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Ventilator-Associated
Pneumonia (VAP)
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of
academic medicine, and medical author. He graduated
from Ross University School of Medicine and has
completed his clinical clerkship training in various
teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale
Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has
served as a test prep tutor and instructor for Kaplan. He has developed several medical courses
and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple
levels in the academic field including faculty member and Department Chair. Dr. Jouria
continues to serves as a Subject Matter Expert for several continuing education organizations
covering multiple basic medical sciences. He has also developed several continuing medical
education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been
contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to
develop an e-module training series for trauma patient management. Dr. Jouria is currently
authoring an academic textbook on Human Anatomy & Physiology.
ABSTRACT
Ventilators are machines that provide life-saving oxygen to patients through a
tube in the nose, mouth, or trachea. However, sometimes germs will enter
through the tube and take up residence in a patient’s lungs, developing into
ventilator-associated pneumonia, or VAP. Although most cases of VAP are
treated successfully with antibiotics, early diagnosis is critical, especially since
many VAP patients are intubated and/or heavily sedated, essentially unable to
alert medical staff to their symptoms. Nurses need to be able to recognize risk
factors and symptoms to provide these early diagnoses and allow for the best
possible outcome for their patients.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the policies
of NurseCe4Less.com and the continuing nursing education requirements of the
American Nurses Credentialing Center's Commission on Accreditation for
registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity,
transparency, and best practice in clinical education for all continuing nursing
education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 2 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Pharmacology content is 0.5 hours (30 minutes).
Statement of Learning Need
The principles of managing the patient on a ventilator is essential for nurses to
know in order to provide safe and appropriate care, and to avoid complications
such as ventilator-assisted pneumonia.
Course Purpose
To provide nursing professionals with knowledge of the basic skills to manage
care of the patient on a ventilator and to prevent ventilator-assisted pneumonia.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 1/1/2016
Termination Date: 4/4/2018
Please take time to complete a self-assessment of knowledge, on page
4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be
provided at the end of the course.
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1. The primary risk factor for the development of hospital-associated
bacterial pneumonia is:
a. Presence of community-acquired pneumonia during admission.
b. Mechanical ventilation.
c. Viral infection during the flu season.
d. Non-compliance with respiratory precautions among healthcare workers.
2. In critically ill, mechanically ventilated patients, signs and
symptoms of VAP include the following except:
a. Fever
b. Purulent Sputum
c. Hypoxemia
d. High blood pressure
3. Early-onset pneumonia (EOP) is VAP pneumonia that develops:
a. Within 24 hours of intubation
b. Within 48 and 96 hours of intubation
c. Between 96 and 110 hours of intubation
d. After two weeks of intubation
4. Placing the patient in a semi-upright position (by elevating the
head of the bed at an angle of _______ may help prevent
aspiration in patients on the ventilator.
a. 10-15 degrees
b. 30 - 45 degrees
c. 45-60 degrees
d. 90 degrees
5. In intubated patients, leakage around the endotracheal cuff allows
secretions to form:
a. Below the glottis and above the endotracheal-tube cuff.
b. Underneath the tongue.
c. Below the carina.
d. In the bronchial tubes.
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Introduction
The primary risk factor for the development of hospital-associated bacterial
pneumonia is mechanical ventilation (with its requisite endotracheal intubation).
In fact, patients who received continuous mechanical ventilation had 5-20 times
the risk of developing hospital-associated pneumonia compared with patients
who were not receiving mechanical ventilation.1 Because of this tremendous
risk, in the last two decades, most of the research on hospital-associated
pneumonia has been focused on Ventilator-associated pneumonia (VAP). While
patients are at risk of developing other forms of hospital and healthcare related
forms of pneumonia, VAP is categorized and studied separately from these other
forms of the illness.2
Ventilator-associated pneumonia is a life-threatening illness with a mortality
rate of 35 – 50%.3 Approximately 15 – 25% of all patients who receive
respiratory support through mechanical ventilation develop VAP.4 It is most
common in patients in trauma, burn and neurosurgical centers, but it is also
present in respiratory support centers and intensive care centers.5 While
patients may experience pneumonia while they are receiving care in a
healthcare setting, VAP is specific to patients who are receiving mechanical
ventilation. It is diagnosed using specific criteria, which includes the
development of pneumonia within 48 hours of being placed on mechanical
ventilation.6 In many instances, it can be challenging to diagnose VAP, as the
patient is often experiencing a number of complications and symptoms as a
result of his or her underlying medical condition.7 In fact, many conditions
produce symptoms that mirror those found in VAP. Diagnosis depends on
confirmatory testing, which includes blood work, specimen cultures and chest
radiographs.8
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Ventilator-associated pneumonia is caused by a number of different
microorganisms, which are identified using the diagnostic strategies listed
above. Early onset VAP develops within 48 and 96 hours of intubation, and it is
often caused by flora in the upper airway.9 These flora typically include
Haemophilus influenza and Streptococcus pneumonia.10
Late onset VAP, which occurs after 96 hours of intubation, is typically caused by
a different series of microorganisms, which commonly include gram-negative
bacilli.11 It is important to identify the type of VAP so that the appropriate
treatment can be administered immediately. In most instances the patient will
receive initial empiric antibiotic therapy to slow the progression of VAP.12
However, once the specific microorganism has been identified, treatment will
often be modified to provide more specific therapy.13 The goal is eradication of
the pathogen. With treatment, many patients will be able to recover fully from
VAP. Therefore, it is important for healthcare providers to be familiar with the
causes, symptoms, and treatment of VAP.
Microbiology Of VAP
Bacteria are the most common pathogen in instances of VAP. However, in some
instances, viral and fungal pathogens can be involved in cases of VAP.9 When
fungal or viral pathogens are present, it is typically in patients who are
immunocompromised.14 While the specific bacteria will differ depending on the
institution, the most common bacterial pathogens include:10

