This document defines ventilator-associated pneumonia (VAP) and identifies factors that increase risk. It also outlines effective strategies for reducing VAP incidence, including proper hand hygiene, oral care, keeping patients' heads of bed elevated, rotational therapy for immobile patients, limiting sedation, and following best practices for ventilation and airway management. Regular monitoring and a multidisciplinary team approach can help implement evidence-based guidelines to decrease VAP rates.

2. ■ State the definition for ventilator
associated pneumonia (VAP)
■ Define who is at greatest risk for the
development of VAP
■ Describe effective strategies for reducing
the incidence of VAP

3. ■ A nosocomial pneumonia associated with
mechanical ventilation that develops within 48 hours
or more of hospital admission and which was not
developing at the time of admission

4. ■ Early onset:
■ Hemophilus influenza
■ Streptococcus pneumoniae
■ Staphylococcus aureus (methicillin sensitive)
■ Escherichia coli
■ Klebsiella
■ Late onset:
■ Pseudomonas aeruginosa
■ Acinetobacter
■ Staphylococcus aureus (methicillin resistant)
■ Most strains responsible for early onset VAP are
antibiotic sensitive. Those responsible for late onset VAP
are usually multi antibiotic resistant

5. ■ Bacteria enter the lower respiratory tract by this
pathways:
■ Aspiration of organisms from the oropharynx
and GI tract (most common cause)
■ Inhalation of bacteria

6. ■ •Staphylococcus aureus - 24.4%
■ •Pseudomonas aeruginosa - 16.3%
■ •Enterobacter spp - 8.4%
■ •Acinetobacter baumannii - 8.4%
■ •Klebsiella pneumoniae - 7.5%
■ •Escherichia coli - 4.6%
■ •Candida spp - 2.7%
■ •Klebsiella oxytoca - 2.2%
■ •Coagulase-negative staphylococci - 1.3%

7. Pre-existing conditions (Non-modifiable risk factors)
■ •Head trauma
■ •Coma
■ •Nutritional deficiencies
■ •Immunocompromised
■ •Multi organ system failure
■ •Acidosis
■ •History of smoking or pulmonary disease

8. ■ Reintubation
■ Supine position
■ Impaired cough/depressed LOC
■ Oropharyngeal colonization
■ Presence of NG/OG tubes and enteral
feeding
■ Cross contamination by staff

9. ■ Hospital acquired pneumonia (HAP) is the
second most common hospital infection
■ VAP is the most common intensive care
unit (ICU) infection

10. ■ VAP occurs in 10 - 65% of all ventilated patients
■ The incidence of VAP is highest in the following
groups:
■ Trauma
■ Burns
■ Neurosurgical population
■ Surgery
■ Mortality rate is 24 – 50%
■ Mortality rate in VAP caused by Pseudomonas or
Acinetobacter is as high as 76%

11. ■ VAP increases:
■ Medical costs
■ Ventilator days
■ ICU and hospital LOS
■ Estimated direct cost of excess hospital stay due
to VAP is $40,000 per patient

12. ■ What are our rates?
■ How do we collect data?
■ What criteria do we use?

13. ■ Radiographic evidence x 2 consecutive days
■ New, progressive or persistent infiltrate
■ Consolidation, opacity, or cavitation
■ At least 1 of the following:
■ Fever (> 38 degrees C) with no other recognized cause
■ Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000
WBC/mm3)
■ At least 2 of the following:
■ New onset of purulent sputum or change in character of
secretions
■ New onset or worsening cough, dyspnea, or tachypnea
■ Rales or bronchial breath sounds
■ Worsening gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)

14. ■ Specific practices have been shown to decrease
VAP
■ Strong evidence that a collaborative,
multidisciplinary approach incorporating many
interventions is paramount
■ Intensive education directed at nurses and
respiratory care practitioners resulted in a 57%
decrease in VAP

15. ■ Hand washing
■ Oral care
■ HOB ↑ 30 degrees (in the absence of medical
contraindications)
■ Patient turning and rotational therapy
■ DVT prophylaxis
■ Daily interruption of sedative infusions
■ Airway/ventilator management

16. ■ Hand washing is the single most important (and
easiest!!!) method for reducing the transmission of
pathogens.

