Ventilator Associated Pneumonia

Source of the Highest Morbidity & Mortality of All HAIs

Ventilator–associated pneumonia (VAP) is one of the top three infection concerns of clinicians today; it may account for up to 60% of all deaths from healthcare-associated infections (HAIs) in the U.S.1 Other key U.S. statistics include:

  • VAP is the most common and deadly healthcare-associated infection, affecting up to 28% of ventilated patients2
  • Healthcare–associated pneumonia patients have a mortality rate of up to 33%1
  • VAP increases patient time in the ICU by 4 to 6 days1
  • Each incidence of VAP is estimated to generate an increased cost of $20,000 to $40,0001

vap thumb

VAP is a global issue. In Germany, between 2001 and 2005, 5.72% of ICU patients developed VAP.3 According to recent statistics, 9.2% of ICU patients in France develop ICU–acquired pneumonia.4 And in the UK, hospital–acquired lower respiratory tract infection adds an average of 12 days to hospital stays, at an average additional cost of $4,149 per patient.5

The CDC's National Nosocomial Infection Surveillance System (NNIS) reported that in 2002, patients receiving continuous mechanical ventilation had 6–21 times the risk of developing healthcare–associated pneumonia compared with patients who were not receiving mechanical ventilation. Because of this tremendous risk, in the last two decades, most of the research on healthcare–associated pneumonia has been focused on VAP.6

Preventing Ventilator-Associated Pneumonia (VAP)
Most initiatives for reducing VAP can be readily incorporated into standard care for ventilated patients without incurring significant expenditure of resources. The following practice recommendations have been adapted from the CDC Guidelines for Preventing Healthcare Associated Pneumonia. 2003, www.cdc.gov; and American Thoracic Society Guidelines for the Management of Adults with Hospital-Acquired, Ventilator-Associated, and Healthcare-Associated Pneumonia 2004, www.thoracic.org.

  • Perform hand hygiene before patient contact or aseptic procedure, after patient contact, contact with the care environment or body fluids regardless of glove use
  • Wear gloves, gowns and face protection following Standard and Transmission-Based Precautions as clinically indicated
  • Make comprehensive patient oral hygiene standard practice
  • Keep patient head of bed elevated >30º unless contraindicated
  • Use a closed-suction system or sterile single-use suction catheter
  • Minimize saline lavage
  • Prevent patient contamination from ventilator circuit condensate
  • Perform oral and subglottic suctioning when necessary
  • Avoid nasal placement of endotracheal (ET) or gastric tubes and consider non-invasive breathing support methods whenever possible
  • Maintain optimal pressure in ET tube cuff while patient is intubated
  • Avoid unnecessary manipulation of ET tube
  • Remove ET tube as early as possible, but avoid inadvertent extubation or re-intubation
  • Prevent cross-contamination with reusable devices and common-use patient equipment
  • Vaccinate staff and patients against influenza
  • Utilize methods for early diagnosis of VAP
  • Write patient care policies, educate staff and monitor compliance

The importance of oral care in the critical environment is well-documented when it comes to the prevention of VAP.7

  • 63% of patients admitted to an ICU have oral colonization with pathogens associated with VAP.8
  • The absence of adequate salivary flow in intubated ICU patients causes severe xerostomia (dry mouth), which may contribute to the development of mucositis (oral tissue inflammation) and oropharyngeal colonization with gram negative bacteria.9
  • If an intubated patient does not receive effective and comprehensive oral hygiene, bacterial plaque develops on teeth within 48 hours.13
  • As dental plaque increases, so does the risk of pneumonia.11
  • Comprehensive oral hygiene has consistently been recognized as an important step in patient care by such leading organizations as:
    • Centers for Disease Control and Prevention (CDC) 1
    • Association for Professionals in Infection Control and Epidemiology (APIC) 12
    • American Association of Critical Care Nurses (AACN) 10
    • Institute for Healthcare Improvement (IHI) 14

Resources & Tools

Research & Reports

Lessons from the Pioneers Reporting Healthcare-Associated Infections (National Conference of State Legislatures)

The National Conference of State Legislatures has released a new report that offers lessons on infection-reporting data from nine of the states that first required medical facilities to report health care-associated infections. The NCSL looked at state laws passed from 2005 to 2009 and interviewed state lawmakers, health care providers and other related groups in Alabama, Colorado, Delaware, Illinois, Massachusetts, New Hampshire, Oregon, Pennsylvania and Washington. Since 2005, the number of states that require health care facilities to report HAIs has jumped from six to 27.

Download PDF

Probiotic Prophylaxis of Ventilator-associated Pneumonia: A Blinded, Randomized, Controlled Trial (Respiratory and Critical Care Medicine)

Lee E. Morrow of Creighton University and colleagues have discovered that cases of ventilator-associated pneumonia in critically ill patients in hospitals were cut in half after patients were given probiotic bacteria. The study involved 138 critically ill patients from a single hospital, who were either given placebo or the probiotic Lactobacillus rhamnosus. Donald Craven of the Lahey Clinic Medical Center in Burlington, Mass., said the results "hold promise for trying to prevent an infection that has serious morbidity, mortality and is a major factor for hospital costs that we’re trying to contain."

Read More

Hospital-Acquired Infections Due to Gram-Negative Bacteria (New England Journal of Medicine)

The New England Journal of Medicine published findings from researchers at Massachusetts General Hospital that suggested gram-negative bacteria play a significant role in about 30 percent of hospital-acquired infections in the U.S. The findings showed that such bacteria were the predominant players in 47 percent of ventilator-associated pneumonia cases and 45 percent of urinary tract infections. The researchers noted that almost any gram-negative bacteria can cause bloodstream infection if an adequate portal of entry is present.

Read More

Study: Overblown Cuffs Common (Anesthesiology News)

Cuff pressures for endotracheal tubes may be too high during surgery, according to a new study by British investigators who are calling for routine monitoring of the devices in the operating room.

The study, by anesthesiologists at University College London, found that endotracheal tube (ETT) cuff pressures averaged 41 cm H2O—16 cm H2O greater than the recommended maximum level of 25 cm H2O in the United Kingdom. Pressures that high could increase patients’ risk for sore throat, hoarseness and difficulty swallowing.

Read More

State of the Art: Ventilator-associated Pneumonia. Jean Chastre and Jean-Yves Fagon

Download PDF

See Other Threats & Solutions