Aerobic GNB - Pseudomonas aeruginosa, Acinetobacter baumanii,
Klebsiella pneumoniae, Escherichia coli

Gram-positive organisms such as Staphylococcus aureus
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The specific type of bacteria will also vary depending on when the patient
develops pneumonia. In instances of early onset pneumonia, patients will
typically be infected with antimicrobial-sensitive bacteria. These strains of
bacteria include:15

Enterobacter spp

E. coli, Klebsiella spp

Proteus spp

Serratia marcescens

Streptococcus pneumonia

Haemophilus influenza

Methicillin-sensitive S. aureus
In instances of late-onset VAP, the patient is typically infected with multidrugresistant pathogens. The most common pathogens include:16

P. aeruginosa

K. pneumonia (extended spectrum beta-lactamase and Klebsiellaproducing carbapanamase strains)

Acinetobacter spp

Stenotrophomonas maltophilia

Burkholderia cepacia

Methicillin-resistant S. aureus
The etiologic agents that cause VAP vary among institutions and settings
primarily because of differences in patient populations, diagnostic methods
employed, and definitions used.6 In general, however, bacteria have been the
most frequently isolated pathogens. In most studies, very few anaerobic
bacteria and viruses were reported, partly because anaerobic and viral cultures
were not performed routinely in the reporting facilities.15
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Microbiology Of CAP
The majority of Community Acquired Pneumonia (CAP) cases are caused by the
Streptococcus pneumonia pathogen. There are other pathogens that are known
to cause CAP, but their prevalence varies.5 Other pathogens present in instances
of CAP include:17

Haemophilus influenza

Mycoplasma pneumonia

Influenza A

Legionella species

Chlamydophilia pneumoniae
While the pathogens listed above are commonly found in cases of CAP, a
number of CAP cases involve unidentifiable pathogens. In fact, approximately 30
– 50% of CAP cases will involve unidentifiable pathogens and/or other causes.18
Some cases of CAP are caused by pathogens that are not typically associated
with CAP. For example, some pathogens that were originally limited to health
care facilities have been found in cases of CAP. The most common health care
related pathogen is methicillin-resistant Staphlococcus aureus (MRSA).19 In
addition, some viruses can be linked to CAP.
It is quite common for patients to develop CAP after infection with potent strains
of influenza.17 Some patients will develop CAP through other viral respiratory
infections such as:20

Parainfluenza virus

Adenovirus

Human metapneumovirus

Herpes zoster virus (HSV)

Varicella-zoster virus (VZV)

Measles
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The following table provides information regarding the type of pathogen and the
prevalence of cases of CAP:21
Identified Pathogens in Community-Acquired Pneumonia
Pathogen
Cases (%)
Streptococcus pneumonia
20-60
Haemophilus influenza
3-10
Staphylococcus aureus
3-5
Gram-negative bacilli
3-10
Legionella species
2-8
Mycoplasma pneumonia
1-6
Chlamydia pneumonia
4-6
Viruses
2-15
Aspiration
6-10
Others
3-5
Mechanical Ventilation
A mechanical ventilator provides a patient with respiratory support in situations
that warrant it. Mechanical ventilators are most often used when patients are
under general anesthesia, or when they are critically ill and unable to breath
independently. Mechanical ventilators provide different levels of oxygen, up to
100%, based on the specific needs of the patient.22 The oxygen and airflow can
be controlled and modified based on the changing status of the patient. In
addition, the tidal volume (volume of respirations) and the number of
respirations per minute can be adjusted so that the patient receives the
appropriate amount of support.23 The goal with all adjustments is to provide
regulated respiratory support. Some patients will only require minimal support,
while others will require full levels of oxygen to support ventilation.24
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Indications
The major indication for mechanical ventilation is acute respiratory failure, of
which there are two basic causes:25
1. Ventilatory (Hypercapnic respiratory failure)

Reduced respiratory drive

Chest wall abnormalities

Respiratory muscle fatigue
2. Inefficient Gas Exchange (Hypoxic respiratory failure)

Intrapulmonary shunt

Ventilation-perfusion mismatch

Decreased FRC
The above are basic indications for mechanical ventilation. However, the
following list provides specific guidelines for the use of mechanical ventilation.
When a patient presents with one or more of the following conditions,
mechanical ventilator support may be necessary:26