17. ■ Remember to wash your hands
■ Before and after patient contact
■ Beginning and end of work day
■ Before and after using gloves
■ After touching contaminated surfaces

18. Health care worker button
Room poster

19. ■ Dental plaque contains multiple pathogens (may include s.
aureus and p. aeruginosa)
■ After 48 hours, normal oral flora of critically ill pts changes
to more virulent gram (-) organisms
■ Aspiration of oral secretions around the cuff and ETT
occurs in all ventilated patients
■ VAP rates are reduced when oral care measures are
included in a comprehensive prevention program

20. ■ Oral decontamination – application of an antibiotic
solution

21. ■ Chlorhexidine oral rinse
■ Antiseptic agent active against both gram (-) and (+)
organisms
■ Allergies are rare
■ May discolor teeth
■ When used prior to intubation has been shown to ↓
respiratory tract infections

22. ■ Best Practice??
■ Daily assessment to determine oral health
■ Brush q 12 hours to prevent plaque
■ Oral cleansing q 2-4 hours to promote healing and
maintain integrity of oral tissues
■ Use of an alcohol-free, antiseptic oral rinse to prevent or
reduce bacterial load of oropharynx
■ Routine suctioning of mouth to manage oral secretions
and minimize risk of aspiration
■ Use of a moisturizer

23. ■ The supine position is an independent risk factor for death
in all ICU patients
■ Major benefit is prevention of aspiration
■ CDC recommends HOB 30-45° unless contraindicated

25. ■ Kinetic therapy (KT) – continuous turning through bedframe
rotation at least 62° on each side
■ Continuous lateral rotation therapy (CLRT) - similar to KT,
but degree of turn < 40°
■ Advantages include more even distribution of
transpulmonary pressures and tidal volume and increased
mobilization of secretions.

26. ■ Rotational therapy is beneficial for patients at high
risk for pneumonia, including patients who are:
■ sedated and ventilated > 3 – 4 days
■ difficult to turn
■ have head injury
■ in traction
■ When rotational beds are not used, turn at least q 2
hours

27. ■ Review of 11 randomized, controlled studies (1073
patients)
■ All rotational therapies included
■ 48% reduction in risk of developing pneumonia
■ Shorter ICU stay (decrease of 2.1 days)
■ No difference in mortality
■ Kinetic therapy more effective than CLRT

28. ■ Predisposes patients to:
■ Thromboemboli
■ Pressure ulcers
■ Gastric aspiration
■ VAP
■ Sepsis
■ Consequences include:
■ Difficulty in monitoring neuro status
■ Increased use of diagnostic procedures
■ Increase ventilator days
■ Prolonged ICU and hospital stay

29. ■ All infusions should be at the lowest rate to achieve effect
■ IV bolus therapy should be used to supplement infusion
when necessary
■ Every patient must be awakened daily unless
contraindicated!

30. ■ Contributes to the development of VAP:
■ Causes mucosal injury, producing decreased mucociliary
clearance
■ Decreases effectiveness of cough
■ Increases binding sites for bacteria
■ Increases mucus secretion
■ Provides a reservoir for bacteria
■ Reintubation is a significant risk factor for VAP

31. ■ Mechanical ventilation
■ Orotracheal intubation
■ Nasotracheal intubation may slightly increase the risk for VAP
■ Ventilator circuitry changes
■ Change only when soiled or malfunctioning
■ Cuff management
■ Maintain at 25-30 cm H2O

32. ■ Suctioning
■ In-line suctioning using closed technique
■ Normal saline
■ Should not be routinely used to suction pts
■ Causes desaturation
■ Can potentially dislodge bacteria
■ Should be used to rinse the suction catheter after
suctioning

33. ■ Should be done using a 14 Fr sterile suction catheter:
■ Prior to lying patient supine
■ Prior to extubation
■ Continuous subglottic suctioning
■ ETT with dedicated lumen to continuously or
intermittently suction above the cuff may reduce the risk
of VAP

34. ■ Heat and Humidity Exchangers (HMEs) should not be
routinely changed unless:
■ Visibly soiled
■ Use Heated Humidification (HH) if:
■ Ventilated longer than 96 hours
■ Thick/bloody secretions
■ Resp. Acidosis
■ Air leak from chest tube or around airway

35. ■ H2 blockers and antacids ↓ incidence of stress ulcers
■ Colonization of the GI tract occurs as the pH rises
■ These organisms ascend the GI tract and gain access to
the trachea

36. ■ Elevate HOB 30 - 45 degrees
■ Routinely verify tube placement

37. ■ Develop processes that enhance efficiency and
communication to help move evidence into practice
■ Implement interventional hygiene
■ Measure the results using standard definitions to capture
and compile data
■ Compare against the benchmarks
■ Celebrate and reward your successes and growth as a
team
■ Check on a quarterly basis continued compliance with the
new program