ClinicalArticle

Ventilator-Associated
Pneumonia
Risk Factors and
Prevention
Beth Augustyn, RN, MSN, ACNP, CCRN

P neumonia is the second most

common nosocomial infection in the
United States and is a leading cause
The incidence of VAP is 22.8% in
patients receiving mechanical venti-
lation,3 and patients receiving venti-
Interventions to prevent VAP
begin at the time of intubation and
should be continued until extubation.
of death due to hospital-acquired latory support account for 86% of With the extreme shortage of nurses
infections.1 Ventilator-associated the cases of nosocomial pneumonia.4 and the resultant increase in the
pneumonia (VAP) is a form of noso- Furthermore, the risk for pneumonia number of less experienced nurses
comial pneumonia that occurs in increases 3- to 10-fold in patients in the intensive care unit, education
patients receiving mechanical venti- receiving mechanical ventilation.5 on the prevention of VAP is essen-
lation for longer than 48 hours.2 VAP is associated with increases tial, because the occurrence of noso-
in morbidity and mortality, hospital comial infections is directly related
length of stay, and costs. The mor- to the adequacy of staff.8 Nurses
tality rate attributable to VAP is 27% need to understand the pathophysi-
and has been as high as 43% when the ology of VAP, risk factors for this
causative agent was antibiotic resist- type of pneumonia, and strategies
This article has been designated for CE credit. ant.6 Length of stay in the intensive that may prevent the disease.
A closed-book, multiple-choice examination
follows this article, which tests your knowledge care unit is increased by 5 to 7 days3
of the following objectives: and hospital length of stay 2- to 3- Pathophysiology
1. Describe the 2 main pathophysiology fold in patients with VAP.2 The cost The onset of VAP can be divided
processes of ventilator-associated pneumonia
(VAP) of VAP is estimated to be an addi- into 2 types: early and late. Early-
2. Identify risk factors for VAP tional $40000 per hospital admission onset VAP occurs 48 to 96 hours
3. Discuss timeframe interventions to prevent per patient with the disease1 and an after intubation and is associated
VAP estimated $1.2 billion per year.7 with antibiotic-susceptible organisms.
Late-onset VAP occurs more than 96
hours after intubation and is associ-
Author
ated with antibiotic-resistant organ-
Beth Augustyn is employed by Chest Medicine Consultants, Chicago, Illinois. isms2 (Table 1). Interventions to
Corresponding author: Beth Augustyn, Chest Medicine Consultants, 2800 N Sheridan Rd, Ste 301, Chicago,
IL 60657 (e-mail: [email protected]). prevent VAP should begin at the
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. time of, or if possible, before intuba-
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. tion. The pathophysiology of VAP

32 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 http://ccn.aacnjournals.org

