Can you prevent

ventilator-associated
Learn how it develops and strategies you can use to reduce
your patients risk of this common complication.
By William C. Pruitt, RRT, AE-C, CPFT, MBA,
and Michael Jacobs, RN, CCRN, CEN, MSN

entilator-associated pneumonia (VAP) in patients

who are already critically ill prolongs their hospitalization and recovery and significantly increases the
risk of complications and death. Preventing VAP is one
goal of the Institute for Healthcare Improvements
100,000 Lives Campaign, unveiled in December 2004.
(For more information, visit http://www.ihiorg/IHI/
Programs/Campaign.
In this article, well describe how you can help prevent
VAP from developing. First, lets review VAP and its causes.
Who let the bugs in?
Ventilator-associated pneumonia is the most common
and lethal form of hospital-acquired pneumonia (also
known as nosocomial pneumonia). It occurs in up to
28% of patients who need mechanical ventilation for
more than 48 hours.
Endotracheal (ET) intubation and mechanical ventilation predispose patients to VAP by interfering with the
normal defense mechanisms that keep microorganisms
from entering the lungs. Endotracheal tubes, especially
cuffed ones, interfere with the mucociliary transport system that helps clear airway secretions. Secretions that
accumulate below and above the ET tube are an ideal
growth medium for pathogens. The ET tube also prevents normal closure of the epiglottis, resulting in an
incomplete seal of the laryngeal structures that normally
protect the lungs. This can contribute to aspiration that
often leads to VAP.
Ventilator-associated pneumonia is characterized by
pulmonary infiltrates and fever. Other assessment findings include leukocytosis, purulent tracheal secretions,
and pathogenic microorganisms cultured from tracheal
aspirate.
Whos at risk?
Patient risk factors for VAP include:
conditions that increase the risk of colonization by
pathogens, such as previous antibiotic therapy or contaminated ventilator equipment

4 CriticalCareChoices2005

conditions that
increase the risk of
aspiration, such as
intubation, presence
of a nasogastric
(NG) tube, or
decreased level of
consciousness
conditions that
impair defense
mechanisms, such
as age extremes
(particularly age 70
or older), malnutrition, diabetes, renal
insufficiency, and
chronic obstructive
pulmonary disease
(COPD).
Other risk factors
are related to poor
infection control
technique by health
care providers, including inadequate hand hygiene and failure to wear gloves when handling respiratory secretions or
equipment contaminated with respiratory secretions.
Types of VAP
Determining the type of VAP can help identify the
responsible nosocomial organisms and guide antibiotic therapy.
Early-onset VAP occurs during the first 3 to 4 days
of mechanical ventilation. The causative organisms
often are the same ones responsible for communityacquired pneumonia; likely to be sensitive to traditional antibiotic therapy, theyre usually easier to treat.
Common organisms implicated in early-onset VAP
include Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis.
Late-onset VAP, which occurs 5 or more days after

C
E
2.0

pneumonia?

initiation of mechanical ventilation, is most commonly due to Staphylococcus aureus, Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae,
and the Enterobacter species. Because these pathogens
may be antibiotic-resistant (for example, methicillinresistant S. aureus), they must be treated with more
powerful antibiotics and antibiotic combinations.
Late-onset VAP, which can increase mortality rates by
50%, has become significantly more prevalent in
recent years.
A clinician may choose to start a patient on antibiotics as soon as she suspects VAP or to delay treatment until the pathogen is identified by an invasive
procedure (such as bronchoscopy, protected specimen
brushings, or bronchoalveolar lavage) and lab analysis. Shell base the decision on the severity of disease,
time of onset, and presence of risk factors.

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Trying noninvasive ventilation

One of the best ways to prevent VAP is to use noninvasive ventilation if appropriate. For some patients, such as
those with acute exacerbations of COPD, noninvasive
positive-pressure ventilation (NPPV) is an alternative to
intubation and mechanical ventilation.
Noninvasive positive-pressure ventilation is administered via a face mask that fits over the mouth and nose
or a nasal mask that fits over the nose. The mask is connected to either a mechanical ventilator or a bi-level positive airway pressure machine using aerosol tubing or a
ventilator circuit.
Noninvasive positive-pressure ventilation can provide
many of the supportive measures found in traditional
mechanical ventilation, including various modes of ventilatory support with rate and volume settings (such as
assist-control or synchronized intermittent mandatory

