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CHAPTER 60: Liberation From Mechanical Ventilation 535

goal is to routinely achieve over 95% compliance. Care bundles make • Bouadma L, Luyt CE, Tubach F, et al. Use of procalcitonin to
it possible to introduce evidence-based preventive measures, includ- reduce patients’ exposure to antibiotics in intensive care units
ing appropriate nurse staffing levels, hand hygiene with alcohol-based (PRORATA trial): a multicentre randomised controlled trial.
formulations, standardized weaning protocols and daily interruption of Lancet. 2010;375:463-474.
sedation, oral care with chlorhexidine, and keeping patients who receive
enteral nutrition in a semirecumbent position. All of these measures • Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir
263
can be consistently applied to all patients in a coordinated way. The aim Crit Care Med. 2002;165:867-903.
of care bundles is therefore only to facilitate and promote changes in • Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of
patient care and encourage compliance with guidelines. Several studies antibiotic therapy for ventilator-associated pneumonia in adults: a
using quasi experimental design have confirmed the usefulness of this randomized trial. JAMA. 2003;290:2588-2598.
strategy for preventing VAP in the ICU. 143,366,443-455 • de Smet AM, Kluytmans JA, Cooper BS, et al. Decontamination of
The lack of methodologic rigor of the reported studies, however, the digestive tract and oropharynx in ICU patients. N Engl J Med.
precludes any conclusive statements about “bundle care” effectiveness or 2009;360:20-31.
cost-effectiveness. The exact set of key-interventions that should be part • Fagon JY, Chastre J, Wolff M, et al. Invasive and noninvasive strat-
of the “VAP-prevention bundle” is also not currently known as well as egies for management of suspected ventilator-associated pneumo-
the factors contributing to its success. 143,456-458 Successful VAP prevention nia. A randomized trial. Ann Intern Med. 2000;132:621-630.
requires an interdisciplinary team, educational interventions, system • Guidelines for the management of adults with hospital-acquired,
innovations, process indicator evaluation, and feedback to healthcare ventilator-associated, and healthcare-associated pneumonia. Am J
workers. As shown by a recent study, simply having a checklist avail- Respir Crit Care Med. 2005;171:388-416.
able for reference without consideration of a robust implementation
and adherence strategy is unlikely to maximize patient outcomes. • Heyland D, Dodek P, Muscedere J, Day A. A randomized trial of
455
Whether this organization and data collection can be generalized to all diagnostic techniques for ventilator-associated pneumonia. N Engl
ICUs remains to be determined, as well as the selection of the “optimal” J Med. 2006;355:2619-2630.
bundle. In the meantime, clinical practice quality indicators must be • Klompas M, Speck K, Howell MD, Greene LR, Berenholtz SM.
developed in parallel with guidelines to check the adequacy between the Reappraisal of routine oral care with chlorhexidine gluconate for
two and to find solutions to improve guideline compliance. patients receiving mechanical ventilation: systematic review and
In the United States, the Centers for Medicare and Medicaid Services meta-analysis. JAMA Intern Med. 2014;174:751-761.
has proposed stopping hospital reimbursements for care made necessary • Magill SS, Klompas M, Balk R, et al. Developing a new, national
by preventable complications, including nosocomial infections, aiming approach to surveillance for ventilator-associated events: executive
for a zero-VAP rate. Although this plan may have the desirable conse- summary. Chest. 2013;144:1448-1452.
459
quences of improving the quality of care, it also may penalize hospitals • Muscedere J, Rewa O, McKechnie K, Jiang X, Laporta D, Heyland
that admit high-risk patients and inadvertently encourage institutions DK. Subglottic secretion drainage for the prevention of ventilator-
to underreport VAP or to overuse antibiotics, thereby favoring dissemi- associated pneumonia: a systematic review and meta-analysis. Crit
nation of multidrug-resistant microorganisms. This possibility further Care Med. 2011;39(8):1985-1991.
underscores the need to carefully evaluate all new strategies potentially • Vincent JL, Bihari DJ, Suter PM, et al. The prevalence of noso-
aimed at preventing VAP against what represents best clinical practices. comial infection in intensive care units in Europe. Results of the
European Prevalence of Infection in Intensive Care (EPIC) Study.
CONCLUSION EPIC International Advisory Committee [see comments]. JAMA.
1995;274:639-644.
VAP is associated with mortality in excess of that caused by the underly-
ing disease alone, particularly in case of infection caused by high-risk
pathogens, such as P. aeruginosa and MRSA. The high level of bacterial
resistance observed in patients who develop VAP limits the treatment REFERENCES
options available to clinicians and encourages the use of antibiotic
regimens combining several broad-spectrum drugs, even if the pretest Complete references available online at www.mhprofessional.com/hall
probability of the disease is low, because initial inappropriate antimi-
crobial therapy has been linked to poor prognosis. Besides its economic
impact, this practice of “spiraling empiricism” increasingly leads to the
unnecessary administration of antibiotics in many ICU patients without CHAPTER Liberation From Mechanical
true infection, paradoxically resulting in the emergence of infections
caused by more antibiotic-resistant microorganisms that are in turn Ventilation
associated with increased rates of patient mortality and morbidity. 60
Every possible effort should therefore be made to obtain, before new Constantine A. Manthous
antibiotics are administered, reliable pulmonary specimens for direct Gregory A. Schmidt
microscope examination and cultures from each patient clinically sus- Jesse B. Hall
pected of having developed VAP. Because respiratory tract colonization
of ICU patients is generally very complex, corresponding to a mix of
self-colonization and cross-transmission, only a multifaceted and multi- KEY POINTS
disciplinary preventive program can be effective.
• Patients are candidates for liberation from mechanical ventilation
when gas exchange or circulatory disturbances which precipitated
KEY REFERENCES respiratory failure have been reversed.
• More than half of all critically ill patients can be successfully liberated
• Bekaert M, Timsit JF, Vansteelandt S, et al. Attributable mortal-
ity of ventilator associated pneumonia: a reappraisal using causal from mechanical ventilation after a brief trial of spontaneous breath-
analysis. Am J Respir Crit Care Med. 2011;184(10):1133-1139. ing on the first day that reversal of precipitating factors is recognized.

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