POLMONITE ASSOCIATA A VENTILAZIONE (VAP) IN OSPEDALI PER ACUTI

La Ventilator-Associated Pneumonia (VAP) è un'infezione nosocomiale nei pazienti ventilati per almeno 48 ore, con un'incidenza del 30% [1,2].
È una complicanza critica in terapia intensiva, associata a sesso maschile, fumo e alto punteggio APACHE II, mentre la profilassi antibiotica è protettiva [1]. La diagnosi si basa su test patogenetici e segni clinici [3], ma la prevenzione è fondamentale [4]. Strategie efficaci includono igiene orale [5,6], aspirazione sottoglottica e mobilizzazione precoce. L’uso di clorexidina per la decontaminazione orale non è raccomandato [7-8], mentre le soluzioni ossidanti e saline mostrano risultati promettenti [5]. Il posizionamento a 45° riduce la VAP, ma nei pazienti neurologici il limite di 30° è preferibile [9]. I tubi endotracheali rivestiti in argento riducono il rischio di VAP, sebbene servano ulteriori studi [10]. La nutrizione enterale con sondini naso-intestinali e il massaggio addominale possono ridurre la VAP [11,12]. La colonizzazione da Candida nei pazienti ventilati è comune e potrebbe influenzare la prognosi [13]. Gli antibiotici inalatori, come colistina, riducono la VAP senza aumentare la resistenza antimicrobica [14]. La tracheostomia precoce riduce la degenza ma ha effetti incerti sulla VAP [15]. Il controllo della pressione della cuffia endotracheale e l'uso di tubi con aspirazione sottoglottica migliorano la prevenzione [16]. I probiotici potrebbero essere utili, ma mancano evidenze definitive [17]. I bundle care sono strumenti efficaci, ma servono più studi per migliorarne l’implementazione [18,19].

 

Riferimenti bibliografici del testo

Studi e revisioni

• De Cassai, A et al.. (2024). Chlorhexidine is not effective at any concentration in preventing ventilator-associated pneumonia: a systematic review and network meta-analysis. Journal of anesthesia, analgesia and critical care, 4(1), 30
• Lukasewicz Ferreira SA et al. Factors predicting non-ventilated hospital-acquired pneumonia: systematic review and meta-analysis. The Journal of hospital infection, 2022;119, 64–76.
• Batra P et al. Efficacy of probiotics in the prevention of VAP in critically ill ICU patients: an updated systematic review and meta-analysis of randomized control trials. Journal of intensive care, 2020;8,81. 
• Ladbrook ME et al. A Systematic Scoping Review of the Cost-Impact of Ventilator-Associated Pneumonia (VAP) Intervention Bundles in Intensive Care. American journal of infection control, 2020;S0196-6553(20)31036-1
• Martin-Loeches, I. et al.(2018). New guidelines for hospital-acquired pneumonia/ventilator-associated pneumonia: USA vs. Europe. Current opinion in critical care, 24(5), 347–352
• Seguin P et al. Effect of oropharyngeal povidone-iodine preventive oral care on ventilator-associated pneumonia in severely brain-injured or cerebral hemorrhage patients: a multicenter, randomized controlled trial. Critical care medicine, 2014;42(1), 1-8
• Cheema, H. A et al. Probiotics for the Prevention of Ventilator-Associated Pneumonia: An Updated Systematic Review and Meta-Analysis of Randomised Controlled Trials. Nutrients. 2022;14(8),1600
• Bassi, G. L et al. Body Position and Ventilator-Associated Pneumonia Prevention. Seminars in respiratory and critical care medicine. 2017;38(3), 371–380
• Álvarez-Lerma F et al. Prevention of ventilator-associated pneumonia: the multimodal approach of the Spanish ICU “Pneumonia Zero” program. Crit Care Med. 2018;46:181–8.
• Wang L et al. Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults requiring mechanical ventilation. Cochrane Database Syst Rev. 2016
• Klompas M et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med. 2014;174:751-761.
• Rabello, F., Araújo, V. E., & Magalhães, S. Effectiveness of oral chlorhexidine for the prevention of nosocomial pneumonia and ventilator-associated pneumonia in intensive care units: Overview of systematic reviews. International journal of dental hygiene.2018;16(4), 441–449
• Ji, W, McKenna et al. Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia. JAMA Netw Open 2019;2:e1913674
• Wolfensberger A. et al. Implementation and evaluation of a care bundle for prevention of non-ventilator-associated hospital-acquired pneumonia (nvHAP) - a mixed-methods study protocol for a hybrid type 2 effectiveness-implementation trial. BMC infectious diseases.2020;20(1), 603
• Munro S et al. (2021). Nonventilator hospital-acquired pneumonia: A call to action: Recommendations from the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) among nonventilated patients. Infection Control & Hospital Epidemiology, 42(8), 991-996
• Baker D & Giuliano K. Prevention practices for nonventilator hospital-acquired pneumonia: A survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN). Infection Control & Hospital Epidemiology. 2020;43(3), 379-380

Documenti, rapporti e Linee Guida

• CDC, January 2025, Ventilator-Associated Event (VAE) For use in adult locations only
• ISID. Guide to infection control in the healthcare setting. Recommendations for the prevention of ventilator-associated pneumonia. Last updated: June 2024.
• NICE Pneumonia in adults: diagnosis and management. Clinical guideline Published: 3 December 2014 Last updated: 31 October 2023
• Klompas M et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infection control and hospital epidemiology,  43(6), 687–713. 
• Kalil AC et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases, 2016;63(5), e61-e111.
• Klompas, M et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infection Control &Hospital Epidemiology, 2014;35(S2), S133-S154.
• Torres, A et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associatedpneumonia (VAP) of the European Respiratory Society (ERS), European Society ofIntensive Care Medicine (ESICM), European Society of Clinical Microbiology andInfectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). EuropeanRespiratory Journal, 2017;50(3).

[Ultimo aggiornamento: Febbraio 2025]