 tracheal tubes cause an abnormal starting treatment is critical. Diagnos-
Table 1 Bacteria associated with
ventilator-associated pneumonia interruption between the upper air- ing VAP remains difficult and contro-
Early onset way and the trachea, bypassing the versial. The diagnosis can be made on
Staphylococcus aureus structures in the upper airway and the basis of radiographic findings,
Streptococcus pneumoniae
Hemophilus influenzae providing bacteria a direct route into clinical findings, results of microbi-
Proteus species the lower airway.10 Because the upper ological tests of sputum, or invasive
Serratia marcescens airway is bypassed, a decrease occurs testing such as bronchoscopy.15 The
Klebsiella pneumoniae
Escherichia coli in the body’s ability to filter and diagnosis is most often based on
Late onset humidify air.12 In addition, the cough visualization of a new or progressive
Pseudamonas aeruginosa reflex is often eliminated and/or infiltrate on chest radiographs.16
Methicillin-resistant Staphylococcus
aureus
decreased by the presence of an However, findings on chest radi-
Acinetobacter species endotracheal tube,2 and mucociliary ographs are not reproducible and
Enterobacter species clearance can be impaired because should not be used alone for the
of mucosal injury during intubation.13 diagnosis of VAP.13 Other causes of
involves 2 main processes: coloniza- An endotracheal tube provides a pulmonary infiltrates visualized on
tion of the respiratory and digestive place for bacteria to bind in the tra- chest radiographs of patients receiv-
tracts and microaspiration of secre- chea, a situation that further increases ing mechanical ventilation include
tions of the upper and lower parts production and secretion of mucus.13 atelectasis, aspiration, pulmonary
of the airway.9 The impairment of these natural embolism, pulmonary edema, alveo-
Colonization of bacteria refers to host defense mechanisms increases lar hemorrhage, pulmonary infarc-
the presence of bacteria without an the likelihood of bacterial coloniza- tion, and acute respiratory distress
active host response.10 Bacterial col- tion and subsequent aspiration of syndrome. The likelihood of VAP
onization of the lungs can be due to the colonized organisms. increases if a patient has clinical
spread of organisms from many dif- Aspiration of gastric contents is signs and symptoms such as fever,
ferent sources, including the orophar- another potential cause of VAP, leukocytosis, and purulent sputum
ynx, sinus cavities, nares, dental because the stomach serves as a reser- in addition to abnormal findings on
plaque, gastrointestinal tract, patient- voir for bacteria. Most patients receiv- chest radiographs.16 The results of
to-patient contact, and the ventilator ing mechanical ventilation have a microbiological tests of sputum spec-
circuit.10 Inhalation of colonized bac- nasogastric or an orogastric tube in imens obtained by either invasive or
teria from any of these sources can place for enteral feedings and admin- noninvasive methods are not suffi-
cause an active host response and, istration of medications or for gastric cient for the diagnosis of VAP, but
ultimately, VAP. decompression. The presence of a culture and sensitivity results can be
The presence of an endotracheal nasogastric or an orogastric tube helpful for choosing an antibiotic.17
tube provides a direct route for colo- interrupts the gastroesophageal
nized bacteria to enter the lower res- sphincter, leading to increased gas- Risk Factors
piratory tract. Upper airway and oral trointestinal reflux and providing a Although any patient with an
secretions can pool above the cuff of route for bacteria to translocate to the endotracheal tube in place for more
an endotracheal tube and line the oropharynx and colonize the upper than 48 hours is at risk for VAP, cer-
tube, forming a biofilm. Starting as airway. Enteral feedings increase both tain patients are at higher risk. The
early as 12 hours after intubation, gastric pH and gastric volume, risk factors for VAP can be divided
the biofilm contains large amounts increasing the risk of both bacterial into 3 categories: host related, device
of bacteria that can be disseminated colonization and aspiration.14 related, and personnel related