Bradypnea or apnea with respiratory arrest

Acute lung injury and the acute respiratory distress syndrome

Tachypnea (respiratory rate >30 breaths per minute)

Vital capacity less than 15 mL/kg

Minute ventilation greater than 10 L/min

Arterial partial pressure of oxygen (PaO2) with a supplemental fraction of
inspired oxygen (FIO2) of less than 55 mm Hg

Alveolar-arterial gradient of oxygen tension (A-a DO2) with 100%
oxygenation of greater than 450 mm Hg

Clinical deterioration

Respiratory muscle fatigue

Obtundation or coma
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
Hypotension

Acute partial pressure of carbon dioxide (PaCO2) greater than 50 mm Hg
with an arterial pH less than 7.25

Neuromuscular disease
The above guidelines and recommendations are used to determine the necessity
of mechanical ventilation. In some instances, mechanical ventilation is not
required. The following is a list of the primary goals of mechanical ventilation,
which should be considered when determining whether or not to provide a
patient with respiratory support.
Goals of Mechanical Ventilation27

Relieve respiratory distress

Decrease work of breathing

Improve pulmonary gas exchange

Reverse respiratory muscle fatigue

Permit lung healing

Avoid complications
The procedure for mechanical ventilation is the same regardless of the patient’s
condition. The patient is intubated, which involves the insertion of an
endotracheal tube into the individual’s trachea. The tube is inserted through the
mouth or nose, depending on the specific needs of the patient.23 Once the tube
is inserted, the patient will begin receiving respiratory support. In some
instances, the patient will control the respiratory rate through spontaneous
breathing. In other instances, the ventilator will control respiration.28 Once the
patient begins receiving mechanical ventilation, continuous monitoring is
necessary. Monitoring includes chest X-rays, arterial blood gas measurement
and analysis, as well as frequent observation.24
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VAP And Pathophysiology
Ventilator-associated pneumonia is divided into two categories, which are
defined by the duration of time between intubation and the onset of illness.
Early onset VAP develops within 48 and 96 hours of intubation and is typically
caused by organisms that are susceptible to antibiotics. Late onset VAP develops
in patients once they have surpassed 96 hours after intubation. Late onset VAP
is typically caused by microorganisms that are resistant to antibiotics.29 The
pathophysiology of VAP includes two distinct components:5

Colonization of the respiratory and digestive tracts

Micro-aspiration of secretions of the upper and lower regions of the airway
Colonization in the lungs occurs as the result of the spread of organisms from a
variety of sources. The most common sources of bacteria include:30

Oropharynx

Sinus cavities

Nares

Dental plaque

Gastrointestinal tract

Patient-to-patient contact

Ventilator circuit
When the bacteria from these sources are inhaled, it will cause an active host
response, which can lead to the development of VAP. Bacteria can also enter the
lower respiratory tract directly through the endotracheal tube. This typically
occurs when upper airway and oral secretions line the endotracheal tube,
forming a biofilm that is composed of large quantities of bacteria, which then
enter the lungs through ventilator assisted breathing.8 In some instances the
biofilm will enter the lung through other means, including:1
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
Installation of saline into the tube

