Ventilator-associated pneumonia: the prevention bundle

Ventilator-associated pneumonia is pneumonia that arrives after intubation because the tube holds the glottis open and secretions pooled above the cuff, colonised by organisms from the mouth and stomach, leak past it into the lungs, so the nurse prevents it with a bundle of measures kept up together on every shift rather than with any one of them — the head of the bed kept raised in the semi-recumbent position unless something contraindicates it, and raised again after every procedure that needed it flat; the mouth cleaned every day with a toothbrush rather than swabs alone, and without routine chlorhexidine, which prevents nothing and may do harm; the cuff kept at the pressure that seals the airway, measured with a manometer, and the secretions above it cleared through a subglottic drainage port where the tube has one and by suctioning the mouth and pharynx before the cuff is deflated, the tube moved or the patient turned; sedation kept to the least that keeps the patient safe, with a daily interruption of sedation paired with a spontaneous breathing trial so that the tube comes out at the earliest day it can, because every day on the ventilator is a day of exposure; the patient sat up, exercised and mobilised early; enteral feeding started early rather than withheld, with the patient watched for intolerance and aspiration; the ventilator circuit changed only when it is visibly soiled or malfunctioning, with condensate drained away from the patient and never tipped back into the airway or the humidifier; hand hygiene and clean gloves before the airway or circuit is touched; and intubation and reintubation avoided where non-invasive support will serve — while the nurse recognises that stress-ulcer prophylaxis, routine circuit changes and chlorhexidine mouthwash are no longer part of the bundle, and reports a new fever, purulent secretions or a rising oxygen requirement in the ventilated patient as a suspected pneumonia rather than as the secretions every ventilated patient has.