Global Health & Medicine. 2023; 5(1):33-39.

Original Article
DOI: 10.35772/ghm.2022.01038

Evaluation of a bundle approach for the prophylaxis of ventilator-

associated pneumonia: A retrospective single-center Study
Keigo Sekihara1,2, Tatsuya Okamoto1,*, Takatoshi Shibasaki1,3, Wataru Matsuda1,3, Kazuhito Funai2, Yuki Yonehiro1,
Chieko Matsubara4, Akio Kimura1,3
1
Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;
2
Department of First Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan;
3
Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;
4
Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan.

Abstract: Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring after the first 48 hours of
intubation and mechanical ventilation and is the most frequent hospital-acquired infection associated with intensive care
unit (ICU) admissions. Herein, we defined a novel VAP bundle including 10 preventive items. We analyzed compliance
rates and clinical effectiveness associated with this bundle in patients undergoing intubation at our medical center.
A total of 684 consecutive patients who underwent mechanical ventilation were admitted to the ICU between June
2018 and December 2020. VAP was diagnosed by at least two physicians based on the relevant United States Centers
for Disease Control and Prevention criteria. We retrospectively evaluated associations between compliance and VAP
incidence. The overall compliance rate was 77%, and compliance generally remained steady during the observation
period. Moreover, although the number of ventilatory days remained unchanged, the incidence of VAP improved
statistically significantly over time. Low compliance was identified in four categories: head-of-bed elevation of 30-
45º, avoidance of oversedation, daily assessment for extubation, and early ambulation and rehabilitation. The incidence
of VAP was lower in those with an overall compliance rate of ≥ 75% than its incidence in the lower compliance
group (15.8 vs. 24.1%, p = 0.018). When comparing low-compliance items between these groups, we found a
statistically significant difference only for daily assessment for extubation (8.3 vs. 25.9%, p = 0.011). In conclusion, the
evaluated bundle approach is effective for the prophylaxis of VAP and is thus eligible for inclusion in the Sustainable
Development Goals.

Keywords: intensive care unit, intratracheal intubation, mechanical ventilation

Introduction prevent pathogens from entering the lower respiratory

tract from both external and internal sources.
Ventilator-associated pneumonia (VAP) is a preventable Preventive bundle approaches reduce the incidence
iatrogenic complication that can develop in patients of VAP. However, VAP prevention bundles are composed
undergoing mechanical ventilation. VAP is the most of different items and may vary substantially between
frequent hospital-acquired infection occurring in the institutions. Each item considered for the prevention
intensive care unit (ICU) and has a high associated of VAP (i.e., included in the VAP prevention bundle)
mortality rate (1). More specifically, the mortality rate in the present study has been extensively studied in
for VAP ranges from 24-51% according to previously prior work (7-9). Some items in the VAP prevention
published findings (2). bundle, including hand hygiene, oral care, and subglottic
The prevention of VAP has great value in the suctioning of secretions from the upper cuff, are effective
management of mechanical ventilation with intratracheal in preventing the invasion of pathogens from outside the
intubation. In addition to the personal, familial, and tube. Other measures aim to prevent pathogen invasion
societal burden of this disease, past reports have from inside the tracheal tube, including the use of closed
demonstrated that VAP increases the length of hospital suction circuits and the use of disposable breathing
stay as well as costs associated with treatment and care circuits.
and the usage of antibiotics in patients with longer For the above mentioned reasons, it is highly
hospital stays (3-6). It is therefore necessary to avert the important to establish effective preventive strategies for
risks of respiratory management in this setting and to VAP (10). However, the generalizability of prior work

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and the effectiveness of the specific bundle approach modified the bundles implemented in studies conducted
presented herein remains unclear. In the present study, by the US Institute for Healthcare Improvement (IHI)
we comprehensively examined the preventive efficacy of and the Japanese Society of Intensive Care Medicine
a VAP prevention bundle consisting of ten items that had (12,13) based on the current evidence base and an
been implemented at our medical center. evolving clinical situation (14,15). For example, we
added "maintenance of adequate cuff pressure (20-
Materials and Methods 30 cmH2O)", "use of a tracheal tube with aspiration
of subglottic secretions", and "early ambulation and
This study was approved by the ethical review rehabilitation" items to the bundle.
board at the National Center for Global Health and Bundle compliance rates were calculated using the
Medicine on September 10, 2021 (approval number: VAP care bundle sheet included in patients' medical
NCGM-S-004300-00). The requirement for written records and were entered into database software
informed consent was waived due to the retrospective (FileMaker Pro, version 19, Claris International Inc.
design of this study. This work was conducted in Cupertino, CA, USA) for subsequent analyses.
accordance with the principles of the Declaration of
Helsinki (as revised in 2013). Statistical analyses