Coughing

Suctioning

Repositioning of the endotracheal tube
In addition to the access routes listed above, the endotracheal tube increases
the risk of infection by interrupting the regular processes of the upper and lower
airways. When an endotracheal tube is inserted, it bypasses the upper airway,
thereby affecting the body’s ability to filter and humidify air.31 The endotracheal
tube also impacts the involuntary cough reflex by eliminating or reducing it.
When the cough reflex is impacted, it can affect the patient’s ability to remove
or clear mucous from the lungs.23 In some patients, the endotracheal tube will
provide an outlet for bacteria to bind to the trachea. When this occurs, the
patient will experience an increase in the production and secretion of mucous.27
All of these factors, which are associated with the impairment of defense
mechanisms, increase the risk of the colonization of bacteria in the patient’s
lung and the subsequent development of VAP.10
Patients are also at risk of developing VAP through the aspiration of gastric
contents. The stomach is a direct source of bacteria when a patient has a
nasogastric or orgogastric tube in place for enteral feeding and pharmaceutical
administration.32 When the patient has a tube in place, it affects the regular
processes of the gastroesophageal sphincter. When this interruption occurs, the
patient will experience an increase in gastrointestinal reflux, which serves as a
route for the translocation of bacteria into the oropharynx.33 This eventually
leads to the colonization of bacteria in the upper airway. In addition to the
effects caused by the tube, enteral feeding causes changes to the gastric pH and
the gastric volume, which increases the patient’s risk of aspiration and provides
an ideal environment for bacterial colonization.34
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Risk Factors
There are a number of different risk factors for VAP, which can be categorized
into patient-related and treatment-related risks. In some instances, the risk
factor can be identified and minimized to prevent infection. In other instances,
the risk factor will have occurred prior to hospitalization, but will increase the
patient’s chances of developing VAP during his or her stay. The following is a list
of the most common VAP risk factors.
Ventilation for 5+ Days
Mechanical ventilation and intubation are the direct causes of VAP. However, the
risk of developing VAP increases once a patient receives ventilator assistance for
more than five days. A number of studies have shown that the duration of
ventilation is directly correlated to the development of VAP. The longer a patient
receives mechanical ventilation, the greater his or her risk of developing VAP.
Therefore, healthcare providers should strive to reduce the duration of
mechanical ventilation as a means of preventing the development of VAP.23
Recent Hospitalization
Patients who have recently been hospitalized have a greater risk of developing
VAP due to potential exposure to multi-drug resistant pathogens. During an
initial assessment and evaluation, the patient history should include questions
regarding recent hospitalizations. In some instances, the ventilated patient will
receive empiric antibiotics as a preventative measure to ensure that the
multidrug-resistant pathogens do not colonize and cause the patient to develop
VAP.16
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Residence in Nursing Home
In long-term care facilities (LTCFs) such as nursing homes, pneumonia is the
first or second most common infection (after those of the urinary tract) acquired
by patients, and accounts for 13-48% of all nursing home-associated infections.
Its seasonal variation mirrors that of influenza, suggesting that influenza plays a
major role in the occurrence of pneumonia in the elderly. Nursing homeassociated pneumonia is associated with a high mortality rate. The case-fatality
rate of pneumonia in nursing home residents is reported to be from 6% to
23%.5
Hemodialysis Treatment
Patients who have recently received hemodialysis treatment have a greater risk
of developing VAP due to potential exposure to multi-drug resistant pathogens.
During an initial assessment and evaluation, the patient history should include
questions regarding hemodialysis. In some instances, the ventilated patient will
receive empiric antibiotics as a preventative measure to ensure that the
multidrug-resistant pathogens do not colonize and cause the patient to develop
VAP.35
Chemotherapy
Patients who are undergoing chemotherapy are at an increased risk of
developing hospital-acquired infections, including ventilator-associated
pneumonia, due to a compromised immune system.16
Intravenous Wound Care
Patients who have recently received intravenous wound care have a greater risk
of developing VAP due to potential exposure to multi-drug resistant pathogens.
During an initial assessment and evaluation, the patient history should include
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questions regarding intravenous wound care. In some instances, the ventilated
patient will receive empiric antibiotics as a preventative measure to ensure that
the multidrug-resistant pathogens do not colonize and cause the patient to
develop VAP.36
Recent Antibiotic Use
Patients who have recently used antibiotics have a greater risk of developing
VAP due to the development of multi-drug resistant pathogens. During an initial
assessment and evaluation, the patient history should include questions
regarding recent antibiotic use. In some instances, the ventilated patient will
receive empiric antibiotics as a preventative measure to ensure that the
multidrug-resistant pathogens do not colonize and cause the patient to develop
VAP.37
Immunocompromised Patients
Immunocompromised patients have a greater risk of developing VAP due to
their increased susceptibility to infections. Patients with the following conditions
are especially susceptible to VAP:30

HIV/AIDS

Cancer

Organ transplantation

Patients on corticosteroids

Patients taking medications that suppress the immune system
Symptoms
When a patient is undergoing mechanical ventilation, it is important to
continuously monitor him or her for signs of VAP. Most patients will display
common symptoms, which make early identification and treatment easier.35 The
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following symptoms, discussed below, are the most common signs of VAP. Once
symptoms have been detected, it is important to begin treatment immediately
to minimize the effects of the illness and prevent further damage.
Fever
Fever is common in instances of VAP due to the level of infection in the body.
Most patients will have an ongoing fever.38
Purulent Sputum
Purulent sputum is infected mucus that the patient produces from the lower
airways. It is comprised of the following components:39

Pus

White blood cells

Cellular debris

Dead tissue

Serous fluid

Viscous liquid
Purulent sputum is typically yellow in color, but in some instances it can be
greenish. When sputum is present, it is indicative of infection. While purulent
sputum is not unique to VAP, it is an indicator of the illness. The sputum will be
cultured to determine the bacterial composition.7
Leukocytosis
Leukocytosis, which is a higher than normal white blood cell count, is often one
of the first signs of VAP. Leukocytosis is indicative of an inflammatory response
to an infection and is most common in bacterial and viral infections.39 There are
five principal types of leukocytosis:40
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
Neutrophilia (the most common form)