CriticalCareChoices2005 5

ventilation), supplemental oxygen, positive end-expiratory pressure, continuous positive airway pressure, and
pressure support. By avoiding intubation and the associated high risk of aspiration around an artificial airway,
this option reduces the risk of VAP.
However, although NPPV has been used for 20 years
by home health care patients needing temporary support, the therapy has the following drawbacks when its
used as a full-support mode instead of traditional
mechanical ventilation.
Because NPPV doesnt secure the airway, leaks with
subsequent loss of tidal volume can be a problem.
The mask may make patients feel claustrophobic.
Suctioning, if needed, can be done nasotracheally or
orotracheally because the patient lacks an artificial airway. Passing the suction catheter though the nasopharynx can be traumatic, and the lower airway may not be
adequately suctioned via this approach. In addition,
nasotracheal suctioning can introduce pathogens into
the lungs, increasing the risk of VAP.
Eating and drinking is difficult if NPPV is being used for
full support. The mask must be removed, interrupting ventilation, for the patient to eat or drink by mouth. Gastric
distension is sometimes a problem, and an NG tube may
be is used to prevent this problem. Patients also may be fed
through the NG tube to avoid discontinuing NPPV.
Because of these drawbacks, NPPV is appropriate only
for short-term ventilator needs. If the patient requires
full ventilatory support for more than 24 hours, hell
need to be intubated and be connected to a traditional
mechanical ventilator.
Ways to prevent VAP
If your patient needs an artificial airway, you can take
steps during the initial insertion to reduce his risk of
developing VAP.
Use meticulous hand hygiene. Wear clean gloves when
appropriate.
Use an oral artificial airway rather than a nasal one if
possible. Nasal intubations increase the risk of nosocomial sinusitis and development of VAP.
Keep the ET tube cuff at minimal occluding volume. This
avoids damage to the tracheal wall. Make sure the cuff is
inflated adequately to reduce the chance that the patient
will aspirate secretions that accumulate above the cuff.
Newer ET tubes now have a dorsal lumen above the cuff
so you can clear tracheal secretions that accumulate in
the subglottic area with either continuous or frequent
intermittent suctioning.
Consider a tracheostomy tube for patients who need longterm ventilation. This option still needs to be studied to
determine if it provides a clear benefit in reducing VAP.
Observe meticulous infection control. If oral intubation is
used, the reusable laryngoscope blade (and stylet) should
have high-level disinfection before use (for example, with
glutaraldehyde). Sterilization also can be used for these

6 CriticalCareChoices2005

reusable items, or single-use disposable blades and stylets

can be used. Suction the patients oropharynx before
insertion. If the sterile ET tube is inadvertently passed
into the esophagus, it should be discarded and a new sterile one should be used for subsequent attempts.
Secure the ET tube to prevent extubation. Unplanned
extubation increases the risk of aspiration and requires
reintubation, both of which raise the patients risk of VAP.
Take aspiration precautions. To reduce the risk of aspiration, elevate the patients head to at least 30 degrees
preferably 45 degrees if not contraindicated. Make sure
the ET tube cuff is properly inflated. Suction above and
below the cuff as needed and before ET tube removal.
Perform frequent mouth care. As oral secretions pool,
pathogens colonize the teeth and oral mucosa. Contaminated oral secretions flow to the subglottic area, where
small amounts may be aspirated. Oral suctioning prevents oral secretions from pooling and toothbrushing
removes the plaque that promotes bacterial growth. A
daily oral hygiene rinse with a chlorhexidine-based solution may prevent or reduce oropharyngeal colonization.
If the patient cant expectorate during brushing or rinsing, perform simultaneous oral suctioning.
Keeping the circuit clean
The ventilator circuit has been studied closely because of
its possible role in VAP. The American Association for
Respiratory Care and the Centers for Disease Control
and Prevention (CDC) each have clinical practice guidelines regarding VAP and the ventilator circuit. Their recommendations include the following.
Dont routinely change the ventilator circuit, but do
change it if its visibly soiled or malfunctioning.
Drain and discard any condensation collecting in the
ventilator tubing, taking care to drain this fluid away
from the patient. Wear gloves when draining fluid and
wash your hands or use an alcohol-based hand rub
(unless your hands are visibly soiled) after performing
this procedure.
Dont change closed system (in-line) suction setups for
infection control purposes. The maximum time for using
these safely before changing is unknown. The CDC
regards the choice of a multiuse closed suction system
versus single-use open suction to be an unresolved issue.
Passive humidification systems, such as heat and moisture exchangers, havent received a clear recommendation
for general use because of issues related to increased antibiotic resistance by pathogens, increased dead space, and risk
of airway occlusion. Likewise, heated humidifiers havent
received a clear recommendation for general use. More
study is needed to resolve the issue of passive humidity
versus humidified delivery. More study also is needed to
resolve issues connected with humidified circuits.
If passive humidifiers are used, they dont have to be
changed more frequently than every 48 hours and may
in some cases be used for up to 1 week. Change the

