Efficacy of Nurse-Led Sedation Protocols in Preventing Ventilator-Associated Pneumonia in Mechanically Ventilated ICU Patients: A Systematic Review
Abstract
Background: Ventilator-associated pneumonia (VAP) remains a significant challenge in intensive care units, especially among mechanically ventilated patients. Sedation protocols, particularly nurse-led interventions, have been suggested to improve patient outcomes by reducing the incidence of VAP. This study evaluated the effectiveness of such protocols on VAP incidence, mechanical ventilation duration and ICU length of stay.
Methods: A comprehensive search of electronic databases, including MEDLINE, EMBASE and Cochrane CENTRAL from inception to 30 August 2024 was conducted following PRISMA guidelines. Nurse-led sedation protocols and their impact on VAP outcomes were selected for meta-analysis. Data extraction included sample size, interventions, control measures and primary outcomes. Statistical analysis was performed using a fixed-effects model to calculate risk differences and odds ratios with heterogeneity assessed using the I² statistic.
Results: The systematic review comprised 15 studies, with 7 studies meeting the criteria for meta-analysis. Nurse-led sedation protocols were associated with a significant reduction in the duration of mechanical ventilation (Risk Difference: -0.21; 95% CI: -0.37 to -0.04, P=0.01). However, analyzing VAP-related mortality, the odds ratio (OR: 0.80; 95% CI: 0.60 to 1.07) indicated no statistically significant difference between intervention and control groups (P=0.14).
Conclusion: Nurse-led sedation protocols show promise in reducing the duration of mechanical ventilation, impact on VAP-related mortality remains inconclusive. Future research should focus on refining these protocols and further evaluating their long-term effects on VAP prevention and patient outcomes.
1. Papazian L, Klompas M, Luyt CE (2020). Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med, 46(5):888-906.
2. Mumtaz H, Saqib M, Khan W, et al (2023). Ventilator associated pneumonia in in-tensive care unit patients: a systematic review. Ann Med Surg (Lond), 85(6):2932-2939.
3. Kalanuria AA, Ziai W, Mirski M (2014). Ventilator-associated pneumonia in the ICU. Crit Care, 18(2):208.
4. Grap MJ, Munro CL, Wetzel PA, et al (2012). Sedation in adults receiving me-chanical ventilation: physiological and comfort outcomes. Am J Crit Care, 21(3):e53-63.
5. Torres A, Niederman MS, Chastre J, et al (2017). International ERS/ESICM/ESCMID/ALAT guide-lines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Res-piratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbi-ology and Infectious Diseases (ESCMID) and Asociación Latinoameri-cana del Tórax (ALAT). Eur Respir J, 50(3): 1700582.
6. Kalil AC, Metersky ML, Klompas M, et al (2016). Management of adults with hos-pital-acquired and ventilator-associated pneumonia: 2016 clinical practice guide-lines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis, 63(5):e61-e111.
7. Mehta S, Burry L, Cook D, et al (2012). Ca-nadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA, 308(19):1985-1992.
8. Hazwani T, Al Ahmady A, Kazzaz Y, et al (2022). Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit. BMJ Open Qual, 11(1): e001501.
9. Barr J, Fraser GL, Puntillo K, et al (2013). Clinical practice guidelines for the management of pain, agitation, and de-lirium in adult patients in the ICU. Crit Care Med, 41(1):263-306.
10. Girard TD, Kress JP, Fuchs BD, et al (2008). Efficacy and safety of a paired sedation and ventilator weaning proto-col for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a random-ized controlled trial. Lancet, 371(9607):126-134.
11. Qi X, Tian S, Yan Y, et al (2020). Nurse-led sedation protocols for mechanically ventilated adults in intensive care units: A systematic review and meta-analysis. J Crit Care, 57:184-190.
12. Quenot JP, Ladoire S, Devoucoux F, et al (2007). Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia. Crit Care Med, 35(9):2031-2036.
13. Treggiari MM, Romand JA, Yanez ND, et al (2009). Randomized trial of light ver-sus deep sedation on mental health after critical illness. Crit Care Med, 37(9):2527-2534.
