This guideline is applicable to all medical, nursing, and midwifery staff caring for neonates in SCRH. 

Ventilator associated pneumonia (VAP) is a significant cause of morbidity and mortality in patients receiving support with ventilation. It can lead to increased antibiotic exposure, prolonged time on the ventilator and bronchopulmonary dysplasia. Neonatal sepsis is associated with neurological morbidity and mortality.

The pathogenesis of VAP usually requires that two processes take place: bacterial colonisation of the aero-digestive tract and translocation of bacterial species via the ETT or aspiration of contaminated secretions into the lower airway. The strategies for preventing VAP therefore focus on reducing the burden of bacterial colonisation in the aero-digestive tract, using non-invasive respiratory support when appropriate, and decreasing the incidence of aspiration.

Ventilator 'care bundles' have been devised to ensure evidence based medicine is delivered reliably. Below is a list of recommendations taken from evidence in 'High Impact Interventions in Saving Patient Lives (DOH)', and adapted for use in neonates who require ventilator support.

All infants in the NNU receiving invasive or non-invasive ventilation should have the following recommendations adhered to:

1. Nurse head up: All babies should be nursed head up 30º unless there is an absolute contraindication eg. Gastroschisis with silo.
2. Rotating positions: Babies should have their position changed every 6-8 hours if clinical stability allows including prone position for a least 6 hours per day.
3. Prone lie: For most babies, especially those on nCPAP or HFNC the best position is prone, followed by lateral lie. Minimal periods of time should be spent supine. Supine positioning is associated with aspiration of colonised oropharyngeal or gastric contents.
4. Careful use of Sedation and paralysis. Sedation should be used sparingly and kept at minimal levels to allow the baby to breathe and cough. Paralysis should be used for the shortest time possible, this should ideally be only a few hours unless specific exceptions e.g. post op diaphragmatic hernia repair.
5. All gases must be humidified.
6. Ventilator tubing: should be changed as per manufacturer instructions and circuit manipulation otherwise avoided. Condensed fluids in ventilator circuit have a risk of bacterial contamination. Numerous circuit changes may increase the incidence of colonisation and the development of VAP.
7. Suction as per attached Badger guideline
8. Oral hygiene as per standard nursing care
9. Extubate babies to non-invasive respiratory support at earliest safe opportunity
10. Gastric ulcer prophylaxis: There is no evidence to support this in neonates as they have a higher gastric pH and are fed early. In addition there is an association with H2 agonists and necrotising enterocolitis and gram negative bacteraemia.

References:

NHS. High Impact Intervention No 5. Care bundle for ventilated patients (or tracheostomy where appropriate).

Rose et al. Semirecumbent Positioning in Ventilator-Dependent Patients: A Multicenter, Observational StudyAmerican Journal of Critical Care. 2010;19:e100-e108

lly H, Badawy M, El-Kholy A et al. Randomized, Contolled Trial on tracheal colonization of ventilated infants; Can gravity prevent ventilator-associated pneumonia? Pediatrics 2008;122;770-774 

Han, J. and Liu, Y. Effect of ventilator circuit changes on ventilator-associated pneumonia: a systematic review and meta-analysis. Respir Care 2010; 55: 467-474

Balaguer A, Escribano J, Roqué i Figuls M. Infant position in neonates receiving mechanical ventilation. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003668. DOI: 10.1002/14651858.CD003668.pub2.

Diego J. Maselli and Marcos I. Strategies in the prevention of ventilator-associated pneumonia. Restrepo Ther Adv Respir Dis, 2011; 5(2): 131-141

Alexiou, V.G., Ierodiakonou, V., Dimopoulos, G. and Falagas, M.E. Impact of patient position on the incidence of ventilator-associated pneumonia: a metaanalysis of randomized controlled trials. J Crit Care, 2009;24: 515_522.