Patients who require invasive mechanical ventilation are at risk for ventilator-associated pneumonia.

VAP (ventilator-associated pneumonia) is associated with prolonged duration of mechanical ventilation (MV), longer length of stay in the intensive care unit (ICU) and hospital, and increased healthcare costs. Hospitals and clinicians are under pressure from legislators and regulatory agencies to implement VAP-prevention strategies. Currently, legislators are considering requiring hospitals to publicly report VAP rates, and the Centers for Medicare & Medicaid Services is considering adding VAP to the list of hospital-acquired conditions that are nonreimbursable.
 

Ventilator-associated pneumonia accounts for 11 percent of hospital-acquired infections (HAIs). In 2002, the estimated number of HAIs in U.S. hospitals was approximately 1.7 million and cost between $28 and $33 billion. The estimated deaths from HAIs in U.S. hospitals were 98,987; 35,967 of these infections were pneumonia.1, 2

 

Key Resources:

1. Klevens RM, Edwards JR, Richards CL, Jr., et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166. [ View Abstract ]

2. Scott RD. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Centers for Disease Control and Prevention. March 2009. Available at:http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf . Accessed October 21, 2013. [ View Abstract ]

 

Incidence

Different regions, diagnostic criteria and hospital locations yield unique VAP-induced rates.

VAP Rate (%) by Location and Criteria

VAP Rate(%)
View Data
Hide Data
Clinical Criteria Surveillance Criteria
U.S.1 4.00% 0.60%
Europe2 19.00% 14.60%
20.00%
15.00%
10.00%
5.00%
U.S.1 Europe2
VAP Rate Clinical Criteria
VAP Rate Surveillance Criteria

VAP Rate Per by 1,000 Ventilator Days by Area of Care3

VAP Rate per 1,000 Ventilator Days
View Data
Hide Data
Area of Care VAP Rate per 1,000 Ventilator Days
Burn 4.9
Trauma 4.7
Neurologic 3.6
Surgical - Major teaching 2.4
Neurosurgical 2.3
Medical/surgical - Major teaching 2.1
Surgical - All other 2
Surgical cardiothoracic 1.7
Medical - Major teaching 1.1
Surgical - Major teaching 1.1
Medical cardiac 1.1
Medical/surgical - All other <= 15 beds 1.1
Pediatric medical/surgical 1.1
Step-down units - Adult step-down (postcritical care) 1.1
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
Burn
Trauma
Neurologic
Surgical - Major teaching
Neurosurgical
Medical/surgical - Major teaching
Surgical - All other
Surgical cardiothoracic
Medical - Major teaching
Surgical - Major teaching
Medical cardiac
Medical/surgical - All other <= 15 beds
Pediatric medical/surgical
Step-down units - Adult step-down (postcritical care)

Outcomes

VAP is associated with increased mortality, length of stay and costs.

Mortality Rates in Patients with VAP Versus Controls

Mortality %
View Data
Hide Data
VAP Mortality Control Mortality Difference
Bercault 20011
(p< 0.0001)
41.00% 14.00% 27.00%
Warren 20032
(p< 0.001)
50.00% 34.00% 16.00%
Rello 20023
(p< 0.713)
30.50% 30.40% 0.10%
Ibrahim 20014
(p< 0.004)
45.50% 32.20% 13.30%
Kollef 20055
(p< 0.0001)
29.30% 10.00% 19.30%
50.00%
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
Bercault 20011
(p< 0.0001)
Warren 20032
(p< 0.001)
Rello 20023
(p< 0.713)
Ibrahim 20014
(p< 0.004)
Kollef 20055
(p< 0.0001)
VAP Mortality
Control Mortality

VAP - Attributable Mortality at 30 and 60 Days

Mortality %
View Data
Hide Data
Attributable Mortality
Bekaert 20116
(30 Day)
4.40%
Bekaert 20116
(60 Day)
5.90%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
Bekaert 20116
(30 Day)
Bekaert 20116
(60 Day)
VAP Attributable Mortality