Lymphocytosis

Monocytosis

Eosinophilia

Basophilia
Low Body Temperature
Low body temperature is a common symptom of VAP. In most instances,
patients will experience low body temperature in conjunction with other
symptoms of VAP. It is not common for patients with VAP to experience low
body temperature in the absence of other symptoms.1
Hypoxemia
Patients with VAP will often experience a lower than normal level of oxygen in
the blood. This condition is known as hypoxemia. The low respiratory levels that
occur when a patient is infected cause this lack of oxygen. The lungs are unable
to function properly, which impacts the amount of oxygen distributed to the rest
of the body.41 Hypoxemia is suspected when the patient presents with shortness
of breath, and is identified through the measurement of the patient’s blood
oxygen level. The measurement is completed using a sample of blood from the
patient’s artery. In some instances, a pulse oximeter will be used to measure
the saturation of oxygen in the patient’s blood, which is then used to determine
the patient’s blood oxygen level.14
Diagnosis
In many instances, VAP can be difficult to diagnose. Typically, providers will use
a combination of symptoms (fever, leukocytosis, purulent secretions, and
hypoxemia) as the first set of criteria for diagnosis. Once symptoms have been
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identified, providers will utilize blood work, lab cultures and chest radiographs to
confirm the presence of VAP. The provider will often use the Clinical Pulmonary
Infection Score, which is scoring system based on the assessment results, to
make an appropriate diagnosis.7
Blood Work
Blood work is not always necessary for the diagnosis and identification of VAP.
However, in some situations, it may be necessary to utilize blood work as a
means of determining the level of infection and the specific pathogen causing
the infection.39 The specific blood work will be determined based on the needs of
the individual patient. The following table provides descriptions of the different
types of blood work and their purpose.42
Test
Description
White blood cell count
High levels indicate infection
Blood cultures
Cultures are done to determine the specific organism causing
the pneumonia, but they usually cannot distinguish between
harmless and dangerous organisms. They are accurate in only
10 - 30% of cases. Their use is generally limited to severe
cases.
Detection of antibodies
Antibodies are immune factors that target specific foreign
invaders. Antibodies that react with mycoplasma or chlamydia
are not present early enough in the course of pneumonia to
allow for prompt diagnosis by this method.
C-reactive protein or
Not generally recommended but may help identify which
procolacitonin
patients with respiratory symptoms have pneumonia and need
to be hospitalized.
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Polymerase Chain
In some difficult cases, PCR may be performed. The test makes
Reaction (PCR)
multiple copies of the genetic material (RNA) of a virus or
bacteria to make it detectable. PCR is useful for identifying
certain atypical bacteria strains, including mycoplasma and
Chlamydia pneumoniae, but it is expensive. One study found
that using a real-time PCR test may help quickly diagnose
Pneumocystis pneumonia in HIV-positive patients.
Chest X-Ray
The chest radiograph is often the first stage of VAP diagnosis. It is used to
identify the white areas in the lungs, called infiltrates, as well as any
complications caused by the pneumonia. The initial chest radiograph is used to
determine the extent of infection so that a treatment protocol can be developed.
It is important to note that other complications will cause abnormal results on
the chest radiograph, so the chest X-ray is not typically the sole diagnostic tool
used when assessing VAP.7
Culture
In many instances, practitioners will utilize sputum samples to further diagnose
VAP. The sputum sample is used to identify the specific organism causing the
infection. To acquire a sample, the patient will have to cough deeply enough to
produce mucous. The mucous is collected and tested. If the patient is unable to
produce a deep enough cough to bring up mucous from the lungs, the sample
will be collected using a tube that is inserted through the nose.41 The tube will
cause the patient to cough deeply, thereby producing an adequate sample. The
sputum sample is examined for:43

Blood, which suggests an infection is present

Color and consistency (if it is gray, green, or brown, an infection is likely)
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Once the sample has been examined, it will be sent to a laboratory for further
analysis. In the laboratory, it will be analyzed to determine if bacteria is present
and if that bacteria is gram-positive or gram-negative.6
Bronchoscopy
A bronchoscopy is often used when a thorough examination of respiratory
secretions is necessary. It is quite invasive, so it is not always appropriate. It is
commonly used to diagnose patients who require immediate diagnosis, such as
those who are immunocompromised or those who show signs of a worsening
condition.44 The following is the standard procedure for the bronchoscopy:42

The patient is given a local anesthetic, oxygen, and sedatives.

The physician inserts a fiber optic tube into the lower respiratory tract
through the nose or mouth.

The tube acts like a telescope into the body, allowing the physician to view
the windpipe and major airways and look for pus, abnormal mucus, or
other problems.

The doctor removes specimens for analysis and can also treat the patient
by removing any foreign bodies or infected tissue encountered during the
process.
Bronchoalveolar Lavage
A bronchoalveolar lavage is used to detect the specific organisms that cause
VAP. This procedure is often used in conjunction with a bronchoscopy, though it
may be used independently in some situations.
During the procedure, the patient receives an injection of saline through a
bronchoscope, which is inserted in the lung. The saline is immediately suctioned
out of the lung, and the fluid is analyzed for specific pathogens.44
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While the procedure is relatively safe, it can cause some complications. They
include:42

