Recommendations
Table 3. Recommendations to Prevent VAP in Pediatric
Patients
Essential Practices: confer minimal risk of harm and some data suggest that they
may lower VAP rates, PedVAE rates, and/or duration of mechanical ventilation
1. Avoid intubation. (M)
a. Use noninvasive positive pressure ventilation (NIPPV) or high-flow oxygen by
nasal cannula whenever safe and feasible.
2. Minimize duration of mechanical ventilation.
a. Assess readiness to extubate daily using spontaneous breathing trials in patients
without contraindications. (M)
b. Take steps to minimize unplanned extubations and reintubations. (L)
c. Avoid fluid overload. (M)
3. Provide regular oral care (i.e., toothbrushing or gauze if no teeth). (L)
4. Elevate the head of the bed unless medically contraindicated. (L)
5. Maintain ventilator circuits:
a. Change ventilator circuits only when visibly soiled or malfunctioning (or per
manufacturer's instructions). (M)
b. Remove condensate from the ventilator circuit frequently and avoid draining the
condensate toward the patient. (L)
6. Endotracheal tube selection and management.
a. Use cuffed endotracheal tubes. (L)
b. Maintain cuff pressure and volume at the minimal occlusive settings to prevent
clinically significant air leaks around the endotracheal tube, typically 20–25 cm
H
2
O. This "minimal leak" approach is associated with lower rates of post-
extubation stridor. (L)
c. Suction oral secretions before each position change. (L)
Additional Approaches: minimal risks of harm and some evidence of benefit in adult
patients but data in pediatric populations are limited
1. Minimize sedation. (M)
2. Use endotracheal tubes with subglottic secretion drainage ports for patients ≥10 years
of age. (L)
3. Consider early tracheotomy. (L)
Approaches that Should Not be Considered a Routine Part of VAP Prevention
1. Prolonged systemic antimicrobial therapy for ventilator-associated tracheitis. (L)
2. Selective oropharyngeal or digestive decontamination. (L)
3. Probiotic prophylaxis. (L)
4. Oral care with antiseptics such as chlorhexidine. (M)
5. Stress ulcer prophylaxis. (L)
6. Silver-coated endotracheal tubes. (L)
Unresolved Issues
1. Closed/in-line suctioning.