humidifier when its visibly soiled or if its malfunctioning. Fill heated humidifiers with sterile water only.
Patient nutrition and VAP
All critically ill patients have high calorie needs to fight
complications and to heal. Because a mechanically ventilated patient cant take foods or fluids orally, he may
need an enteral tube for feedings. Unfortunately, an
enteral tube increases his risk of aspiration and VAP, so
take these preventive steps:
Advocate for an orogastric tube instead of an NG tube, if
appropriate. An NG tube increases the patients risk of
nosocomial sinusitis and pathogen contamination of the
oropharyngeal area from the nasopharyngeal area.
Routinely verify correct feeding tube placement by more than
one method, including measuring the pH of gastric aspirate.
Monitor the patients tolerance of gastric feedings.
Auscultate bowel sounds and measure abdominal girth
frequently. Measure residual gastric volume at least every
4 hours during continuous feedings and before each
intermittent feeding, to decrease the likelihood of gastric
distension and aspiration. Less than 200 ml is generally
considered an acceptable amount of gastric residual volume, although this can vary from institution to institution. If residual volume is more than 200 ml, stop the
enteral feeding for 2 hours, then reassess residual volume.
Elevate the patients head to at least 30 degrees at all times
for continuous feedings or during and for 1 hour after intermittent feedings. This helps minimize the risk of reflux
and pulmonary aspiration.

Learning to prevent VAP

Education is key to preventing VAP. A recent study found
that VAP rates at two teaching hospitals and two community hospitals were reduced by an average 46% after respiratory care practitioners and intensive care unit nurses completed a staff-development program about risk factors and
strategies to prevent VAP. A team approach was important;
the study authors found that in one of the community hospitals, where few respiratory therapists completed the staffdevelopment program, VAP rates remained unchanged.
A growing problem in health care facilities, VAP raises
the cost of care and increases patient-care time, hospital
length of stay, and patient morbidity. Strategies to prevent and treat VAP are effective only if staff is educated
about them and encouraged to follow best practice
guidelines.
SELECTED REFERENCES
Babcock H, et al. An educational intervention to reduce ventilator-associated
pneumonia in an integrated health system: A comparison of effects. Chest.
125(6):2224-2231, June 2004.
Kollef M. Prevention of hospital-associated pneumonia and ventilator-associated
pneumonia. Critical Care Medicine. 32(6):1396-1405, June 2004.
Tablan O, et al. Guidelines for preventing health-care associated pneumonia,
2003: Recommendations of the Centers for Disease Control and Prevention and
the Healthcare Infection Control Practices Advisory Committee. Morbidity and
Mortality Weekly Report. 53(RR-3):1-36, March 26, 2004.
http://www.cdc.gov/ncidod/hip/pneumonia. Accessed September 25, 2004.
William C. Pruitt is an instructor in the department of cardiorespiratory sciences at the
University of South Alabama in Mobile and a p.r.n. respiratory therapist at Springhill
Medical Center in Mobile. Michael Jacobs is a clinical assistant professor in the adult health
department at the University of South Alabamas College of Nursing and a p.r.n. nursing
supervisor and emergency department staff nurse at Ocean Springs (Miss.) Hospital.
The authors have disclosed that they have no significant relationship with or financial interest
in any commercial companies that pertain to this educational activity.

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Can you prevent ventilator-associated pneumonia?

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CriticalCareChoices2005 7

C E

2.0

ANCC/AACN CONTACT HOURS

Can you prevent ventilator-associated pneumonia?