Patient selection and diagnosis of VAP Differences in categorical variables were analyzed
using Chi-square tests, whereas continuous variables
All patients who were admitted to the general ICU at were analyzed using t-tests. All cumulative survival
our institution between June 2018 to December 2020, curves were estimated using the Kaplan-Meier method.
were older than 20 years of age, and received intubated Intergroup differences were evaluated using log-rank
mechanical ventilation for more than 48 hours were tests.
eligible for inclusion. We included 1,903 patients who The VAP incidence was calculated by dividing the
were admitted to our ICU. number of VAP cases by the total number of ventilator-
We use the following artificial respirators at days and multiplying the result by 1,000 (1). Hypothesis
our department: the Dräger Evita ® Infinity V500 testing regarding differences in the incidence of VAP
(Dräger, Lübeck, Germany) and the Nihon Kohden® was conducted to compare the pre- and post-intervention
HAMILTON-G5 (Nihon Kohden, Tokyo, Japan). In VAP incidence rates using z-scores. We considered two-
addition, was the Taper Guard® Evac (Medtronic, Dublin, sided p-values of < 0.05 as the threshold for statistical
Ireland) the tracheal intubation tube used herein; this significance. All statistical analyses were performed
tube uses subglottic suctioning. using the R statistical software (ver. 3.0.2, The R Project
VAP was evaluated based on the diagnostic criteria for Statistical Computing, Vienna, Austria. http://www.
for clinically defined pneumonia delineated by the r-project.org).
United States (US) Centers for Disease Control and
Prevention (1). The infection control team, radiology Results
department, and ICU physicians at our medical center
screened suspected cases of VAP, and the supervising Among the 1,903 included patients, 684 (36%) received
ICU specialist made a final diagnosis of VAP based on mechanical ventilation. The clinical characteristics of
chest imaging test results, clinical signs/symptoms, and the patients in the intubation and non-intubation groups
laboratory findings. We evaluated the severity of all VAP are shown in Table 1. The intubation group included 406
patients using sequential organ failure assessment (SOFA) (59%) men and the median age at the time of admission
scores at ICU admission and on ICU discharge (11). was 64 years (standard deviation, ± 17 years). The
patients in the intubation group had mean SOFA scores
Bundle implemented at our institution of 7.1 ± 3.4 on admission and 4.9 ± 3.8 at discharge,
respectively. The median length of patients' ICU stays
T h e VA P p r e v e n t i o n b u n d l e e v a l u a t e d i n t h e was 8.2 ± 7.0 days. Forty-eight patients died in the ICU
current study consisted of the following ten items in the intubation group and the overall mortality rate was
(Supplemental Figure S1); i) hand hygiene, ii) 7.0%.
head-of-bed elevation (30-45º), iii) oral care with The reasons for ICU admission are described in
cetylpyridinium chloride (CPC), iv) avoidance of Table 1. In the intubation group, gastrointestinal surgery
oversedation, v) proper breathing circuit management, exhibited the highest frequency (181 patients, 26.5%),
vi) appropriate maintenance of endotracheal tube followed by cardiovascular surgery (114 patients,
cuff pressure, vii) closed system and subglottic 16.7%). In terms of types of admission, emergency
suctioning, viii) daily assessment for extubation, ix) surgery exhibited the highest frequency (369 patients,
early ambulation and rehabilitation, and x) peptic ulcer 53.9%), followed by scheduled surgery (184 patients,
and deep vein thrombosis (DVT) prophylaxis. We 26.9%).