Allergic reactions to the sedatives or anesthetics

Asthma attacks in susceptible patients

Bleeding

Fever
CDC Recommendations
The CDC provides the following guidelines for the threshold levels for cultures:45
Threshold values for cultured specimens used in the diagnosis of pneumonia
Specimen collection/technique
Lung parenchyma*
Values
>104 CFU/g tissue
Bronchoscopically (B) obtained specimens
Bronchoalveolar lavage (B-BAL)
>104 CFU/ml
Protected BAL (B-PBAL)
>104 CFU/ml
Protected specimen brushing (B-PSB)
>103 CFU/ml
Nonbronchoscopically (NB) obtained (blind) specimens
NB-BAL
>104 CFU/ml
NB-PSB
>103 CFU/ml
CFU = colony forming units; g = gram; ml = milliliter
* Open-lung biopsy specimens and immediate post-mortem specimens obtained by
transthoracic or transbronchial biopsy
Clinical Pulmonary Infection Score
The Clinical Pulmonary Infection Score (CPIS) scores the patient based on the
findings from each assessment. However, there is some controversy regarding
the accuracy of the score and its correlation to VAP.46
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The following is the Clinical Pulmonary Infection Score criteria:46
A score > 6 at baseline or at 72 h is considered suggestive of pneumonia. If <= 6 at 72
hours patient probably doesn't have pneumonia and antibiotics probably can be stopped.
Temperature (C)
>= to 36.5 and, or equal to 38.4 ................ 0 point
>= to 38.5 and, or equal to 38.9................. 1 point
>= to 39 and, or equal to 36...................... 2 points
Blood leukocytes, mm3
>= 4,000 and, <= to 11,000...................... 0 point
<4,000 or > 11,000.................................. 1 point
and, if band forms >= to 50%.................... 1 point
Tracheal secretions
Absence of tracheal secretions...................... 0 point
Presence of nonpurulent tracheal secretions ... 1 point
Presence of purulent tracheal secretions......... 2 points
Oxygenation
PaO2/FIO2, mm Hg >240 or ARDS (ARDS defined as PaO2/FIO2 <= equal to 200,
pulmonary artery wedge pressure <= to 18 mm Hg and acute bilateral
infiltrates).................................................... 0 point
<= equal to 240 and no ARDS........................ 2 points
Pulmonary radiography
No infiltrate................................................ 0 point
Diffuse (or patchy) infiltrate.......................... 1 point
Localized infiltrate........................................ 2 points
Progression of pulmonary infiltrate
No radiographic progression ........................ 0 point
Radiographic progression (no CHF or ARDS).. 2 points
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Culture of tracheal aspirate
Pathogenic bacteria cultured in rare or light quantity or no growth.. 0 points
Pathogenic bacteria cultured in moderate or heavy quantity............ 1 point
Same pathogenic bacteria seen on Gram stain, add 1 point............. 1 point
------------------------------------------------------------------------------------Notes:
CPIS at baseline is assessed on the basis of the first five variables, i.e., temperature, blood
leukocyte count, tracheal secretions, oxygenation, and character of pulmonary infiltrate.
CPIS at 72 h is calculated based on all seven variables and took into consideration the
progression of the infiltrate and culture results of the tracheal aspirate.
A score > 6 at baseline or at 72 h is considered suggestive of pneumonia.
VAP Treatment
Ventilator-associated pneumonia treatment is administered in one of two ways.
The initial, and frequently used approach, is empiric treatment. With this
approach, patients are given broad-spectrum antibiotics without the
identification of the pathogen that is causing the infection. The second method
of treatment involves targeted antibiotic therapy, which is used when the
specific infection-causing organism has been identified. In many instances, both
methods of treatment will be used.
The ultimate goal with therapy is to balance the use of broad-spectrum
treatment with more specific therapy once the infection-causing agent has been
identified.8
Empiric Therapy
Empiric treatment is typically administered before the infection-causing
organism has been identified. With this approach, the patient receives broad
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spectrum antibiotic therapy with the goal of reducing or eliminating the primary
infectious agent.47
The following antibiotics are frequently used when providing empiric treatment
to the patient:
Early Onset (< 5 days since admission)

Ceftriaxone 2 g IV or IM q 24 h or

Levofloxacin 750 mg IV or PO q 24 h or

Moxifloxacin 400 mg IV or PO q 24 h or

Ciprofloxacin 400 mg IV q 8 h or

Ampicillin-sulbactam 3 g IV or IM q 6 h or

Ertapenem 1 g IV or IM q 24 h
Duration of therapy: 8 days
Late onset (≥ 5d since admission), MDR risk factors present, or diagnosis of
HCAP:5,6,

Cefepime 2 g IV q 8 h or

Ceftazidime 2 g IV q 8 h or

Imipenem 500 mg IV q6h or 1 g IV q 8 h or

Meropenem 1 g IV q 8 h or

Piperacillin-tazobactam 4.5 g IV q 8 h PLUS
Vancomycin 15 mg/kg IV q 12 h or

Linezolid 600 mg IV q 12 h PLUS
Ciprofloxacin 400 mg IV q 8 h or

Levofloxacin 750 mg IV q 24 h
Duration of therapy: Depends on specific needs of patient.48
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Once the patient begins receiving empiric treatment, he or she will be
continuously monitored to assess the impact the medicine is having on the
infection. The following guidelines are used during the assessment of empiric
treatment:49

If clinical improvement is noted in 48 -72 h and cultures are negative,
consider stopping antibiotics

If clinical improvement is noted in 48 – 72 h and cultures are positive,
adjust regimen per susceptibilities and continue antibiotics for 7 – 8 days