into the lungs by ventilator-induced (Table 2). Host-related risk factors
breaths.10-12 In addition, the biofilm Diagnosis include preexisting conditions such
may become dislodged by instillation Because every patient who is intu- as immunosuppression, chronic
of saline into the endotracheal tube, bated and receiving ventilatory sup- obstructive lung disease, and acute
suctioning, coughing, or reposition- port is at risk for VAP, making an respiratory distress syndrome. Other
ing of the endotracheal tube.12 Endo- accurate diagnosis of this disease and host-related factors include patients’

http://ccn.aacnjournals.org CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 33

 Table 2 Risk factors for ventilator-
risk for VAP. The question of whether
Table 3 Strategies to prevent
associated pneumonia placement of nasogastric or orogas- ventilator-associated pneumonia
Host related tric tubes distal to the pylorus Prevent colonization
Underlying medical conditions decreases the risk of aspiration and Follow protocol for hand washing
Immunosuppression Use oral decontamination
Chronic obstructive lung disease
VAP remains unanswered. The results Use stress ulcer prophylaxis
Adult respiratory distress syndrome of studies on the relationship between Avoid saline lavage with suctioning
Patients’ body position use of small-bore feeding tubes and Turn patients at least every 2 hours
Level of consciousness Change ventilator circuit no more
Number of intubations the incidence of VAP have been than every 48 hours
Medications inconclusive. The Centers for Disease Prevent aspiration
Device related Control and Prevention makes no Position the head of the bed >30º
Endotracheal tube Minimize the use of narcotic and
recommendations about routine use sedative agents
Ventilator circuit
Nasogastric or orogastric tubes of postpyloric feeding tubes or small- Thoroughly suction the oropharynx
bore feeding tubes, because these Use endotracheal tubes that have
Personnel related
continuous subglottic suction ports
Improper hand washing issues remain controversial and fur- Monitor gastric residual volumes for
Failure to change gloves between
contacts with patients
ther research is needed.1 overdistention
Maintain adequate endotracheal tube
Not wearing personal protective Improper hand washing resulting cuff pressures of at least 20 cm H2O
equipment when antibiotic resistant in the cross-contamination of patients
bacteria have been identified
is the biggest personnel-related risk
factor for VAP. Patients who are resistant organisms have been iden-
body positioning, level of conscious- intubated and receiving mechanical tified increases the risk of cross-
ness, number of intubations, and ventilation often need interventions contamination between patients.1
medications, including sedative such as suctioning or manipulation
agents and antibiotics. In one study,18 of the ventilator circuit. These inter- Prevention
bacterial contamination of endotra- ventions increase the likelihood of Although VAP has multiple risk
cheal secretions was higher in patients cross-contamination between patients factors, many nursing interventions
in the supine position than in patients if healthcare staff do not use proper can reduce the incidence of this dis-
in the semirecumbent position. hand-washing techniques. Failure to ease (Table 3). Prevention of pneu-
Whether due to a pathophysiologi- wash hands and change gloves monia, both in and outside of the
cal process, medication, or injury, between contaminated patients has hospital, begins with vaccination
decreased level of consciousness been associated with an increased (Figure 1).22 Nurses are the first line
resulting in the loss of the cough and incidence of VAP.21 In addition, fail- of defense in preventing bacterial
gag reflexes contributes to the risk of ure to wear proper personal protec- colonization of the oropharynx and
aspiration and therefore increased tive equipment when antibiotic- the gastrointestinal tract. Meticulous
risk for VAP.19 Reintubation and sub-
sequent aspiration can increase the No or
likelihood of VAP 6-fold.20 Has the person been unsure
Vaccination indicated
Device-related risk factors include vaccinated previously?

