days), with with an an estimated estimated cost cost savings savings of of $4,992 per per case case of of YAP YAP prevented prevented (or (or $1,872 per per patient). The patient). The limitations limitations of of CASS CASS include include the the need need for more for more staff staff education education and and monitoring, monitoring, difficulty difficulty identifying target identifying target patients patients who who will will receive receive ventiventilation lation for> for> 48 h, h, and and data data suggesting suggesting that that CASS CASS may be may be less less effective effective in in preventing preventing late-onset late-onset VAP VAP (ie, 2: (ie, 2: 5 5 days).6.7 days).6.7 Late-onset Late-onset VAP VAP is more likely likely to to involve involve ETT is more ETT biofilm and biofilm and more more antibiotic-resistant antibiotic-resistant pathogens, pathogens, such such as as 1--;3.7 Biofllm-encased Pseud0100nas Pseudomonas aeruginosa. aeruginosa.I--;3.7 Biofilm-encased bacteria bacteria ETT lumen lumen are are protected protected against against host host defenses defenses in in the the ETT and killing killing by by antibiotics, antibiotics, which which may may be be aa potential potential risk risk and factor for for VAP.2,:3 VAP.2,:3 This This issue issue was was addressed addressed in in aa ranranfactor domized shIdt study" that that compared compared the the efficacy efficacy of of aa colloicolloidomized dal dal silver-coated silver-coated ETT ETT that that was was designed designed to to prevent prevent bacterial bacterial colonization colonization and and biofilm biofilm formation formation to to aa conconventional The incidence incidence of of VAP, ventional ETT. ETT. The VAP, which which required required aa microbiological confmnation by by BAL BAL with with 2: 2: 10 1044 microbiological confmnation organisms per per milliliter, milliliter, was was Significantly significantly lower organisms lower in in the the www.chestjournal.org www.chestjournal.org

silver-ETT group silver-ETT group (4.8% vs vs 7.,5%, respectively; respectively; = 0.03), 0.03), with with aa relative relative risk risk reduction reduction of of 36%. 36%. The The p= p silver-ETT group silver-ETT group also also had had delayed delayed onset onset ofVAP, ofVAP, with with its greatest its greatest effect effect occurring occurring in in patients patients who who received received ventilation for ventilation for > > 48 h, h, and and was was also also effective effective in in reducing reducing the the number number of of cases cases of of VAP VAP due due to to P P aeruginosa and methicillin-resistant methicillin-resistant Staphylococcus aeruginosa and Staphylococcus aureus. aureus. Over the Over the past past 5 5 years, years, there there has has been been aa significant significant reduction in reduction in VAP VAP rates rates attributed attributed to to better better infection infection as well well control and control and quality quality improvement improvement measures, measures, as as The cornerstones cornerstones as aa positive positive change change in in culture.P:" culture. 2- 4 The for begin with with excellent excellent infection infection for VAP VAP prophylaxis prophylaxis begin control, antibiotic antibiotic stewardship, stewardship, staff staff education, education, and and control, 2- 44 Checklists, adequate nurse/patient nurse/patient staffing staffing ratios. ratios. 2adequate Checklists, "ventilator bundles," "ventilator bundles," and and team team care care have have also also had had major positive major positive impacts. impacts. 33 ,5,9 Sedation vacation vacation is is an an ,5 ,9 Sedation part of of the the "ventilator "ventilator bundle" bundle" that that facilifaciliimportant important part 2-- 44 In tates early tates early extubation. extubation. 