If there is no clinical improvement and cultures are negative, look for
alternative diagnoses

If there is no clinical improvement and cultures are positive, adjust
regimen per susceptibilities
Targeted Drug Therapy
While empiric treatment is successful in many instances of VAP, it is often
necessary to employ targeted antibiotic therapy that is tailored to the specific
pathogen causing the infection. Targeted drug therapy is used in situations
where empiric treatment is not effective or not appropriate, or in situations that
require treatment that will attack a specific organism.50
Patient Care During Treatment
It is important to utilize proper methods for patient care while administering
treatment for VAP. These care strategies will help prevent further infection,
while reducing the risk of the patient developing additional complications. The
most important care strategies include feeding and body positioning, intubation
considerations, and oral hygiene.
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Feeding and Body Positioning
It is important to ensure that the patient receives proper feeding and body
positioning while receiving mechanical ventilation and treatment for VAP.
Feeding
1. Acidified enteral feeding:
Because enteral feeding can increase gastric pH and result in gastric
colonization, acidification of enteral solutions has been advocated to
prevent gastric and tracheal colonization in patients receiving such
treatment.32
2. Continuous versus intermittent enteral feeding:
Continuous enteral feeding of mechanically ventilated patients, a common
practice in ICUs, has been associated with increased gastric pH,
subsequent gastric colonization with Gram-negative bacilli, and a high
incidence of pneumonia; whereas intermittent enteral feeding has been
associated with lower gastric pH and lower rates of pneumonia.33
Body Positioning
Placing the patient in a semi-upright position (by elevating the head of the bed
at an angle of 30 - 45 degrees) is beneficial in preventing aspiration. The
increased risk for pneumonia in intubated, mechanically ventilated patients is
partly due to the transmission of oropharyngeal microorganisms via passage of
the endotracheal tube into the trachea during intubation, as well as to
depressed host defenses secondary to the patient's severe underlying illness. In
addition, bacteria can collect on the surface of the endotracheal tube over time
and form a biofilm that protects the bacteria from antimicrobial agents or host
defenses.51
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Intubation Considerations
In the intubated patient, leakage around the cuff of the endotracheal tube
allows bacteria laden secretions (which pool below the glottis and above the
endotracheal-tube cuff) direct access to the lower respiratory tract.27 The effect
of using an endotracheal tube that has a separate dorsal lumen, which allows
drainage (i.e., removal by suctioning) of the subglottic secretions, has been
compared to that of a conventional endotracheal tube.52
Non-Invasive Positive Pressure Ventilation (NPPV) has been shown to reduce the
need for, and duration of, intubation, and has resulted in improved survival. In
several studies, the use of NPPV resulted in a decreased risk for pneumonia.35
Repeat Endotracheal Intubation
Repeat insertion of the endotracheal tube soon after it is removed from a
patient who is taken off ventilator support has been shown to be a risk factor for
pneumonia. Using Non-Invasive Ventilation instead may help reduce the risk.27
Oral Care
Proper oral care is crucial in intensive care patients, especially those on a
ventilator. Studies have shown that the risk of developing hospital acquired
pneumonia and ventilator associated pneumonia is reduced when a patient
receives appropriate oral care during his or her stay in the intensive care unit.53
To ensure that oral hygiene standards are consistent throughout all facilities,
the following guidelines, from the American Association of Critical Care Nurses,
were developed:54
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Recommended Oral Care Interventions For All Hospitalized Patients
Written Protocol and Training

Intervention: Written oral care protocol and training should be in place.

Rationale: Policy is designed to provide a standard of care, which should be
reinforced in training and should allow for consistent care of all patients.
Initial Assessment

Intervention: Conduct an initial admission assessment of the patient’s oral health
and self-care deficits.

Rationale: Assessment allows for initial identification of oral hygiene problems.
Dental Plaque Removal

Intervention: Use a small, soft toothbrush to brush teeth, tongue and gums at
least twice daily to remove dental plaque. Foam swabs or gauze should not be
used, as they are not effective tools for this task.

Rationale: Dental plaque, identified as a source of pathogenic bacteria associated
with respiratory infection, requires mechanical debridement from tooth, tongue
and gingival surfaces.
Toothpaste

Intervention: Use toothpaste, which contains additives that assist in the
breakdown of mucus and biofilm in the mouth.

Rationale: Additives such as sodium bicarbonate have been shown to assist in
removing debris accumulations on oral tissues and teeth.
Antiseptic Mouth Rinse

Intervention: Use an alcohol-free, antiseptic rinse to prevent bacterial colonization
of the oropharyngeal tract.

Rationale: Mouthwashes with alcohol cause excessive drying of oral tissues.
Hydrogen peroxide and CHG-based rinses have been shown to assist in removing
oral debris as well as provide antibacterial properties.
Moisturizer

Intervention: Use a water-soluble moisturizer to assist in the maintenance of
healthy lips and gums at least once every two hours.