the endotracheal tube, the ventilator Yes

circuit, and the presence of a nasogas- Yes
Was the person aged No
tric or an orogastric tube. Secretions Have >5 years elapsed
>65 years at the time
pool above the cuff of an endotra- since the first dose?
of last vaccination?
cheal tube, and low cuff pressures can Yes*
lead to microaspiration and/or leak- No
age of bacteria around the cuff into Vaccination not indicated
the trachea.14 As mentioned earlier, Figure 1 Algorithm for giving pneumococcal vaccine.
nasogastric and orogastric tubes dis- *Note: For any person who has received a dose of pneumococcal vaccine at age >65 years, revaccination is
not indicated.
rupt the gastroesophageal sphincter,
Reprinted from Centers for Disease Control and Prevention.22
leading to reflux and an increased

34 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 http://ccn.aacnjournals.org

hand washing for 10 seconds should firmed to decrease the incidence of versus closed suction systems.29 When
be performed before and after all VAP in patients receiving mechani- a closed system is used, the suction
contact with patients.1 In addition, cal ventilation. catheter should be rinsed free of
gloves should be worn when contact Bacterial colonization of the secretions away from the patient.
with oral or endotracheal secretions stomach can lead to aspiration and Furthermore, saline lavage of
is possible. Strategically placing a sign colonization of the respiratory tract. endotracheal tubes before suction-
on a patient’s door to remind health- Most patients receiving mechanical ing dislodges bacteria from the
care workers to wash their hands ventilation are given stress ulcer endotracheal tube into the lower air-
and wear gloves is an easy and cost- prophylaxis, often with medications ways, increasing the risk for VAP.30
effective measure that can help mini- that increase the gastric pH. A study25 Saline lavage has long been consid-
mize transmission of bacteria between in the 1980s indicated that pathogens ered a means to liquefy secretions
patients. The use of protective gowns multiply in an alkaline gastric envi- and prevent plugs of mucus in
is not recommended as routine prac- ronment. In the largest study26 on the endotracheal tubes. However, in
tice, but gowns should be used when risk for VAP with stress ulcer pro- one study,31 saline instillation did
antibiotic-resistant pathogens have phylaxis, ranitidine, an H2-receptor not thin secretions; rather it reduced
been isolated and identified.1 blocker, significantly reduced the the amount of oxygen that reached
Oral decontamination, by reduc- risk of clinically important bleeding the lungs and increased blood pres-
ing the amount of bacteria within a without increasing the risk of VAP sure, heart rate, intracranial pressure,
patient’s oral cavity, can be accom- or mortality. In another large study,27 and the risk for VAP. Maintaining
plished by both mechanical and mechanical ventilation for greater adequate hydration, ensuring proper
pharmacological interventions. than 48 hours was associated with a humidification of the ventilatory
Mechanical interventions include 16-fold increase in the risk for gas- circuit, and using nebulizer or
tooth brushing and rinsing of the trointestinal bleeding. In research28 mucolytic agents can help decrease
oral cavity to remove dental plaque; conducted in a pediatric intensive the viscosity of secretions and elimi-
pharmacological interventions care unit, VAP rates did not differ nate the need for saline lavage.30,31
involve the use of antimicrobial between patients receiving ranitidine, Prophylactic use of systemic antibi-
agents.23 Bacteria in dental plaque omeprazole, or sucralfate for stress otics does not decrease the incidence
can be removed by brushing the teeth ulcer prophylaxis. Unfortunately, as of VAP and when the agents are used
and thoroughly suctioning secre- the use of proton pump inhibitors inappropriately, antibiotic resistance
tions from the mouth. Both of these for stress ulcer prophylaxis has can develop.32
interventions decrease the likelihood increased, few studies have been con- Routine turning of patients a min-
of colonization of the oropharynx. ducted in adults to address whether imum of every 2 hours can increase
Pharmacological interventions the incidence of VAP is affected by the pulmonary drainage and decrease
include twice-a-day use of chlorhexi- use of these inhibitors. In summary, the risk for VAP. Use of beds capable
dine oral rinse. In a study24 of patients according to the studies done so far, of continuous lateral rotation can
undergoing cardiac surgery, use of stress ulcer prophylaxis does not decrease the incidence of pneumo-
chlorhexidine decreased the inci- play a significant role in the devel- nia but do not decrease mortality or
dence of VAP by decreasing coloniza- opment of VAP but may prevent the duration of mechanical ventilation.33
tion. In another study,7 use every 6 serious complication of gastrointesti- These beds are costly and are not
hours of a solution containing gen- nal bleeding. necessary for routine use in the pre-
tamicin, colistin, and vancomycin Mucus in the airways can become vention of VAP,1 although the use of
decreased the incidence of VAP by stagnant and serve as a medium for specialty beds may be cost-effective
16% and resulted in an estimated cost bacterial growth. Maintenance of and therapeutic for patients with
savings of $13000 for every case of aseptic technique when performing poor oxygenation or impaired
VAP prevented. Unfortunately, except endotracheal suctioning is essential wound healing.
for patients undergoing cardiac sur- to prevent contamination of the air- Colonization of the ventilator
gery, no evidence-based protocols for ways. No difference has been found circuit can also play a role in the
oral care have been tested and con- in the incidence of VAP with open development of VAP. Daily changes

http://ccn.aacnjournals.org CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 35