14. Jackson DL, Proudfoot CW, Cann KF, et al (2010). A systematic review of the impact of sedation practice in the ICU on re-source use, costs and patient safety. Crit Care, 14(2): R59.
15. Lu R, Song H, Wang L, et al (2022). The Application of the Nurse-Led Sedation and Analgesia Management in ICU after Heart Surgeries. Evid Based Complement Al-ternat Med, 2022: 7706172.
16. Review Manager (RevMan) [Computer pro-gram]. Version 5.4 (2020). The Cochrane Collaboration.
17. Shahabi M, Yousefi H, Yazdannik AR, et al (2016). The effect of daily sedation in-terruption protocol on early incidence of ventilator-associated pneumonia among patients hospitalized in critical care units receiving mechanical ventila-tion. Iran J Nurs Midwifery Res, 21(5):541-546.
18. Qi Z, Yang S, Qu J, et al (2021). Effects of nurse-led sedation protocols on me-chanically ventilated intensive care adults: A systematic review and meta-analysis. Aust Crit Care, 34(3):278-286.
19. Muller L, Chanques G, Bourgaux C, et al (2008). Impact of the use of propofol remifentanil goal-directed sedation adapted by nurses on the time to extuba-tion in mechanically ventilated ICU pa-tients: the experience of a French ICU. Ann Fr Anesth Reanim, 27(6):481. e1-8.
20. Croce MA, Brasel KJ, Coimbra R, et al (2013). National Trauma Institute pro-spective evaluation of the ventilator bundle in trauma patients: does it really work? J Trauma Acute Care Surg, 74(2):354-60.
21. Weheida SM, Omran ES, Taha AS (2022). Effect of Designed Bundle Protocol about Ventilator Associated Pneumonia on Nurses’ Performance, Compliance, and Patient Outcomes. Evid Based Nurs Res, 4(3):71-85.
22. Aitken LM, Kydonaki K, Blackwood B, et al (2021). Inconsistent relationship between depth of sedation and intensive care outcome: systematic review and meta-analysis. Thorax, 76(11):1089-1098.
23. Mastrogianni M, Katsoulas T, Galanis P, et al (2023). The Impact of Care Bundles on Ventilator-Associated Pneumonia (VAP) Prevention in Adult ICUs: A Sys-tematic Review. Antibiotics (Basel), 12(2):227.
24. Melsen WG, Rovers MM, Groenwold RH, et al (2013). Attributable mortality of ventilator-associated pneumonia: a me-ta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis, 13(8):665-71.
25. Koenig SM, Truwit JD (2006). Ventilator-associated pneumonia: diagnosis, treat-ment, and prevention. Clin Microbiol Rev, 19(4):637-57.
26. Timsit JF, Esaied W, Neuville M, et al (2017). Update on ventilator-associated pneumonia. F1000Res, 6:2061.
27. Balit CR, LaRosa JM, Ong JSM, et al (2021). Sedation protocols in the pediatric in-tensive care unit: fact or fiction? Transl Pediatr, 10(10):2814-2824.
28. Wu D, Wu C, Zhang S, Zhong Y (2019). Risk Factors of Ventilator-Associated Pneumonia in Critically III Patients. Front Pharmacol, 10:482.
29. Bonten MJ, Kollef MH, Hall JB (2004). Risk factors for ventilator-associated pneu-monia: from epidemiology to patient management. Clin Infect Dis, 38(8):1141-9.
30. Mo Y, Booraphun S, Li AY, et al (2024). In-dividualised, short-course antibiotic treatment versus usual long-course treatment for ventilator-associated pneumonia (REGARD-VAP): a multi-centre, individually randomised, open-label, non-inferiority trial. Lancet Respir Med, 12(5):399-408.
31. Gurunathan S, Thangaraj P, Wang L, et al (2024). Nanovaccines: an effective ther-apeutic approach for cancer therapy. Bi-omed Pharmacother, 170: 115992.