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Compliance rates for the VAP bundle and the VAP decreased from 2018 to 2020. The total VAP incidence
incidence was 31.5 per 1,000 ventilator-days during the observation
period (Figure 2B).
The compliance rate for each item is shown in Figure
1. In our ICU, we routinely implement several items as Prophylaxis effects based on compliance rates for the
part of our standard of care: hand hygiene (i), oral care VAP bundle
with CPC (iii), proper breathing circuit management
(v), appropriate maintenance of endotracheal tube cuff Table 1. Characteristics of ventilated and non-ventilated
pressure (vi), and peptic ulcer and DVT prophylaxis (x). patients, June 2018 to December 2020
The compliance rate was 100% for each item. Non-
Variable Intubated
Subglottic suction (vii) was not implemented in intubated
only a few emergency surgery cases, and hence this
Patients receiving MV, n 684 1,219
preventive measure achieved a compliance rate of 92.6%. Male sex, n (%) 406 (59.3) 779 (63.9)
Conversely, we could not implement early ambulation Age, mean ± SD 63.9 ± 17.2 66.9 ± 14.5
and rehabilitation (ix) effectively, and the compliance SOFA score on ICU admission, mean ± SD 7.1 ± 3.4 2.3 ± 2.1
SOFA score at ICU discharge, mean ± SD 4.9 ± 3.8 1.6 ± 1.9
rate for this preventive measure reached only 5.8%. The
ICU length of stay (days), mean ± SD 8.2 ± 7.0 2.7 ± 1.6
compliance rates for the remaining three measures (ii, iv, ICU mortality (%) 48 (7.0) 7 (0.6)
and viii) were each approximately 50%. Reasons for these
findings included restrictions on therapeutic management, Underlying disease, n (%)
Gastrointestinal surgery 181 (26.5) 484 (39.7)
decreased levels of consciousness, and unstable vital
Cardiovascular surgery 114 (16.7) 105 (8.6)
signs. The total compliance rate for the ten measures Respiratory surgery 5 (0.7) 294 (24.1)
comprising the VAP prevention bundle was 77.0%. Neurosurgery 240 (35.1) 144 (11.8)
Ventilator-days and VAP incidence in the intubation Other surgery 13 (1.9) 24 (2.0)
Emergency and critical care medicine 26 (3.8) 2 (0.2)
group are shown in Figure 2. In Japan, ventilator-
Internal medicine 51 (7.5) 24 (2.0)
days increased considerably in April 2020 due to the Cardiovascular medicine 51 (7.5) 142 (11.6)
coronavirus disease 2019 pandemic. This time period Pediatrics 3 (0.4) 0 (0)
represented the start of the pandemic in Japan and
Type of admission, n (%)
the uptick in this metric might have occurred due to
Scheduled surgery 184 (26.9) 934 (76.6)
evolving surveillance and treatment methods. However, Emergency surgery 369 (53.9) 117 (9.6)
the number of ventilator-days was almost unchanged in Coronary intervention 21 (3.1) 104 (8.5)
every other month, and the median number of ventilator- Medical 110 (16.1) 64 (5.3)
Trauma 41 (6.0) 15 (1.2)
days was 6.17 days (Figure 2A).
Although VAP incidence varied each month (ranging ICU, intensive care unit; MV, mechanical ventilation; SD, standard
from 0.0 to 96.2 per 1,000 ventilator-days), it gradually deviation; SOFA, sequential organ failure assessment.

Figure 1. Compliance rate of the VAP bundle. SBT, spontaneous breathing trial; DVT, deep vein thrombosis.

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According to the total compliance rate of 77.0% reported group. We observed statistically significant differences
above, the 684 patients who required mechanical in the proportion of VAP occurrence between the two
ventilation were divided into two groups using a cut-off groups (p = 0.02, Figure 3A).
value of 75%. The evaluated clinical outcomes included Moreover, 11 patients (2.9%) died in the high
the incidence of VAP, as shown in Table 2, as well as compliance group, in contrast with 37 (12.4%) who died
associated mortality rates. in the low compliance group (p < 0.001, Figure 3B).
Regarding total compliance rates, the high Relationships between the incidence of VAP and the
compliance group comprised 385 patients (56%) with a bundle items with low compliance rates (ii, iv, viii, and
compliance rate of ≥ 75%, whereas the low compliance ix) are presented in Figure 4.
group comprised 299 (44%) with a compliance rate of < Only daily assessment for extubation (viii)
75%; 61 (15.8%) developed VAP in the high compliance demonstrated statistically significant differences
group, in contrast with 72 (24.1%) in the low compliance with regard to the proportion of VAP cases; the high
compliance group included 252 patients (37%) and
the low compliance group included 432 (63%). A
total of 21 patients (8.3%) developed VAP in the high
compliance group, whereas 112 (25.9%) developed
VAP in the low compliance group (p = 0.011, Figure
4C, Table 2). No other items exhibited statistically
significant differences.