of the ventilator circuit do not seem agents in the intensive care unit hypothesized that silver nitrate
to decrease the incidence of VAP.34 must be done cautiously, because interferes with the ability of bacteria
The Centers for Disease Control and pain can limit deep breathing and to line the endotracheal tube and
Prevention does not recommend impair oxygenation. Daily interrup- form a biofilm. In a study11 of dogs
changing the ventilator circuit more tions of continuous sedative infu- receiving mechanical ventilation,
than once every 48 hours,1 and sions can shorten the duration of endotracheal tubes coated with sil-
research35 has indicated that chang- mechanical ventilation by more ver nitrate were less likely to become
ing the ventilator circuit as infre- than 2 days and length of stay in the colonized with bacteria than were
quently as once a week does not intensive care unit by 3.5 days.38 traditional endotracheal tubes. Fur-
increase the risk for VAP. It is rec- Monitoring gastric residual volumes ther studies are needed to determine
ommended that the ventilator circuit and administering agents to increase the cost-effectiveness of these coated
be changed when visibly soiled.1 gastric motility have been suggested tubes in preventing VAP.
Many investigators have compared as ways to prevent gastric overdis-
the impact of heat and moisture tention.2 Although the effectiveness Role of Nurses
exchangers on the incidence of VAP of these interventions in reducing The effects of VAP on morbidity,
with the impact of heated humidifiers. VAP has not been tested in clinical mortality, length of hospital stay,
The results were inconclusive as to trials, it is reasonable to avoid gas- and cost are immense. Education
which form of humidity is associated tric overdistention in an attempt to plays a key role in the management
with a higher incidence of VAP. prevent aspiration. of patients with VAP. Use of self-study
In addition to strategies to prevent Because secretions tend to pool education modules on the nursing
colonization, strategies to prevent above the cuffs of endotracheal tubes, care of patients at risk for VAP can
aspiration can also be used to decrease the oropharynx should be thoroughly decrease the rate of this type of
the risk for VAP. Because the pres- suctioned to prevent aspiration of pneumonia, the number of days of
ence of an endotracheal tube predis- the pooled secretions before an mechanical ventilation, and the cost
poses patients to VAP, patients should endotracheal tube is replaced. Pres- of the disease.8
be assessed on a daily basis for sure in the cuff should be measured Healthcare systems can also play
potential weaning and extubation and should be maintained at no less a role in preventing VAP by employ-
from mechanical ventilation. Several than 20 cm H2O.39 Maintaining ade- ing outcome managers to provide a
methods of assessing readiness for quate cuff pressures decreases the more comprehensive approach to VAP
extubation exist. These include T- likelihood that secretions will leak prevention. In one study,42 the dura-
piece trials, weaning intermittent around the cuff or be aspirated. Use tion of mechanical ventilation, hos-
mandatory ventilation, and pressure- of tubes with ports for continuous pital and intensive care unit lengths
support ventilation.36 subglottic suctioning can decrease of stay, and mortality decreased
Positioning patients in a semi- the incidence of VAP by 50%,40 and when an outcome manager was used.
recumbent position with the head of costs per episode of VAP have been Outcome managers can be responsi-
the bed elevated 30º to 45º prevents reduced as much as $18000 when ble for ensuring that protocols to
reflux and aspiration of bacteria from endotracheal tubes with continuous prevent VAP and other complica-
the stomach into the airways. Sim- subglottic suctioning are used rather tions of intubation and mechanical
ply elevating the head of the bed 30º than traditional endotracheal tubes.41 ventilation are developed and are
can decrease VAP by 34%.37 Impaired Studies are also being conducted being followed appropriately. The
gastric emptying can lead to overdis- with endotracheal tubes coated with use of ventilator pathways and/or
tention, or increased gastric residual silver nitrate. Use of urinary catheters protocols with preprinted order sets
volume, of the stomach and the poten- coated with silver nitrate has been (Figure 2) can also lead to improved
tial for regurgitation and aspiration. associated with a decreased incidence outcomes for patients. A simple, yet
Minimizing the use of narcotic agents of urinary tract infections; therefore, cost-effective way to ensure compli-
can help prevent aspiration of gastric it is thought that endotracheal tubes ance with elevating the head of the
and/or oral contents.2 Decreasing coated with silver nitrate might bed is random daily audits. The
use of narcotic and/or sedative decrease the incidence of VAP. It is rationale for why a patient cannot

36 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 http://ccn.aacnjournals.org

 Adult Ventilator Pathway / Critical Care

(Use ballpoint pen only)

Date Date
Hour Orders Hour Nurse
1. Initiate Adult Ventilator Management Pathway.

2. Ventilator to be managed by:

3. Ventilator settings:
FiO2 _______ Rate _______ PEEP _______
Tidal volume _______ Mode _______ Pressure support _______

4. Complete daily weaning parameter and document in EMTEK by 0900.

5. Initiate Rapid Wean Protocol when stability criteria are met. If Rapid
Wean Protocol fails, initiate Ventilator Extended Weaning Protocol.

6. Initiate diuretic regimen for patients in CHF or pulmonary edema.

7. Nutrition consult on admission.

8. Place on appropriate bed/overlay per skin care guidelines.

9. Daily CXR while in ICU.

10. Initiate Continuous Lateral Rotation Therapy if P/F Ratio < 250 after
twelve hours in ICU.

11. Initiate prophylactic oral hygiene.

12. Keep head of bed > 45º unless contra-indicated.

13. PT/OT evaluation and treatment. Pt. activity level: ____________________________

Place L’nard boots.

14. Prealbumin Monday/Thursday

15. Sedation/analgesia per ventilation sedation order sheet to keep Riker

score between -1 and +1.

16. Schedule care conference during acute phase of mechanical ventilation.

91-4642 12/02 © 2003 Advocate Health Care

Figure 2 Adult ventilator pathway/critical care.

Abbreviations: CHF, congestive heart failure; CXR, chest radiograph; FiO2, fraction of inspired oxygen; ICU, intensive care unit; OT, occupational therapy; PEEP, positive
end-expiratory pressure; P/F ratio, ratio of PaO2 to fraction of inspired oxygen; Pt, patient; PT, physical therapy.
Reprinted with permission from Advocate Lutheran General Hospital, Park Ridge, IL.