Rationale: Dryness and cracking of oral tissues and lips provide regions for
bacterial proliferation. A water-soluble moisturizer allows tissue absorption and
added hydration.
Avoid Lemon Glycerin Swabs

Intervention: Avoid using lemon-glycerin swabs for oral care to moisten oral
mucosa.
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
Rationale: Lemon-glycerin compounds are acidic and cause drying of oral tissues.
Assessment of Oral Cavity

Intervention: Conduct an initial admission as well as daily assessment of the lips,
oral tissue, tongue, teeth, and saliva of each patient on a mechanical ventilator.

Rationale: Assessment allows for initial identification of oral hygiene problems and
for continued observation of oral health.
Elevate Head

Intervention: Keep head of bed elevated at least 30 degrees, and position patient
so that oral secretions pool into the buccal pocket; especially important during
feeding, brushing teeth, etc.

Rationale: Elevation prevents reflux and aspiration of gastric contents; oral
secretions may drain into the subglottic area where they can become rapidly
colonized with pathogenic bacteria.
Oral and Orotracheal Suctioning

Intervention: Suction patient’s mouth and oropharynx routinely and as indicated
by patient’s secretion production, using either continuous subglottic suctioning or
manual method. Do not use same catheter to suction both mouth and trachea.

Rationale: Minimize aspiration of contaminated secretions into lungs.
Prognosis
Ventilator-associated pneumonia is the leading cause of mortality from
nosocomial infections in hospitals. Ventilator-associated pneumonia has an
overall mortality rate of 20 – 40%.55 However, the specific percentage will
depend on the infectious agent, the type of treatment used, and the presence of
any underlying conditions. In instances of early onset VAP, the outcome is more
favorable, as the infection is typically caused by an organism that does not have
multiple drug resistance.16 The outcome for patients with late onset VAP is less
favorable, as the infection is most likely the result of multidrug-resistant
organisms, blood stream infections, and ineffective initial antibiotic therapy.48
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The fatality rates for hospital-associated pneumonia in general, and VAP in
particular, are high. In instances of hospital-associated pneumonia, VAP
accounted for 60% of all deaths due to hospital-associated infections.56 In
studies in which invasive techniques were used to diagnose VAP, the mortality
rates ranged from 4% in patients with VAP, but without antimicrobial therapy,
to 73% in patients with VAP caused by Pseudomonas or Acinetobacter spp.31
These wide ranges suggest that a patient’s risk of dying from VAP is affected by
multiple factors, such as the patient's underlying disease(s) and organ failure,
and the infecting organism(s).57
Summary
Mechanical ventilators provide life-saving oxygen to patients through a tube in
the nose, mouth, or trachea. However, sometimes germs will enter through the
tube and take up residence in a patient’s lungs, developing into ventilatorassociated pneumonia. Ventilator-associated pneumonia is a life threatening
illness with a mortality rate of 35 – 50%. Approximately 15 – 25% of all
patients who receive respiratory support through mechanical ventilation develop
VAP. It is most common in patients in trauma, burn and neurosurgical centers,
but it is also present in respiratory support centers and intensive care centers.
While patients may experience pneumonia while they are receiving care in a
healthcare setting, VAP is specific to patients who are receiving mechanical
ventilation. It is diagnosed using specific criteria, which includes the
development of pneumonia within 48 hours of being placed on mechanical
ventilation. In many instances, it can be challenging to diagnose VAP, as the
patient is often experiencing a number of complications and symptoms as a
result of his or her underlying medical condition. In fact, many conditions
produce symptoms that mirror those found in VAP.
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Although most cases of VAP are treated successfully with antibiotics, early
diagnosis is critical, especially since many VAP patients are intubated and/or
heavily sedated and unable to alert medical staff to their symptoms. Therefore,
nurses need to be able to recognize risk factors and symptoms to provide these
early diagnoses and allow for the best possible outcome for their patients.
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1. The primary risk factor for the development of hospital-associated
bacterial pneumonia is:
a. Presence of community-acquired pneumonia during admission.
b. Mechanical ventilation.
c. Viral infection during the flu season.
d. Non-compliance with respiratory precautions among healthcare
workers.
2. In critically ill, mechanically ventilated patients, signs and
symptoms of VAP include the following except:
a. Fever
b. Purulent Sputum
c. Hypoxemia
d. High blood pressure
3. Early-onset pneumonia (EOP) is VAP pneumonia that develops:
a. Within 24 hours of intubation
b. Within 48 and 96 hours of intubation
c. Between 96 and 110 hours of intubation
d. After two weeks of intubation
4. Placing the patient in a semi-upright position (by elevating the
head of the bed at an angle of _______ may help prevent
aspiration in patients on the ventilator.
a. 10-15 degrees
b. 30 - 45 degrees
c. 45-60 degrees
d. 90 degrees
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5. In intubated patients, leakage around the endotracheal cuff allows
secretions to form:
a. Below the glottis and above the endotracheal-tube cuff.
b. Underneath the tongue.
c. Below the carina.
d. In the bronchial tubes.
CORRECT ANSWERS:
1. b
2. d
3. b
4. b
5. a
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References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within the
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