32. Prakash P, Selvam K, Gayathiri E, et al (2022). Plant-Based Natural Bioactive Compounds 2,4-Ditert-Butylphenolas: A Potential Candidates Against SARS-Cov-2019. Energy Nexus, 6: 100080.
33. Gurunathan S, Thangaraj P, Das J, Kim JH (2023). Antibacterial and antibiofilm ef-fects of Pseudomonas aeruginosa derived outer membrane vesicles against Strepto-coccus mutans. Heliyon, 9(12): e22606.
34. Klompas M, Branson R, Cawcutt K, et al (2022). Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol, 43(6):687-713.
2. Mumtaz H, Saqib M, Khan W, et al (2023). Ventilator associated pneumonia in in-tensive care unit patients: a systematic review. Ann Med Surg (Lond), 85(6):2932-2939.
3. Kalanuria AA, Ziai W, Mirski M (2014). Ventilator-associated pneumonia in the ICU. Crit Care, 18(2):208.
4. Grap MJ, Munro CL, Wetzel PA, et al (2012). Sedation in adults receiving me-chanical ventilation: physiological and comfort outcomes. Am J Crit Care, 21(3):e53-63.
5. Torres A, Niederman MS, Chastre J, et al (2017). International ERS/ESICM/ESCMID/ALAT guide-lines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Res-piratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbi-ology and Infectious Diseases (ESCMID) and Asociación Latinoameri-cana del Tórax (ALAT). Eur Respir J, 50(3): 1700582.
6. Kalil AC, Metersky ML, Klompas M, et al (2016). Management of adults with hos-pital-acquired and ventilator-associated pneumonia: 2016 clinical practice guide-lines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis, 63(5):e61-e111.
7. Mehta S, Burry L, Cook D, et al (2012). Ca-nadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA, 308(19):1985-1992.
8. Hazwani T, Al Ahmady A, Kazzaz Y, et al (2022). Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit. BMJ Open Qual, 11(1): e001501.
9. Barr J, Fraser GL, Puntillo K, et al (2013). Clinical practice guidelines for the management of pain, agitation, and de-lirium in adult patients in the ICU. Crit Care Med, 41(1):263-306.
10. Girard TD, Kress JP, Fuchs BD, et al (2008). Efficacy and safety of a paired sedation and ventilator weaning proto-col for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a random-ized controlled trial. Lancet, 371(9607):126-134.
11. Qi X, Tian S, Yan Y, et al (2020). Nurse-led sedation protocols for mechanically ventilated adults in intensive care units: A systematic review and meta-analysis. J Crit Care, 57:184-190.
12. Quenot JP, Ladoire S, Devoucoux F, et al (2007). Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia. Crit Care Med, 35(9):2031-2036.
13. Treggiari MM, Romand JA, Yanez ND, et al (2009). Randomized trial of light ver-sus deep sedation on mental health after critical illness. Crit Care Med, 37(9):2527-2534.
14. Jackson DL, Proudfoot CW, Cann KF, et al (2010). A systematic review of the impact of sedation practice in the ICU on re-source use, costs and patient safety. Crit Care, 14(2): R59.
15. Lu R, Song H, Wang L, et al (2022). The Application of the Nurse-Led Sedation and Analgesia Management in ICU after Heart Surgeries. Evid Based Complement Al-ternat Med, 2022: 7706172.
16. Review Manager (RevMan) [Computer pro-gram]. Version 5.4 (2020). The Cochrane Collaboration.
17. Shahabi M, Yousefi H, Yazdannik AR, et al (2016). The effect of daily sedation in-terruption protocol on early incidence of ventilator-associated pneumonia among patients hospitalized in critical care units receiving mechanical ventila-tion. Iran J Nurs Midwifery Res, 21(5):541-546.
18. Qi Z, Yang S, Qu J, et al (2021). Effects of nurse-led sedation protocols on me-chanically ventilated intensive care adults: A systematic review and meta-analysis. Aust Crit Care, 34(3):278-286.