38 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 http://ccn.aacnjournals.org

have the head of the bed elevated associated pneumonia. Crit Care Med. prevention of upper gastrointestinal bleed-
2002;30(11):2407-2412. ing in patients requiring mechanical venti-
should be documented.3 Standard- 9. Livingston DH. Prevention of ventilator- lation. Canadian Critical Care Trials Group.
associated pneumonia. Am J Surg. 2000; N Engl J Med. 1998;338(12):791-797.
ized orders or pathways can be a 179(2 suppl 1):12-17. 27. Cook DJ, Fuller HD, Guyatt GH, et al. Risk
friendly reminder to healthcare 10. Kunis KA, Puntillo KA. Ventilator-associated factors for gastrointestinal bleeding in criti-
pneumonia in the ICU: its pathophysiology, cally ill patients. Canadian Critical Care Tri-
providers about the importance of risk factors, and prevention. Am J Nurs. als Group. N Engl J Med. 1994;330(6):
interventions to prevent VAP. 2003;133(8):64AA-64GG. 377-381.
11. Olson ME, Harmon BG, Kollef MH. Silver- 28. Yildizdas D, Yapicioglu H, Yilmaz HL.
coated endotracheal tubes associated with Occurrence of ventilator-associated pneu-
reduced bacterial burden in the lungs of monia in mechanically ventilated pediatric
Summary mechanically ventilated dogs. Chest. 2002; intensive care patients during stress ulcer
VAP, although often preventable, 121:863-870. prophylaxis with sucralfate, ranitidine, and
12. Morehead RS, Pinto SJ. Ventilator-associated omeprazole. J Crit Care. 2002;17(4):240-245.
has a large impact on morbidity and pneumonia. Arch Intern Med. 2002;160(13): 29. Zeitoun SS, de Barros AL, Diccini S. A
1926-1930. prospective, randomized study of ventila-
mortality. Together with other health- 13. De Rosa FG, Craven DE. Ventilator-associated tor-associated pneumonia in patients using
care providers, nurses play a key role pneumonia: current management strate- a closed vs open suction system. J Clin Nurs.
gies. Infect Med. 2003;20(5):248-259. 2003;12(4):484-489.
in preventing VAP. Many of the inter- 14. Ferrer R, Artigas A. Clinical review: Non- 30. Moore T. Suctioning techniques for the
antibiotic strategies for preventing ventilator- removal of respiratory secretions [published
ventions are part of routine nursing associated pneumonia. Crit Care. 2001;6(1): correction appears in Nurs Stand. 2003;
care. Education for all healthcare 45-51. 18(13):31]. Nurs Stand. 2003;18(9):47-55.
15. Porzecanski I, Bowton DL. Diagnosis and 31. Akgul S, Akyolcu N. Effects of normal
providers should focus on the risk treatment of ventilator-associated pneumo- saline on endotracheal suctioning. J Clin
nia. Chest. 2006;130:597-604. Nurs. 2002;11:826-830.
factors for VAP and on preventive 16. Grossman RF, Fein A. Evidence-based 32. Leone M, Garcin F, Bouvenot J, et al.
measures. In order to further decrease assessment of diagnostic tests for ventilator- Ventilator-associated pneumonia: breaking
associated pneumonia: executive summary. the vicious circle of antibiotic overuse. Crit
the incidence of VAP, protocols and Chest. 2000;117(4 suppl 2):177S-181S. Care Med. 2007;35:379-385.
17. Rello J, Paiva JA, Baraibar J, et al. Interna- 33. Kirschenbaum L, Azzi E, Sfier T, Tietjen P,
monitoring tools must be developed. Astiz M. Effect of continuous lateral rota-
tional Conference for the Development of
VAP is not a new diagnosis, but edu- Consensus on the Diagnosis and Treatment tional therapy on the prevalence of ventila-
of Ventilator-associated Pneumonia. Chest. tor-associated pneumonia in patients
cation and research on the preven- 2001;120(3):955-970. requiring long-term ventilatory care. Crit
tion of this life-threatening problem 18. Torres A, Serr-Batlles J, Ross E, et al. Pul- Care Med. 2002;30(9):1983-1986.
monary aspiration of gastric contents in 34. Collard HR, Saint S, Matthay MA. Preven-
are ongoing. patients receiving mechanical ventilation: tion of ventilator-associated pneumonia: an
the effect of body position. Ann Intern Med. evidence-based systematic review. Ann
1992;116:540-543. Intern Med. 2003;138(6):494-501.
Financial Disclosures 35. Hess D. Ventilator circuit change and venti-