Hospital Length of Stay (LOS) May Increase in Patients with VAP Versus Controls

Days
View Data
Hide Data
VAP Hospital LOS Control Hospital LOS Difference
Warren 20032
(p< 0.001)
38 13 25
Rello 20023
(p< 0.001)
25.5 14 11.5
Kollef 20055
(p< 0.0001)
23 7.5 15.5
40
35
30
25
20
15
10
5
Warren 20032
(p< 0.001)
Rello 20023
(p< 0.001)
Kollef 20055
(p< 0.0001)
VAP LOS
Control LOS

ICU Length of Stay (LOS) May Increase in Patients with VAP Versus Controls

Days
View Data
Hide Data
VAP ICU LOS Control ICU LOS Difference
Bercault 20011
(p< 0.0001)
31 26 5
Warren 20032
(p< 0.001)
26 4 22
Rello 20023
(p< 0.001)
11.7 5.6 6.1
35
30
25
20
15
10
5
Bercault 20011
(p< 0.0001)
Warren 20032
(p< 0.001)
Rello 20023
(p< 0.001)
VAP ICU LOS
Control ICU LOS

Hospital Costs May Increase in Patients with VAP Versus Controls

Dollars
View Data
Hide Data
VAP Costs Control Costs Difference
Warren 20032
(p< 0.001)
$70,568 $21,620 $48,948
Rello 20023
(p< 0.001)
$104,983 $63,689 $41,294
Kollef 20055
(p< 0.0001)
$150,841 $25,218 $125,623
Hugonnet 20047
(p< 0.001)
$24,727 $17,438 $7,289
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
Warren 20032
(p< 0.001)
Rello 20023
(p< 0.001)
Kollef 20055
(p< 0.0001)
Hugonnet 20047
(p< 0.001)
VAP Costs
Control Costs

Pathogenesis

VAP is directly linked to the aspiration of colonized secretions.

Oropharyngeal Colonization

  • The oropharyngeal colonizing flora is often the source of the causative organisms of VAP.1
  • Interventions that reduce oropharyngeal colonization reduce the incidence of VAP.2
  • The sequence of colonization in patients undergoing mechanical ventilation is the oropharynx (36 h), the stomach (36-60 h), the lower respiratory tract (60-84 h) and thereafter the endotracheal tube (60-96 h)3
  • While microaspiration of contaminated secretion is the primary pathway for VAP, biofilm on the endotracheal tube may play a role in maintaining the infection.4

Microaspiration

  • The major source of infection may be contaminated oropharyngeal secretions that leak through folds of the inflated ETT cuff.5, 6
  • Microaspiration occurs in virtually 100 percent of inflated high-volume, low-pressure ETT cuffs.6
  • Microaspiration is reduced but still present in the semirecumbent position compared to the supine position.7

1. Garrouste-Orgeas M, Chevret S, Arlet G, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med. 1997;156(5):1647-1655. [ View Abstract ]

2. Chlebicki MP, Safdar N. Topical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis. Crit Care Med. 2007;35(2):595-602. [ View Abstract ]

3. Feldman C, Kassel M, Cantrell J, et al. The presence and sequence of endotracheal tube colonization in patients undergoing mechanical ventilation. Eur Respir J. 1999;13(3):546-551. [ View Abstract ]

4. Deem S, Treggiari MM. New endotracheal tubes designed to prevent ventilator-associated pneumonia: do they make a difference? Respir Care. 2010;55(8):1046-1055. [ View Abstract ]

5. Cardenosa Cendrero JA, Sole-Violan J, Bordes Benitez A, et al. Role of different routes of tracheal colonization in the development of pneumonia in patients receiving mechanical ventilation. Chest. 1999;116(2):462-470. [ View Abstract ]

6. Blunt MC, Young PJ, Patil A, Haddock A. Gel lubrication of the tracheal tube cuff reduces pulmonary aspiration. Anesthesiology. 2001;95(2):377-381. [ View Abstract ]

7. Orozco-Levi M, Torres A, Ferrer M, et al. Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med. 1995;152(4 Pt 1):1387-1390. [ View Abstract ]

 

Interventions target colonization or microaspiration

VAP-reduction interventions generally focus on either reducing oropharyngeal colonization or preventing aspiration of colonized secretions.

