Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Preventing ventilator-associated pneumonia in Australian ICUs

  Ventilator-associated pneumonia (VAP) is a preventable complication of invasive mechanical ventilation. It often develops when bacteria from the oropharynx or stomach enter the lower airways, aided by microaspiration around an endotracheal tube, gastric distension, impaired cough and airway biofilm. Ventilation duration and depth of sedation influence risk, making every hour without unnecessary intubation meaningful.

  Effective prevention is a bundle rather than a single technique. Daily airway review, oral hygiene, aspiration reduction, hand hygiene, device handling and prompt extubation reinforce one another. The bundle matters when each element is tied to a bedside routine, an accountable role and a measurable outcome.

  Australian teams also work with familiar realities. Public and private hospitals in Sydney, Melbourne, Brisbane, Perth and Adelaide receive patients through different referral and transfer pathways. National infection-control expectations coexist with state and territory requirements, while devices and consumables move through tenders, private purchasing and local distributors. Alcohol hand rub at handover, shared equipment and family participation shape daily routines. Patients from regional or remote services may reach intensive care after a long transfer.

  The practical focus is how a unit can make prevention reliable from intubation to extubation. A useful program combines evidence-based airway care with local governance, workforce training and review of outcomes.

  Why Australian ICUs need a bundled approach

  VAP is a clinical syndrome within hospital-acquired pneumonia, not a synonym for any new fever or chest infiltrate in a ventilated patient. Diagnosis requires compatible clinical and imaging findings and exclusion of alternatives such as pulmonary oedema, atelectasis, pulmonary embolism and aspiration of gastric contents. This distinction protects patients from unnecessary antibiotics and improves infection-surveillance data.

  The burden depends on exposure and vulnerability. Deep sedation, prolonged immobility, poor oral care, a full stomach, device-related microtrauma and reduced host defences create different pathways to infection. A bundle can address these pathways, but its value depends on consistent execution during rounds, night shifts, transfers and staffing changes.

  Australian units can make execution visible by recording bundle elements in the bedside record, assigning ownership to each check and reviewing deviations without blame. Repeated omissions are system signals: they may reveal equipment shortages, unclear escalation, workload or training gaps.

  Reduce aspiration and shorten exposure to the airway

  Head-of-bed elevation to 30–45 degrees is a core measure unless clinically contraindicated. It reduces reflux and aspiration while limiting dependent lung stasis. Position should be checked after transfers, imaging and linen changes, not only at the start of a shift. Gastric overdistension and excessive fluid administration should be avoided where possible.

  Airway choices also shape risk. Subglottic suction may suit selected patients expected to need prolonged ventilation or at high risk of aspiration, provided staff can maintain it safely. Monitor endotracheal cuff pressure with a manometer and keep it within the unit’s evidence-based range; an under-inflated cuff permits leakage, while an over-inflated cuff can injure tissue.

  Sedation and ventilation plans should be reviewed at least daily. Safe interruption or lightening of sedation, assessment of airway protection and readiness for extubation, and spontaneous breathing trials can reduce exposure where the patient’s condition permits. Non-invasive ventilation before intubation and appropriately supported oxygen therapy after extubation may also avoid invasive support. Extubation is the point at which the prevention pathway has succeeded.

  Make infection prevention dependable

  Alcohol-based hand rub should be accessible at the bedside and used at the moments defined by the Australian Commission on Safety and Quality in Healthcare. For airway care, this includes before touching the airway, after contact with respiratory secretions and after removing gloves, even when gloves were worn. Standard and transmission-based precautions should follow the clinical situation rather than habit.

  Oral hygiene should be scheduled, documented and adapted to the patient’s mouth, swallowing status and sedation. Chlorhexidine-containing products require a clear local protocol because routine use has limited benefit and can cause adverse effects. Endotracheal tubes, suction equipment and breathing circuits should be secure and dry; closed-suction systems and avoiding routine circuit changes reduce unnecessary disconnection. Required equipment should be available at the point of care.

  Microbiological surveillance can reveal unit patterns, but it should support prevention rather than trigger treatment of colonisation. Routine prophylactic antibiotics should not be used solely to prevent VAP. If pneumonia is suspected, obtain appropriate specimens and reassess treatment promptly. Antimicrobial stewardship teams should review prescriptions and support de-escalation when cultures and clinical progress no longer justify continued therapy.

  Fit the program to Australian hospital systems

  The National Safety and Quality Health Service Standards, particularly the standard on preventing and controlling infections, provide the national framework for governance, hand hygiene, surveillance and antimicrobial stewardship. State and territory legislation, health-service agreements, credentialing and local policy add operational requirements. A prevention program should name the responsible committee, specify how compliance is audited and connect evidence with the obligations applying to that service.

  The Australian device market creates a second implementation layer. Medical devices supplied for patient care generally need inclusion in the Australian Register of Medical Devices through an Australian sponsor. Public and private purchasers use different tendering and governance processes, so biomedical engineering, infection prevention, pharmacy and procurement should agree on standardised airway equipment, oral-care supplies and cuff manometers before deployment.

  Distance adds a third. A ventilated patient transferred from a regional hospital to a metropolitan tertiary ICU may arrive with unfamiliar circuits, incomplete documentation or different infection-control practices. A transfer checklist should verify airway security, humidification, suction pressures, observations, microbiology results and the next review time. Consistency preserves the bundle across hospitals.

  Practical prevention priorities for the ICU team

  A concise bundle is easier to sustain during morning rounds, overnight handovers and family discussions. It should combine evidence-based bedside actions with unit systems that make omission visible and correction rapid.

  Clinical actions each shift

  • Check head-of-bed elevation, oral-care completion, sedation depth and readiness for extubation.
  • Maintain cuff pressure, secure the airway and use closed suction where indicated.
  • Review lung-protective ventilation, gastric distension, mobility and respiratory therapy needs.
  • Record any missed element and the reason, with a plan for completion.

  Unit systems that support the bundle

  • Place alcohol hand rub, PPE and all required airway supplies within reach.
  • Assign nursing, medical, respiratory therapy and infection-prevention ownership.
  • Audit bundle elements during daily safety huddles and monthly quality reviews.
  • Feed infection trends and antimicrobial data back to the treating team.

  Together, these measures treat VAP as a time-limited, system-dependent risk. They also support broader goals: fewer antibiotic days, safer extubations, less exposure to invasive devices and stronger infection-control confidence among staff and families.

  The concrete next step is to begin a 30-day audit of head-of-bed elevation, oral care, daily sedation review and ventilator-free days, then assign one owner to each documented gap.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)