None reported. 19. Schleder BJ. Taking charge of ventilator-
associated pneumonia. Nurs Manage. lator associated pneumonia. http://www
2003;34(8):29-32. .utdol.com/utd/content/topic.do?top-
20. Torres A, Gatell JM, Aznar E, et al. icKey=cc_medi/9368&type=A&selectedTi-
References tle=2-16. Accessed February 13, 2007.
1. Tablan OC, Anderson LJ, Besser R, et al. Re-intubation increases the risk of nosoco-
mial pneumonia in patients needing 36. Jubran A, Tobin MJ. Methods of discontin-
Guidelines for preventing health-care-asso- uing mechanical ventilation. http://www
ciated pneumonia, 2003: recommendations mechanical ventilation. Am J Respir Crit
Care Med. 1995;152(1):137-141. .utdol.com/utd/content/topic.do?top-
of CDC and the Healthcare Infection Con- icKey=cc_medi/7284&type=A&selectedTi-
trol Practices Advisory Committee. MMWR 21. Kollef MH. Prevention of hospital-associated
pneumonia and ventilator-associated pneu- tle=2-16. Accessed February 13, 2007.
Recomm Rep. 2004;53(RR-3):1-36. 37. AACN practice alert: ventilator-associated
2. Kollef MH. The prevention of ventilator- monia. Crit Care Med. 2004;32:1396-1405.
22. Centers for Disease Control and Prevention. pneumonia. AACN Clin Issues. 2005;16(1):
associated pneumonia. N Engl J Med. 105-109.
1999;340(8):627-634. Prevention of pneumococcal disease: rec-
ommendations of the Advisory Committee 38. Kress JP, Pohlman AS, O’Connor MF, Hall
3. Safdar N, Dezfulian C, Collard HR, Saint S. JB. Daily interruption of sedative infusions
Clinical and economic consequences of ven- on Immunization Practices (ACIP). MMWR
Recomm Rep. 1997;46(RR-8):1-24. http:// in critically ill patients undergoing mechan-
tilator-associated pneumonia: a systematic ical ventilation. N Engl J Med. 2000;342:
review. Crit Care Med. 2005;33(10):2184-2193. www.cdc.gov/mmwr/preview/mmwrhtml
/00047135.htm#top. Updated May 2, 2001. 1471-1477.
4. Richards MJ, Edwards JR, Culver DH, 39. Pfeifer LT, Orser L, Gefen C, McGuinness
Gaynes RP. Nosocomial infections in med- Accessed May 11, 2007.
23. Munro CL, Grap MJ. Oral health and care R, Hannon CV. Preventing ventilator-
ical intensive care units in the United associated pneumonia: what all nurses
States. Crit Care Med. 1999;27:887-892. in the intensive care unit: state of the sci-
ence. Am J Crit Care. 2004;13:25-33. should know. Am J Nurs. 2001;101(8):24AA-
5. Chastre J, Fagon JY. Ventilator-associated 24GG.
pneumonia. Am J Respir Crit Care Med. 24. DeRiso AJ Jr, Ladowski JS, Dillon TA,
Justice JW, Peterson AC. Chlorhexidine glu- 40. Craven DE. Preventing ventilator-associated
2002;165(7):867-903. pneumonia in adults: sowing seeds of
6. Craven DE. Epidemiology of ventilator- conate 0.12% oral rinse reduces the inci-
change. Chest. 2006;130(1):251-260.
associated pneumonia. Chest. 2000;117 dence of total nosocomial respiratory
41. Shorr AF, O’Malley PG. Continuous subglot-
(4 suppl 2):186S-187S. infection and nonprophylactic systemic
tic suctioning for the prevention of ventilator-
7. van Nieuwenhoven CA, Buskens E, Bergmans antibiotic use in patients undergoing heart
associated pneumonia: potential economic
DC, van Tiel FH, Ramsay G, Bonten MJ. surgery. Chest. 1996;109(6):1556-1561.
implications. Chest. 2001;119(1): 228-235.
Oral decontamination is cost-saving in the 25. Donowitz LG, Page MC, Mileur BL, Guen-
42. Burns SM, Earven S, Fischer C, et al. Imple-
prevention of ventilator-associated pneu- ther SH. Alteration of normal gastric flora
mentation of an institutional program to
monia in intensive care units. Crit Care Med. in critical care patients receiving antacid
improve clinical and financial outcomes of
2004;32(1):126-130. and cimetidine therapy. Am J Infect Control. mechanically ventilated patients: one-year
8. Zack JE, Garrison T, Trovillion E, et al. 1986;7:23-26. outcomes and lessons learned. Crit Care
Effect of an education program aimed at 26. Cook D, Guyatt G, Marshall J, et al. A com- Med. 2003;31(12):2752-2763.
reducing the occurrence of ventilator- parison of sucralfate and ranitidine for the

http://ccn.aacnjournals.org CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 39