Reduction in Oropharyngeal Colonization

Peptic Ulcer Disease (PUD) Prophylaxis

Both H2 antagonists and antacids have been identified as risk factors for VAP because they decrease intragastric acidity, which can result in greater colonization of pathogenic bacteria.1 However, trials investigating alternative therapies have been inconclusive regarding the prevention of VAP.1 The American Thoracic Society suggests that the risks and benefits of PUD prophylaxis regimens should be weighed before prescribing.1

Daily Oral Care with Chlorhexidine

Oral care is designed to reduce VAP by reducing oropharyngeal bacterial colonization.2

Selective Decontamination of the Digestive Tract

Gram-negative bacterial colonization of the stomach during critical illness is considered to be the source of microorganisms isolated from sputum cultures of patients with VAP.3 Selective decontamination of the digestive track (SDD) uses prophylactic antibiotic therapy to reduce bacterial colonization.3

Silver-Coated Endotracheal Tubes

Biofilm on the endotracheal tube is considered to be a source of reinfection in patients with VAP.Silver has a very effective broad-spectrum antimicrobial effect and is believed to reduce biofilm on endotracheal tubes.5

Semirecumbent Position

This method is typically defined as raising the head of the bed to an angle of 30-45 degrees, and is thought to reduce VAP by decreasing the migration of gastric pathogens into the subglottic space.6

Efficacy of VAP Interventions that Target Oropharyngeal Colonization

VAP Rate
View Data
Hide Data
VAP Rate Control VAP Rate Intervention Difference
1. Oral antiseptics2 13.70% 10.60% 3.10%
2. PUD prophlyaxis7 19.10% 16.20% 2.90%
3. Selective decontamination of the digestive tract3 40.00% 19.00% 21.00%
4. Silver coated endotracheal tube5 7.50% 4.80% 2.70%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
1. Oral antiseptics2 2. PUD prophlyaxis7 3. Selective decontamination of the digestive tract3 4. Silver coated endotracheal tube5
VAP Rate Control
VAP Rate Intervention

1. Meta-analysis (14 studies, 2,481 participants) (P= 0.004)2

2. Randomized controlled trial (1,200 participants) (P=0.19)7

3. Meta-analysis (33 studies, 5,697 participants) 3

4. Randomized controlled trial (1,509 participants) (P=0.03)5

Microaspiration Prevention

Cuff Pressure Monitoring

ETT cuffs that are not frequently monitored are often inflated to a pressure that is outside recommended cuff pressure range. It has been proposed that maintaining the ETT cuff pressure to the appropriate level may prevent secretions from aspirating through the microchannels on the cuff.8

Subglottic Secretion Drainage

Subglottic secretion drainage removes oral and gastric secretions from the subglottic space, preventing microaspiration that could lead to VAP.9 Continuous or intermittent aspiration of subglottic secretions is done with a specialized endotracheal tube with a separate dorsal lumen.

Ultrathin Cuff

An ultrathin cuff membrane may reduce the formation of channels within the ETT cuff through which pathogens may leak compared to conventional thickness cuffs.10

Taper-Shaped Cuff

The unique design of some ETT tapered-shaped cuffs may reduce the formation of channels within the ETT cuff through which pathogens may leak compared to barrel-shaped cuffs.11

Efficacy of VAP Interventions that Target Microaspiration

VAP Rate
View Data
Hide Data
VAP Rate Control VAP Rate Intervention Difference
5. Cuff pressure management 15.00% 15.00% No difference
6. Cuff pressure management 26.20% 9.80% 16.40%
7. Semirecumbent position 23.00% 11.90% 11.10%
8. Subglottic secretion drainage 21.00% 11.00% 10.00%
9. Polyurethane-taper shaped cuff 42.00% 23.00% 19.00%
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
5. Cuff pressure management8 6. Cuff pressure management12 7. Semi- recumbent position6 8. Subglottic secretion drainage9 9. Poly- urethane-taper shaped cuff13
VAP Rate Control
VAP Rate Intervention

5. Randomized controlled trial (142 participants) (P=0.89)8

6. Randomized controlled trial (122 participants) (P=0.03)12

7. Meta-analysis (3 studies, 337 participants) (P=0.16)6

8. Meta-analysis (10 studies, 2,213 participants) (P<0.00001)9

9. Randomized controlled trial (134 participants) (P=0.026)13

1. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [ View Abstract ]

2. Labeau SO, Van de Vyver K, Brusselaers N, Vogelaers D, Blot SI. Prevention of ventilator-associated pneumonia with oral antiseptics: a systematic review and meta-analysis. Lancet Infect Dis. 2011;11(11):845-854. [ View Abstract ]