19. Muller L, Chanques G, Bourgaux C, et al (2008). Impact of the use of propofol remifentanil goal-directed sedation adapted by nurses on the time to extuba-tion in mechanically ventilated ICU pa-tients: the experience of a French ICU. Ann Fr Anesth Reanim, 27(6):481. e1-8.
20. Croce MA, Brasel KJ, Coimbra R, et al (2013). National Trauma Institute pro-spective evaluation of the ventilator bundle in trauma patients: does it really work? J Trauma Acute Care Surg, 74(2):354-60.
21. Weheida SM, Omran ES, Taha AS (2022). Effect of Designed Bundle Protocol about Ventilator Associated Pneumonia on Nurses’ Performance, Compliance, and Patient Outcomes. Evid Based Nurs Res, 4(3):71-85.
22. Aitken LM, Kydonaki K, Blackwood B, et al (2021). Inconsistent relationship between depth of sedation and intensive care outcome: systematic review and meta-analysis. Thorax, 76(11):1089-1098.
23. Mastrogianni M, Katsoulas T, Galanis P, et al (2023). The Impact of Care Bundles on Ventilator-Associated Pneumonia (VAP) Prevention in Adult ICUs: A Sys-tematic Review. Antibiotics (Basel), 12(2):227.
24. Melsen WG, Rovers MM, Groenwold RH, et al (2013). Attributable mortality of ventilator-associated pneumonia: a me-ta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis, 13(8):665-71.
25. Koenig SM, Truwit JD (2006). Ventilator-associated pneumonia: diagnosis, treat-ment, and prevention. Clin Microbiol Rev, 19(4):637-57.
26. Timsit JF, Esaied W, Neuville M, et al (2017). Update on ventilator-associated pneumonia. F1000Res, 6:2061.
27. Balit CR, LaRosa JM, Ong JSM, et al (2021). Sedation protocols in the pediatric in-tensive care unit: fact or fiction? Transl Pediatr, 10(10):2814-2824.
28. Wu D, Wu C, Zhang S, Zhong Y (2019). Risk Factors of Ventilator-Associated Pneumonia in Critically III Patients. Front Pharmacol, 10:482.
29. Bonten MJ, Kollef MH, Hall JB (2004). Risk factors for ventilator-associated pneu-monia: from epidemiology to patient management. Clin Infect Dis, 38(8):1141-9.
30. Mo Y, Booraphun S, Li AY, et al (2024). In-dividualised, short-course antibiotic treatment versus usual long-course treatment for ventilator-associated pneumonia (REGARD-VAP): a multi-centre, individually randomised, open-label, non-inferiority trial. Lancet Respir Med, 12(5):399-408.
31. Gurunathan S, Thangaraj P, Wang L, et al (2024). Nanovaccines: an effective ther-apeutic approach for cancer therapy. Bi-omed Pharmacother, 170: 115992.
32. Prakash P, Selvam K, Gayathiri E, et al (2022). Plant-Based Natural Bioactive Compounds 2,4-Ditert-Butylphenolas: A Potential Candidates Against SARS-Cov-2019. Energy Nexus, 6: 100080.
33. Gurunathan S, Thangaraj P, Das J, Kim JH (2023). Antibacterial and antibiofilm ef-fects of Pseudomonas aeruginosa derived outer membrane vesicles against Strepto-coccus mutans. Heliyon, 9(12): e22606.
34. Klompas M, Branson R, Cawcutt K, et al (2022). Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol, 43(6):687-713.
| Files | ||
| Issue | Vol 54 No 8 (2025) | |
| Section | Review Article(s) | |
| DOI | https://doi.org/10.18502/ijph.v54i8.19573 | |
| Keywords | ||
| Ventilator-associated pneumonia Sedation protocols Nurse-led intervention nurse practice pattern Intensive care unit Mechanical ventilation interactive ventilatory support | ||
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How to Cite
1.
Shen L, Li H. Efficacy of Nurse-Led Sedation Protocols in Preventing Ventilator-Associated Pneumonia in Mechanically Ventilated ICU Patients: A Systematic Review. Iran J Public Health. 2025;54(8):1643-1655.
