Clinical review: Airway hygiene in the intensive care unit

Table 1 Recommendations for airway hygiene in critically ill patients for reduction in health-care-associated pneumonia

Strategies	Recommended for clinical use	Grade	Reduction in HCAP	Reduction in mortality	Refs
Effective strategies
Chlorhexidine gluconate oral rinse	Yes	A	Yes	No	11–14
Endotracheal suctioning on 'as needed' basis (compared with routine suctioning)	Yes	A	No increased incidence of HCAP	No	45,57,58
Kinetic therapy	Yes^a	A	Inconclusive	No	105–111
Ineffective strategies
Selective digestive decontamination	No	A	Inconclusive	No	15–33
Oral topical iseganan	No	B	No	No	35
Aerosolized mucus-controlling agents	No	U	N/A	N/A	85–88
Endotracheal instillation of saline	No	C	N/A	N/A	52,53
Chest physiotherapy	No	A	Inconclusive	No	114, 117–125
Strategies of equivocal or undetermined effectiveness
Continuous subglottic suctioning	Yes^b	A	Yes	No	70–75
Bronchoscopy	Yes^c	B	N/A	N/A	114
Closed (in-line) endotracheal suctioning (compared with open suctioning)	Yes^d	A	Inconclusive	No	59–68

The grading scheme used is as follows: A, supported by at least two randomized, controlled investigations; B, supported by at least one randomized, controlled investigation; C, supported by nonrandomized, concurrent-cohort investigations, historical-cohort investigations, or case series; U, undetermined or not yet studied in clinical investigations. HCAP, healthcare-associated pneumonia; N/A, not applicable. ^aThe increased cost of kinetic beds is offset by the decreased length of stay; ^bthis strategy is recommended for patients expected to require more than 72 hours of mechanical ventilation; ^cthis strategy is recommended for patients with acute atelectasis involving more than a single lung segment in the absence of air bronchograms who remain symptomatic after 24 hours of chest physiotherapy; ^dthis strategy is recommended for patients requiring mechanical ventilation for more than four days.

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