CE Test Test ID C0742: Ventilator-Associated Pneumonia: Risk Factors and Prevention
Learning objectives: 1. Describe the 2 main pathophysiology processes of ventilator-associated pneumonia (VAP)
2. Identify risk factors for VAP 3. Discuss timeframe interventions to prevent VAP

1. Ventilator-associated pneumonia (VAP) can occur in patients who 7. Enteral feedings increase the risk of which of the following?
have received mechanical ventilation for longer than how many hours? a. Bacterial colonization and growth
a. 72 hours b. VAP and infection
b. 24 hours c. Bacterial colonization and aspiration
c. 96 hours d. Bacteria translocation and colonization
d. 48 hours
8. Which of the following clinical signs and symptoms indicate the likelihood
2. Increases in which of the following are associated with VAP? of VAP?
a. Morbidity, mortality, hospital length of stay, and costs a. Fever and purulent sputum
b. Ventilator time, length of stay, time in intensive care unit (ICU), and costs b. Fever, leukocytosis, and purulent sputum
c. Morbidity, mortality, ventilator time, and time in ICU c. Leukocytosis and purulent sputum
d. Length of stay, costs, ventilator time, and time in ICU d. Positive sputum culture, fever, and leukocytosis

3. Interventions to prevent VAP should begin at what time? 9. What is the biggest personnel-related risk factor for VAP development?
a. When the patient is admitted to the ICU a. Improper hand washing
b. When the patient is intubated b. Changing gloves between contaminated patients
c. When the patient receives oxygen c. Wearing personal protective equipment
d. When the patient has decreased oxygenation d. Improper room cleaning between patient admissions

4. Early onset of VAP occurs after how many hours of intubation? 10. Which of the following interventions decrease
a. 48 to 96 hours the likelihood of colonization of the oropharynx?
b. 24 to 72 hours a. Thoroughly suctioning secretions from the nose and mouth
c. 48 to 72hours b. Thoroughly suctioning the nose and brushing the teeth
d. 72 to 96 hours c. Thoroughly suctioning the mouth and brushing the gums
d. Thoroughly suctioning the secretions from the mouth and brushing the teeth
5. Where does colonization of bacteria occur in VAP?
a. Respiratory system 11. VAP can be decreased by 34% by simply elevating the head of bed how
b. Digestive system many degrees?
c. Upper and lower parts of the airway a. 30°
d. Respiratory and digestive system b. 40°
c. 45°
6. Biofilm can be disseminated into the lungs by ventilator-induced d. 35°
breaths or can be dislodged by which of the following?
a. Instillation of saline into the endotracheal tube and intubation for more than 12. The use of tubes with ports for continuous subglottic
12 hours suctioning can decrease the incidence of VAP by what percentage?
b. Warm humidified air through the ventilator circuit and suctioning a. 27%
c. Intubation for more than 12 hours and repositioning of the endotracheal tube b. 75%
d. Instillation of saline into the endotracheal tube, suctioning, coughing, and c. 50%
repositioning of the endotracheal tube d. 45%

Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. K a 2. K a 3. K a 4. K a 5. K a 6. K a 7. K a 8. K a 9. K a 10. K a 11. K a 12. K a
Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb
Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc
Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd
Test ID: C0742 Form expires: August 1, 2009 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: A,
Synergy CERP A Test writer: Brenda K. Hardin-Wike, RN, CNS, MSN, CCNS
Program evaluation Name Member #
Yes No
Objective 1 was met K K Address
Objective 2 was met K K City State ZIP
Objective 3 was met K K
Content was relevant to my Country Phone
Mail this entire page to: nursing practice K K
My expectations were met K K E-mail
AACN This method of CE is effective RN Lic. 1/St RN Lic. 2/St
101 Columbia for this content K K
The level of difficulty of this test was: Payment by: K Visa K M/C K AMEX K Discover K Check
Aliso Viejo, CA 92656 K easy K medium K difficult
To complete this program, Card # Expiration Date
(800) 899-2226 it took me hours/minutes. Signature

The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN
programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.