Discussion

In the present study, patients with high compliance rates

for the evaluated VAP prevention bundle demonstrated
a lower incidence of VAP than the VAP incidence of
those with low compliance rates (Figure 3). Daily
assessment for extubation (viii) affected the incidence
of VAP, such that those with high compliance showed a
lower incidence of VAP than those in the low compliance
group (Figure 4C). However, no other items showed
statistically significant differences.
In this study, the intubation group included patients
with various risk factors and profiles, such as high
SOFA scores, an increased length of hospital stay, and
Figure 2. Number of ventilator-days and VAP incidence high mortality rates (Table 1). Risk factors increasing
during the observation period. (A) The number of
ventilator-days, (B) VAP incidence (per 1,000 ventilator- the incidence of VAP have been reported in many prior
days). VAP, ventilator-associated pneumonia. reports, and include long-term intubation, disorders of

Table 2. Clinical outcomes as relevant to the ventilator-associated pneumonia (VAP) prevention bundle evaluated at our
medical center
Ventilator- VAP incidence
VAP bundle items Patients (n) VAP (n) ICU-days VAP (%) p-value*
days (per 1,000 MV days)

Total compliance
High (compliance ≥ 75%) 385 61 9.13 6.49 15.8 24.4
0.018
Low (compliance < 75%) 299 72 6.91 5.74 24.1 42.0
Gatching up the bed to 30-45º
High (compliance ≥ 75%) 330 60 9.34 6.59 18.2 27.6
0.545
Low (compliance < 75%) 354 73 7.06 5.77 20.6 35.7
Avoidance of oversedation
High (compliance ≥ 75%) 378 61 7.89 5.59 16.1 28.9
0.217
Low (compliance < 75%) 306 72 8.49 6.88 23.5 34.2
Daily assessments for extubation
High (compliance ≥ 75%) 252 21 6.65 4.10 8.3 20.3
0.011
Low (compliance < 75%) 432 112 9.04 7.37 25.9 35.2
Early ambulation and rehabilitation
High (compliance > 0%) 76 27 16.17 13.67 35.5 26.0
0.900
Low (0% compliance) 608 106 7.16 5.23 17.4 33.3
Total 684 133 8.16 6.17 19.4 31.5

ICU, intensive care unit; MV, mechanical ventilation. *Generalized Wilcoxon test.

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Figure 3. Proportion of VAP occurrence according to the compliance rate. (A) Proportion of VAP patients, (B) Survival
probability. VAP, ventilator-associated pneumonia.

Figure 4. Proportion of VAP occurrence according to the preventive item. (A) Gatching up the bed, (B) Avoid oversedation, (C)
Daily assessments for extubation, (D) Early ambulation. VAP, ventilator-associated pneumonia.

consciousness, and various comorbidities (16-18). We outcomes overall.

introduced the bundle approach described herein to at- The favorable consequences of including an
risk patients with the aim of preventing VAP. educational program were proven in a past study, in
In consideration of such risk factors, the US IHI which the resulting incidence of VAP was reduced
and the Japanese Society of Intensive Care Medicine by 51% (2). In this study, the incidence of VAP has
have included item x (i.e., the peptic ulcer and DVT decreased over time due to better management (overall
prophylaxis item) in their protocols. In Japan, the and for each preventive measure included in the
incidence rates of obesity and pulmonary embolism are bundle) as compared with our management capabilities
lower than the respective incidence of each condition in immediately after the introduction of the preventive
the US (12,13). Hence, DVT prophylaxis has less clinical bundle. One potential reason for this may be that the
importance in Japan than it does in the US, and we level of nursing care has improved over time because
conclude that preventive measures should be modified nurses' awareness of and training regarding VAP care has
based on the clinical situation specific to each institution. increased.
The incidence of VAP gradually decreased after the Our department was able to comply with many of
introduction of our modified bundle (Figure 2). We the measures implemented in the evaluated preventive
emphasize that our selected measures led to good clinical bundle, hence yielding a median compliance rate of

