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Table 132-3

Pathogenic Mechanisms and Corresponding Prevention Strategies for Ventilator-Associated Pneumonia

Pathogenic MechanismPrevention Strategy
Oropharyngeal colonization with pathogenic bacteria
Elimination of normal floraAvoidance of prolonged antibiotic courses
Large-volume oropharyngeal aspiration around time of intubationShort course of prophylactic antibiotics for comatose ptsa
Gastroesophageal refluxPostpyloric enteral feedingb; avoidance of high gastric residuals, prokinetic agents
Bacterial overgrowth of stomachAvoidance of prophylactic agents that raise gastric pHb; selective decontamination of digestive tract with nonabsorbable antibioticsb
Cross-infection from other colonized ptsHand washing, especially with alcohol-based hand rub; intensive infection control educationa; isolation; proper cleaning of reusable equipment
Large-volume aspirationEndotracheal intubation; rapid-sequence intubation technique; avoidance of sedation; decompression of small-bowel obstruction
Microaspiration around endotracheal tube
Endotracheal intubationNoninvasive ventilationa
Prolonged duration of ventilationDaily awakening from sedation,a weaning protocolsa
Abnormal swallowing functionEarly percutaneous tracheostomya
Secretions pooled above endotracheal tubeHead of bed elevateda; continuous aspiration of subglottic secretions with specialized endotracheal tubea; avoidance of reintubation; minimization of sedation and pt transport
Altered lower respiratory host defensesTight glycemic controlb; lowering of hemoglobin transfusion threshold

aStrategies demonstrated to be effective in at least one randomized controlled trial.

bStrategies with negative randomized trials or conflicting results.