Ventilator Associated
Pneumonia (VAP)
Author: Marianne Chulay, RN, DNSc, FAAN
Consultant, Clinical Research and Critical Care Nursing
Reviewers: Suzi Burns, Mary Jo Grap,
Judy Verger, and Lori Jackson
Issued 01/2008
Ventilator Associated Pneumonia
(VAP) Practice Alert
Prevention of Ventilator
Associated Pneumonia (VAP)
Ventilator Associated Pneumonia
(VAP) Practice Alert
2
Lecture Content
 Epidemiology of VAP
 Prevention strategies
 HOB elevation
 Ventilator equipment changes
 Continuous removal of subglottic secretions
 Handwashing
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Epidemiology of
Ventilator Associated Pneumonia
(VAP)
Ventilator Associated Pneumonia
(VAP) Practice Alert
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Nosocomial Pneumonias
 Account for 15% of all hospital associated
infections
 Account for 27% of all MICU acquired
infections
 Primary risk factor is mechanical ventilation
(risk 6 to 21 times the rate for nonventilated
patients)
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Craven, Chest 2000; 117:186S-187S.
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Susceptibility to
Nosocomial Pneumonias
Intubation
Altered
Host
Defenses
Tracheal
Colonization
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Increased
Nosocomial
Pneumonias
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Primary Route of Bacterial Entry
into Lower Respiratory Tract
 Micro or macro aspiration of
oropharyngeal pathogens
 Leakage of secretions
containing bacteria around
the ET cuff
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VAP Etiology


Most are bacterial pathogens, with Gram
negative bacilli common
Pseudomonas aeruginosa
 Proteus spp
 Acinetobacter spp
 Staphlococcus aureus


Early VAP associated with non-multi-antibioticresistant organisms
Late VAP associated with antibiotic-resistant
organism
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Significance of
Nosocomial Pneumonias
 Mortality ranges from 20 to 41%, depending on
infecting organism, antecedent antimicrobial
therapy, and underlying disease(s)
 Leading cause of mortality from nosocomial
infections in hospitals
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Heyland et al, Am J Respir Crit Care Med 1999; 159:1249
Bercault et al, Crit Care Med 2001; 29:2303
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Significance of Nosocomial
Pneumonias
 Increases ventilatory support requirements and ICU stay
by 4.3 days
 Increases hospital LOS by 4 to 9 days
 Increases cost - > $11,000 per episode
 Estimates of VAP cost / year for nation > $ 1.2 billion
Heyland et al, Am J Respir Crit Care Med 1999;159:1249
Craven, Chest 2000;117:186-187S
Rello et al, Chest 2002;122:2115
Safdar et al, Critical Care Medicine 2005;33:2184-93
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VAP Prevention
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Continuous Removal of Subglottic
Secretions
Use an ET tube with
continuous suction
through a dorsal lumen
above the cuff to prevent
drainage accumulation.
CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2004 ATS / IDSA
Guidelines for VAP 2005
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Continuous Removal of
Subglottic Secretions
 Mahul et al. Int Care Med 1992;18:20-25
 Valles et al. Ann Int Med 1995;122:179-186
 Kollef et al. Chest 1999;116:1339-1346
 Smulders et al. Chest 2002;121:858-862
 Dezfulian et al. Am J Med 2005;118:11-18 (meta-analysis)
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VAP Reduction with ET Suction
Above the Cuff
Percent (%)
20
15
10
5
0
No Suction
Suction
Smulders et al. Chest;121:858-862
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HOB Elevation
HOB at 30-45º
CDC Guideline for Prevention of Healthcare Associated Pneumonias
2004 ATS / IDSA Guidelines for VAP 2005
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HOB Elevation
 Torres et al, Annals of Int Med 1992;116:540-543
 Ibanez et al. JPEN 1992;16:419-422
 Orozco-Levi et al. Am J Respir Crit Care Med
1995;152:1387-1390
 Drakulovic et al. Lancet 1999;354:1851-1858
 Davis et al. Crit Care 2001;5:81-87
 Grap et al. Am J of Crit Care 2005 14:325-332
HOB at 30-45º
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HOB Elevation Leads to
Significant Deduction in VAP
25
% VAP
20
15
10
5
0
Supine
HOB Elevation
Ventilator Associated Pneumonia (VAP) Practice Alert
Dravulovic et al. Lancet
1999;354:1851-1858
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Is HOB Elevation Done?
 Grap et al. Am J Crit Care
1999;8:475-480
 Grap et al. Am J Crit Care
2005;14:325-332
60
Degrees of
HOB Elevation
% with HOB Elevation
Despite effectiveness
of HOB elevation,
compliance is poor.
40
20
0 to 20
21 to 30
31 to 40
> 40
0
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Frequency of
Equipment Changes
No Routine
Changes
Ventilator
Tubing
Between
Patients
Not Enough
Data
Ambu
Bags
Inner
Cannulas
of Trachs
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
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Handwashing
What role does handwashing play
in nosocomial pneumonias?
Albert, NEJM 1981; Preston, AJM 1981;
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
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VAP Prevention
Wash hands or use an alcohol-based
waterless antiseptic agent before and
after suctioning, touching ventilator
equipment, and/or coming into contact
with respiratory secretions.
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP, 2007
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VAP Protection
Use a continuous subglottic suction
ET tube for intubations expected to
be > 24 hours
Keep the HOB elevated to at least
30 degrees unless medically
contraindicated
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP, 2007
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No Data
to Support These Strategies

Use of small bore versus large bore gastric
tubes

Continuous versus bolus feeding

Gastric versus small intestine tubes

Closed versus open suctioning methods

Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
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Oral Care
 Role of oral care, colonization of the
oropharynx, and VAP unclear – dental plaque
may be involved as a reservoir
 Limited research on impact of rigorous oral care
to alter VAP rates
 Surveys indicate most nurses use foam swabs
rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Grap M. Amer J of Critical Care 2003;12:113-119.
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Need Further Assistance?
For more information or further
assistance, please contact a clinical
practice specialist with the AACN
Practice Resource Network.
Email:
practice@aacn.org
Phone:
(800) 394-5995
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