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77%. This higher compliance rate led to a lower VAP bundle approach in the intubated patients evaluated
incidence. Moreover, a subgroup analysis of the four herein. We plan to enact these preventive measures at our
measures with the lowest compliance rates showed that medical center using this VAP bundle. This approach was
only daily assessment for extubation (item viii) was effective for the prophylaxis of VAP and is hence eligible
statistically significantly different between compliance for inclusion in our Sustainable Development Goals.
groups. Prior studies have reported that early extubation
is difficult in older patients as well as in patients in poor Funding: This work was supported in part by the
general condition and/or with consciousness disorders International Health Research and Development Fund
due to brain injury (19,20). Invasive surgery for older from the Ministry of Health, Labor and Welfare in
patients and those with cerebrovascular disease may Japan (Grant No. 20A01) and by the Projects for Global
lead to prolonged intubation, even at our institution. In Extension of Medical Technologies (TENKAI Projects).
these cases, tracheostomy and aggressive nutritional These funders had no role in the design, conduct, or
management may reduce the occurrence of VAP (21,22). reporting of this work.
We would also like to consider tracheostomy for long-
term management in future research. Conflict of Interest: The authors have no conflicts of
In the preventive bundle evaluated herein, "early interest to disclose.
ambulation and rehabilitation" was the only item that
showed low compliance rates. The clinical effects of References
early ambulation and rehabilitation have been proven
(23,24). We aim to identify the factors contributing 1. National Healthcare Safety Network. Ventilator-associated
to inadequate management as well as to improve (VAP) and Non-ventilator-associated Pneumonia
management methods in future work. We also note (PNEU) Event. 2021. https://www.cdc.gov/nhsn/pdfs/
pscmanual/6pscvapcurrent.pdf (accessed April 25, 2022)
that our medical staff has experienced some difficulty
2. Salahuddin N, Zafar A, Sukhyani L, Rahim S, Noor MF,
implementing ambulation and rehabilitation programs Hussain K, Siddiqui S, Islam M, Husain SJ. Reducing
in normally intubated patients (other than tracheostomy ventilator-associated pneumonia rates through a staff
patients) due to bucking and blood pressure fluctuations, education programme. J Hosp Infect. 2004; 57:223-227.
which may occur given inadequate sedation. In our 3. Rosenthal VD. Health-care-associated infections in
ICU, we try to achieve a 90° gatch-up position or a developing countries. Lancet. 2011; 377:186-188.
standing position using a Sara® Combilizar device (Arjo, 4. Melsen WG, Rovers MM, Groenwold RH, et al.
Attributable mortality of ventilator-associated pneumonia:
Stockholm, Sweden) under mild sedation. We hope to
A meta-analysis of individual patient data from
increase the number of cases undergoing therapeutic randomised prevention studies. Lancet Infect Dis. 2013;
ambulation and rehabilitation protocols in the future. 13:665-671.
Our study had several limitations. First, this was a 5. Alp E, Kalin G, Coskun R, Sungur M, Guven M, Doganay
retrospective study that only included Japanese patients M. Economic burden of ventilator-associated pneumonia
from a single institution. However, our database is large in a developing country. J Hosp Infect. 2012; 81:128-130.
and has been continuously updated based on uniform 6. Kollef MH, Hamilton CW, Ernst FR. Economic impact
follow-up protocols. Second, although a general rule was of ventilator-associated pneumonia in a large matched
cohort. Infect Control Hosp Epidemiol. 2012; 33:250-256.
similarly applied to all patients when diagnosing VAP, the
7. Abbott CA, Dremsa T, Stewart DW, Mark DD, Swift CC.
diagnostic criteria for VAP are somewhat controversial. Adoption of a ventilator-associated pneumonia clinical
For example, criteria that have been considered for VAP practice guideline. Worldviews Evid Based Nurs. 2006;
diagnoses (and remain controversial) include evaluation 3:139-152.
of the patient's respiratory condition (i.e., based on the 8. Jadot L, Huyghens L, De Jaeger A, et al. Impact of a VAP
fraction of inspired oxygen and positive-end-expiratory bundle in Belgian intensive care units. Ann Intensive Care.
pressure findings) (1). Third, according to the diagnostic 2018; 8:65.
9. Sousa AS, Ferrito C, Paiva JA. Application of a ventilator
criteria for VAP described above, we evaluated
associated pneumonia prevention guideline and outcomes:
respiratory function and symptoms in reaching VAP A quasi-experimental study. Intensive Crit Care Nurs.
diagnoses; however, the data for bacterial composition 2019; 51:50-56.
in mechanical ventilation patients' sputum tests included 10. Xie J, Yang Y, Huang Y, et al. The current epidemiological
many missing values. Fourth, we could not identify landscape of ventilator-associated pneumonia in
survival effects for VAP. No patient died from VAP the intensive care unit: A multicenter prospective
in this study; the main cause of death in our ICU was observational study in China. Clin Infect Dis. 2018;
67:S153-S161.
primary disease or other severe complications thereof. A
11. Vincent JL, de Mendonça A, Cantraine F, Moreno R,
multicenter prospective study is required for confirming Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S.
the efficacy of the VAP bundle approach in intubated Use of the SOFA score to assess the incidence of organ
patients admitted to the ICU. dysfunction/failure in intensive care units: Results of a
In conclusion, an observed decreased incidence of multicenter, prospective study. Working group on "sepsis-
VAP was a critically important outcome of the VAP related problems" of the European Society of Intensive

(38)
Global Health & Medicine. 2023; 5(1):33-39. www.globalhealthmedicine.com

Care Medicine. Crit Care Med. 1998; 26:1793-1800. 2016; 95:e4852.