GENERAL PURPOSE To familiarize nurses with the latest recommendations for preventing ventilator-associated pneumonia (VAP). LEARNING OBJECTIVES After
reading the preceding article and taking this test, you should be able to: 1. Identify the risk factors for and significance of VAP. 2. Describe prevention strategies for VAP.
3. Identify the two types of VAP.
1. Which statement is correct about VAP?
a. More patients die from VAP than any other nosocomial pneumonia.
b. VAP occurs in up to 48% of patients who need
mechanical ventilation.
c. VAP is the least common type of nosocomial
pneumonia.
d. VAP is characterized by bilateral pleural effusions.
2. Which statement is correct about an ET tube?
a. It keeps microorganisms from entering the lungs.
b. It helps the mucociliary transport system.
c. It facilitates normal epiglottis closure.
d. It predisposes patients to VAP.
3. Which statement is correct about late-onset
VAP?
a. It occurs during the first 4 to 7 days of mechanical
ventilation.
b. It can increase patient mortality rates by 50%.
c. Its usually easier to treat than early-onset VAP.
d. Its become significantly less prevalent recently.

5. Which statement is correct about NPPV?

a. Copious bronchial secretions are easily removed
with NPPV.
b. Full ventilatory support must be temporarily suspended during oral nutrition.
c. Loss of tidal volume is less likely with NPPV than
with an ET tube.
d. A nasogastric tube cant be used with NPPV.

12. Which statement is correct about draining

ventilator tubing condensation?
a. Drain the fluid in the tubing toward the patient.
b. Use an alcohol-based hand rub if your hands are
visibly soiled.
c. Wearing gloves isnt necessary.
d. Discard any liquid that collects in the tubing.
13. Which statement is correct about passive
humidification systems?
a. Heat and moisture exchangers (HMEs) have
received a clear recommendation for general use.
b. Heated humidifiers should be filled with distilled,
nonsterile water.
c. HMEs may increase microbial antibiotic resistance.
d. HMEs decrease dead space.

8. Which of the following is least likely to cause

VAP?
a. a properly secured ET tube
b. unplanned extubation
c. self-extubation
d. reintubation

14. To prevent aspiration during enteral feedings,

a. use an orogastric tube instead of a nasogastric
tube if possible.
b. elevate the patients head to at least 20 degrees
during continuous feedings.
c. measure residual gastric volume at least every 12
hours during continuous feedings.
d. stop the feeding for 4 hours if residual volume is
100 ml.

10. Which statement is correct about mouth

care for an intubated patient?
a. Mouth care is contraindicated in a patient with an
ET tube.
b. An alcohol-based oral rinse is recommended to
lower bacterial growth.
c. Oral suctioning is needed during mouth care if the
patient cant expectorate.
d. Mouth care doesnt affect the VAP rate.

6. Which statement is correct about an ET tube

cuff?
a. It should be inflated enough to keep the patient

ENROLLMENT FORM

7. Proper infection control practices for oral

intubation include
a. discarding an ET tube if esophageal intubation
occurs more than twice.
b. disinfecting reusable laryngoscopes with alcohol
after each use.
c. suctioning the oropharynx before intubation.
d. avoiding the use of disposable stylets.

9. Aspiration precautions for an intubated

patient include
a. elevating the head of the bed no more than 20
degrees.
b. suctioning above and below the cuff just before
extubation.
c. suctioning through the ET tube only.
d. deflating the cuff to prevent pooling of oral secretions.

4. Compared with intubation and mechanical

ventilation, NPPV
a. is inappropriate for use in home care.
b. requires an oral or nasal ET tube.
c. increases the risk of VAP.
d. can provide assist-control ventilation.

11. Recommended guidelines for mechanical

ventilation include
a. routinely changing the ventilator circuit.
b. changing in-line suction setups every 8 hours.
c. changing passive humidifiers every 24 hours.
d. changing the ventilator circuit when its visibly
soiled.

from aspirating secretions that accumulate above

the cuff.
b. It should be inflated to maximum volume once in
the trachea.
c. An inflated cuff cant injure the wall of the trachea.
d. Use a cuffless ET tube to decrease the risk of VAP.

15. Common organisms implicated in earlyonset VAP include

a. Staphylococcus aureus.
b. Acinetobacter baumannii.
c. Pseudomonas aeruginosa.
d. Moraxella catarrhalis.

CriticalCareChoices2005, May, Can you prevent ventilator-associated pneumonia?

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