2 In aa recent recent weaning weaning trial, trial, 10 10 patients who patients who were were randomized randomized to to the the interruption interruption of of sedation sedation with with spontaneous spontaneous awakening awakening followed followed by by spontaneous spontaneous breathing breathing had had Significantly Significantly more more sponspontaneously breathing breathing days days (p (p < < 0.02), earlier earlier disdistaneously charge from from the the ICU ICU and and hospital hospital (p (p < < 0.01), and and charge increased survival survival time time (p (p < < 0.01) 0.01) than than the the control control increased group, which which received received "usual "usual care" care" plus spontanegroup, plus aa spontaneous breathing breathing trial. trial. ous Unfortunately, the the numerous numerous successes successes in in YAP Unfortunately, YAP prophylaxis have have some some individuals individuals suggesting suggesting that that prophylaxiS VAP is now an an historical historical disease disease or or "medical VAP is now "medical error" error" CHEST /134/5/ /134/5/ NOVEMBER, NOVEMBER, 2008 2008 CHEST

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with an an expectation expectation for with for "zero "zero VAP" VAP" in in all all hospitals. hospitals. can be but VAP disease that VAP is is aa complex complex disease that can be prevented, prevented, but not eliminated.w Furthermore, the the use use of of VAP VAP as not eliminated. 3 ,9 Furthermore, as aa premature and and has has many many pitfalls, quality indicator indicator is is premature pitfalls, such as as definitions definitions that that lack lack specificity, specificity, as as well the well as as the such absence of of adjustments adjustments for for the the severity severity of of underlying underlying absence differences in in patient patient case case mixesY,J mixes.v-' 11 In In disease and disease and differences of the the public reporting of of VAP VAP rates, lieu of lieu public reporting rates, we we support support public of process process measures measures that that are are public monitoring monitoring of standarddesigned to to prevent YAP, which could be be standardized, measured, and and therefore therefore provide provide aa better better comcomized, measured, hospitalsy,ll parison of quality among hospitals.v-!' The accurate accurate diagnosis diagnosis of of VAP limited by lack of of The VAP is is limited by lack common, diagnostic standard."ll Patients aa common, diagnostic "gold "gold standard."ll Patients have ready ready access with suspected VAP have access to to lower lower evaluated by airway sputum, which which can be be evaluated by smear smear and and microbiological We suggest suggest the the routine routine use use microbiological culture. culture. We of aa microbiological confirmation of of YAP, YAP, as as is is of microbiological confirmation currently the diagnosis diagnosis of of urinary urinary tract currently used used for for the tract infections. This This confirmation confirmation should should rest rest heavily on infections. heavily on cliquantitative quantitative microbiological microbiological techniques techniques to to help help clinicians distinguish distinguish between between colonization colonization and and infecinfecnicians tion due to ventilator-associated tion ventilator-associated tracheobronchitis (VAT) or or VAP.2,l2 VAP.2,l2 (VAT) emerging as factor for, for, precursor precursor to, VAT VAT is is emerging as aa risk risk factor to, and aa new new focus focus for for YAP YAP prophylaxis.P and and prophylaxis. l2 Nseir Nseir and l2 used coworkers-s used serial, serial, quantitative, coworkers quantitative, endotracheal endotracheal aspirates the levels levels of of bacterial colonization aspirates to to follow follow the bacterial colonization order to to identify VAT having having aa in order identify patients patients with with VAT in 4 to 10 bacterial pathogen pathogen concentration concentration of of :::::10 :::::104 bacterial 10 66 organisms per per milliliter milliliter who who would would be be eligible eligible to to organisms undergo aa randomization randomization trial trial of of targeted targeted antibiotic antibiotic undergo therapy who were were randomtherapy vs vs no no therapy. therapy. Patients Patients who randomized ized to to receive receive targeted targeted antibiotic antibiotic therapy therapy for for VAT VAT had < 0.02), more had aa significant significant decrease decrease in in YAP YAP (p (p < 0.02), more "mechanical ventilation-free ventilation-free days" days" (p < 0.001), "mechanical (p < 0.001), as as well as as lower lower leu leu mortality mortality and and fewer fewer hospital well hospital days days (p < 0.05). VAP occurred occurred in in 41 of the the control control group group (p < 0.05). VAP 41 % % of the patients If and in in none none of of the and patients treated treated with with antibiotics. antibiotics. If confirmed, these these data suggest aa new paradigm for for confmned, data suggest new paradigm managing managing VAT VAT and and preventing preventing YAP, YAP, and and possibly possibly aa future future standardized standardized microbiological microbiological "benchmark" "benchmark" for for assessing assessing lower lower respiratory respiratory tract tract infections. infections. Investing planting aa tree. tree. It It Investing in in prophylaxis prophylaxiS is is like like planting must be be nurtured nurtured and and pruned pruned while while it and must it grows grows and produces the the seeds seeds for for more more trees. trees."3 Effective Effective proproduces programs need need constant constant attention, attention, may increase the the grams may increase initial costs, costs, but but will will pay pay huge huge rewards rewards by by improving improving initial patient outcomes outcomes and and substantially substantially reducing patient reducing healthhealthcare care costs. costs. Prophylaxis ProphylaxiS invariably invariably trumps trumps disease, disease, circumvents and saves saves preprecircumvents diagnosis diagnosis and and therapy, therapy, and cious health-care health-care dollars, dollars, and and therefore therefore should should be be cious our highest our highest priority.2-4 priority.2-4 ACKNOWLEDGMENT: The The authors authors thank thank Kathleen Kathleen A. ACKNOWLEDGMENT: A. Craven, Craven, RN, MPH, MPH, for for her her excellent excellent suggestions suggestions and and careful careful review review of of the the RN,

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manuscript; and and Nick Nick Zias, Zias, MD, manuscript; MD, for for his his assistance assistance in in preparing preparing Figure 1. Figure 1.

Donald E. Craven, MD MD Donald E. Craven, Burlington, MA MA Burlington, Karin Hjalmarson, Hjalmarson, MD MD Karin Boston, MA Boston, MA

Dr. Craven Dr. Craven and and Dr. Dr. Hjalmarson Hjalmarson are are affiliated affiliated with with the the DepartDepartCenter and and ment of Infectious Infectious Diseases, Diseases, Lahey Lahey Clinic Clinic Medical Medical Center ment of the the Tufts Tufts University University School School of of Medicine. Medicine. Dr. received research research funds funds from from Bard, Bard, Inc. Inc. for for the North the North Dr. Craven Craven received American Silver-Coated Silver-Coated ENndotracheal ENndotracheal Tube Tube (NASCENT (NASCENT American Study). Dr. Dr. Hjalmarson Hjalmarson has Study). has reported reported to to the the ACCP ACCP that that no no signifisignifiof interest cant interest exist exist with with any any companies/organizations companies/organizations cant conflicts conflicts of article, whose in this this altiele. whose products products or or services services may may be be discussed discussed in Reproduction prohibited without without written written pennission permission of this this artiele artiele is is prohibited Reproduction of from the the American of Chest Chest Physicians Physicians (www.chestjoumal. (www.chestjoumal. fi'om American College College of orglmisc/reprints.shtml). orglmisc/reprints.shtml). Craven, MD, Department of of Correspondence to: Correspondence to: Donald Donald E. E. Craven, MD, Department Infectious Lahey Clinic Clinic Medical Center, 41 41 Mall Mall Bd, Infectious Diseases, Diseases, Lahey Medical Center, Rd, Burlington, MA 01805; e-Ilwil: e-mail: [email protected] Burlington, MA 01805; [email protected] DOl: 1O.1378/chest.08-1735 1O.1378/chest.08-1735 DOl:

REFERENCES REFERENCES Chastre J. Ventilator-associated pneumonia. pneumonia. Am 11 Chastre J. Fagon Fagon ]Y. ]Y. Ventilator-associated Am JJ Respir Crit Crit Care Care Med Med 2002; 2002; 16.5:867-903 16.5:867-903 Respir American Thoracic Thoracic Society, Society, Infectious Infectious Diseases Diseases Society Society of of 22 American America. Guidelines Guidelines for for the the management management of of adults adults with with America. hospital-acquired, ventilator-associated, ventilator-associated, and and healthcarehealthcarehospital-acquired, associated associated pneumonia. pneumonia. Am Am JJ Respir Respir Crit Crit Care Care Med Med 2005; 2005; 171:388-416 171:388-416 Craven DE. Preventing ventilator-associated ventilator-associated pneumonia pneumonia in :3:3 Craven DE. Preventing in adults: of change. change. Chest Chest 2006; 2006; 130:251-260 130:251-260 adults: sowing sowing seeds seeds of Tablan OC, OC, Anderson Anderson LJ, LJ, Besser Besser R, al, Guidelines Guidelinesfor prevent44 Tablan R, et et aI. for preventing health-care-associated health-care-associated pneumonia, pneumonia, 2003: 2003: recommendarecommendaing tions of of CDC CDC and and the Healthcare Infection Infection Control Control Practices Practices tions the Healthcare Advisory Committee. Committee. MMWR MMWR Recomm Recomm Rep Rep 2004; 53:1-36 Advisory 2004; 53:1-36 Lorente L, L, Blot Blot S, S, Rello Rello J. J. Evidence Evidence on on measures measures for for the the 55 Lorente prevention of of ventilator-associated ventilator-associated pneumonia. pneumonia. Eur Eur Respir Respir JJ prevention 2007; 30:1193-1207 30:1193-1207 2007; Bouza E, Perez MJ, MJ, Munoz P, et Continuous aspiration aspiration of of 66 Bouza E, Perez Munoz P, et al. aI. Continuous subglottic subglottic secretions secretions in in the the prevention prevention of of ventilator-associated ventilator-associated pneumonia of major major heart heart sursurpneumonia in in the the postoperative postoperative period period of gery. Chest Chest 2008; 2008; 134:938-946 134:938-946 gery. Dezfulian C, C, Shojania Shojania K, K, Collard Collard HR, et a!' Subglottic 77 Dezfulian HR, et a!. Subglottic secretion drainage drainage for for preventing preventing ventilator-associated ventilator-associated pneupneusecretion monia: aa meta-analysis. meta-analysis. Am Am JJ Med Med 2005; 2005; 118:11-18 118:11-18 monia: Kollef MH, MH, Bekele Bekele A, A, Anzueto Anzueto A, et al. Silver-coated endotraendotra88 Kollef A, et al. Silver-coated cheal tubes tubes and and incidence incidence of of ventilator-associated ventilator-associated pneumonia: pneumonia: cheal the NASCENT NASCENT randomized randomized trial. trial. JAMA 300:805--81.3 the JAMA 2008; 2008; 300:805--81.3 Craven DE, 99 Lisboa Lisboa T, T, Craven DE, Rello Rello J. J. Safety Safety in in critical critical care care and and pulmonary f(lr pulmonary medicine: medicine: should should VAP VAP be be aa quality quality indicator indicator for patient patient safety? safety? Clin Clin Pulm Pulm Med Med 2008 2008 (in (in press) press) 10 10 Girard Girard TD, TD, Kress Kress JP, JP, Fuchs Fuchs BD, BD, et et al. al. Efficacy Efficacy and and safety safety of of aa paired paired sedation sedation and and ventilator ventilator weaning weaning protocol protocol for for memechanically in intensive intensive care care (Awakening (Awakening chanically ventilated ventilated patients patients in and and Breathing Breathing Controlled Controlled trial): trial): aa randomised randomised controlled controlled trial. trial. Lancet Lancet 2008; 2008; 371:126-134 371:126-134 11 11 Klompas Klompas M, M, Kullldorff Kullldorff M, M, Platt Platt R. R. Risk Risk of of misleading misleading ventilator-associated pneumonia rates rates with with use use of of standard standard ventilator-associated pneumonia Infect Dis Dis 2008; clinical and and microbiological microbiological criteria. criteria. Clin Clin Infect 2008; clinical 46:1443-1446 46:1443-1446 12 Nseir Nseir S, Favory R, et al. al. Antimicrobial Antimicrobial treattreat12 S, Favory R, Jozefowicz Jozefowicz E, E, et ment for for ventilator-associated ventilator-associated tracheobronchitis: tracheobronchitis: aa randomrandomment ized controlled controlled multicenter multicenter study. study. Crit Crit Care Care 2008; 2008; 12:R62 12:R62 ized