12. I n s t i t u t e f o r H e a l t h c a r e I m p r o v e m e n t . H o w - t o 21. Chorath K, Hoang A, Rajasekaran K, Moreira A.
Guide: Prevent Ventilator-Associated Pneumonia. Association of early vs late tracheostomy placement with
2005. http://www.ihi.org/resources/Pages/Tools/ pneumonia and ventilator days in critically ill patients: A
HowtoGuidePreventVAP.aspx (accessed April 25, 2022) meta-analysis. JAMA Otolaryngol Head Neck Surg. 2021;
13. The Japanese Society of Intensive Care Medicine. 147:450-459.
Ventilator-Associated Pneumonia Prevention Bundle (VAP 22. Ścisło L, Walewska E, Bodys-Cupak I, Gniadek A, Kózka
Bundle). 2010. https://www.jsicm.org/pdf/2010VAP.pdf M. Nutritional status disorders and selected risk factors of
(accessed April 25, 2022). (in Japanese) ventilator-associated pneumonia (VAP) in patients treated
14. Eom JS, Lee MS, Chun HK, Choi HJ, Jung SY, Kim YS, in the intensive care ward - A retrospective study. Int J
Yoon SJ, Kwak YG, Oh GB, Jeon MH, Park SY, Koo Environ Res Public Health. 2022; 19:602.
HS, Ju YS, Lee JS. The impact of a ventilator bundle on 23. Girard TD, Alhazzani W, Kress JP, et al. An official
preventing ventilator-associated pneumonia: A multicenter American Thoracic Society/American College of
study. Am J Infect Control. 2014; 42:34-37. Chest Physicians clinical practice guideline: Liberation
15. Horan TC, Andrus M, Dudeck MA. CDC/NHSN from mechanical ventilation in critically ill adults.
surveillance definition of health care-associated infection Rehabilitation protocols, ventilator liberation protocols,
and criteria for specific types of infections in the acute and cuff leak tests. Am J Resp Crit Care Med. 2017;
care setting. Am J Infect Control. 2008; 36:309-332. 195:120-133.
16. Wu D, Wu C, Zhang S, Zhong Y. Risk factors of 24. Schweickert WD, Pohlman MC, Pohlman AS, et al.
ventilator-associated pneumonia in critically ill patients. Early physical and occupational therapy in mechanically
Front Pharmacol. 2019; 10:482. ventilated, critically ill patients: A randomised controlled
17. Jaffal K, Six S, Zerimech F, Nseir S. Relationship between trial. Lancet. 2009; 373:1874-1882.
hyperoxemia and ventilator associated pneumonia. Ann
Transl Med. 2017; 5:453. ----
18. Wałaszek M, Kosiarska A, Gniadek A, Kołpa M, Wolak Z, Received April 25, 2022; Revised August 17, 2022; Accepted
Dobroś W, Siadek J. The risk factors for hospital-acquired September 12, 2022.
pneumonia in the intensive care unit. Przegl Epidemiol.
2016; 70:15-20, 107-110. Released online in J-STAGE as advance publication September
19. Coplin WM, Pierson DJ, Cooley KD, Newell DW, 30, 2022.
Rubenfeld GD. Implications of extubation delay in brain-
injured patients meeting standard weaning criteria. Am J *Address correspondence to:
Respir Crit Care Med. 2000; 161:1530-1536. Tatsuya Okamoto, Department of Intensive Care Medicine,
20. Lai CC, Chen CM, Chiang SR, Liu WL, Weng SF, Sung National Center for Global Health and Medicine, 1-21-1,
MI, Hsing SC, Cheng KC. Establishing predictors for Toyama, Shinjuku, Tokyo 162-8655, Japan.
successfully planned endotracheal extubation. Medicine. E-mail: [email protected]

Supplementary Data

Supplemental Figure S1. Graphic symbol of ten items in VAP bundle. VAP, ventilator-associated pneumonia.

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