Ventilator Bundles in Transition: From Prevention of Ventilator-Associated Pneumonia to Prevention of Ventilator-Associated Events

Abstract

Implementation of ventilator bundles is associated with reductions in ventilator-associated pneumonia (VAP). However, the new surveillance model of ventilator-associated events (VAEs) has shifted the focus from VAP to objective, generalized signs of pulmonary decompensation not specific to VAP. This raises the question of whether the ventilator bundle also is effective in reducing VAE. This narrative review examined 6 studies published since 2013 that assessed the impact of ventilator bundles on the incidence of VAE, and a seventh study that examined its impact on mortality. All 7 studies were low-level evidence, and only 1 study was prospective. The findings among the studies were inconsistent, and the only prospective study found no difference in bundle adherence between those who did and did not develop VAE. However numerous factors may explain the apparent lack of efficacy. Most of these factors were related to the retrospective nature of the studies, such as suboptimal documentation of bundle procedures and the presence of potential non-modifiable risk factors, as well as insufficient performance of most bundle components. In some studies, low VAE incidence also raised uncertainty about the veracity of results. Despite these limitations, there was evidence suggesting that stress ulcer prophylaxis may increase VAE risk, and oral care with chlorhexidine may increase both VAE and mortality risk. The largest study found significant reductions in duration of intubation with weaning, sedation, and head of bed elevation, as well as reduced mortality risk with weaning and sedation bundle elements. Nonetheless, these studies should be useful in designing future prospective controlled studies to determine what elements of a future prevention bundle might be effective in reducing VAEs. At this juncture, and based on the limited evidence to date, it appears that incorporating daily sedation interruptions and spontaneous breathing trials are the factors most likely to reduce VAEs.

Use of the modified Glasgow Coma Scale score to guide sequential invasive‑noninvasive mechanical ventilation weaning in patients with AECOPD and respiratory failure

“…It is believed that the duration of SBT should be between 30-120 min ( 18 ); however, it is not clear whether the same duration is applicable to patients who require mechanical ventilation because of different diseases. It has been found that SBT may cause a delay in weaning and may also cause VAP, which in turn may contribute to increased mortality ( 19 ). In China, the switching point is mainly the PIC window, as proposed by the Beijing Institute of Respiratory Diseases ( 20 ), while other countries, such as England, have employed a 48-h window for this purpose ( 21 ).…”

Accuracy of ventilator-associated events for the diagnosis of ventilator-associated lower respiratory tract infections

“…Second, the impact of a ventilator bundle on VAE incidence is unknown. Few studies have focused on the preventability of VAE, but it seems [20][21][22]. Our results show that many VAE were non-infectious events as atelectasis, pleural effusion or acute pulmonary embolism.…”

Nursing research priorities in critical care in Brazil: Delphi Study

“…The risk for VAP is associated with several variables such as: malnutrition, dental diseases, traumatic injuries, immuno-suppression, and previous exposure to antibiotic therapy. The use of bundles for care/prevention can be mentioned, which have measures that, when put into practice together, allow for a great chance of decreasing VAP acquisition (26)(27) . In a recent study, the association of a learning strategy with a bundle of care for critically ill patients undergoing mechanical ventilation showed a decrease in the incidence rate of sustained VAP over the time of the experience (28) .…”