3. Liberati A, D'Amico R, Pifferi S, Torri V, Brazzi L, Parmelli E. Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev. 2009(4):CD000022. [ View Abstract ]

4. Gil-Perotin S, Ramirez P, Marti V, et al. Implications of endotracheal tube biofilm in ventilator-associated pneumonia response: a state of concept. Crit Care. 2012;23;16(3):R93. [Epub ahead of print] [ View Abstract ]

5. Kollef MH, Afessa B, Anzueto A, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300(7):805-813. [ View Abstract ]

6. Niël-Weise BS, Gastmeier P, Kola A, Vonberg RP, Wille JC, van den Broek PJ. An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Crit Care. 2011;15(2):R111. [ View Abstract ]

7. Cook D, Guyatt G, Marshall J, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. N Engl J Med. 1998; 19;338(12):791-797. [ View Abstract ]

8. Valencia M, Ferrer M, Farre R, et al. Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trial. Crit Care Med. 2007;35(6):1543-1549. [ View Abstract ]

9. Wang F, Bo L, Tang L, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: an updated meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2012;72(5):1276-1285. [ View Abstract ]

10. Fernandez JF, Levine SM, Restrepo MI. Technologic advances in endotracheal tubes for prevention of ventilator-associated pneumonia. Chest. 2012;142(1):231-238. [ View Abstract ]

11. Zanella A, Scaravilli V, Isgrò S, et al. Fluid leakage across tracheal tube cuff, effect of different cuff material, shape, and positive expiratory pressure: a bench-top study. Intensive Care Med. 2011;37(2):343-347. [ View Abstract ]

12. Nseir S, Zerimech F, Fournier C, et al. Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am J Respir Crit Care Med. 2011;184(9):1041-1047. [ View Abstract ]

13. Poelaert J, Depuydt P, De Wolf A, Van de Velde S, Herck I, Blot S. Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: a pilot study. J Thorac Cardiovasc Surg. 2008 ;135(4):771-776. [ View Abstract ]

Guidelines

Summary of intervention recommendations in published guidelines for the prevention of ventilator-associated pneumonia.

Intervention ATS/ISDA1 CDC/ HICPAC2 CCCS/ CCCTG3 AHRQ4 IHI5 AACN6 SHN7
Continuous aspiration of subglottic secretions I II x (Consider) x   VI x
Enteral nutrition preferred to parenteral II UNRESOLVED ISSUE         xX
Maintain endotracheal cuff pressures >20 cm H2O II            
Oral preferred to nasal gastric tube placement II            
Oral preferred to nasal intubation II IB x       x
Recommendation for closed suction or single-use open suction   No Preference Closed Suction Recommended        
Intervention ATS/ISDA CDC/HICPAC CCCS/ CCCTG AHRQ IHI AACN SHN
Appropriate hand disinfection I 1A         x
Contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or inline medication nebulizers II IB          
Develop and implement a comprehensive oral-hygiene program (which might include the use of an antiseptic agent) for patients in acute-care settings or residents in long-term care facilities at high risk of developing healthcare-associated pneumonia   II     x   x
Do not routinely change the patient’s ventilator circuit based on duration of use   IA x     VI  
Modulation of oropharyngeal colonization by the use of oral chlorhexidine Not Recommended UNRESOLVED ISSUE     x   x
Passive humidifiers or heat-moisture exchangers Unresolved UNRESOLVED ISSUE x        
Routine use of selective digestive decontamination Not Recommended UNRESOLVED ISSUE   x      
Semirecumbent positioning I II x x x VI x
Stress bleeding prophylaxis with either H2antagonists or sucralfate Either UNRESOLVED ISSUE Sucralfate not recommended H2antagonists H2antagonists preferred/ consider PPIs    
Intervention ATS/ISDA CDC/HICPAC CCCS/ CCCTG AHRQ IHI AACN SHN
Avoid intubation and reintubation when possible I II          
Deep venous thrombosis (DVT) prophylaxis         x   x
Kinetic beds     X (Consider)        
Maintaining adequate staffing levels in the ICU II            
Noninvasive ventilation when possible I II          
Practices that promote patient mobility and autonomy             x
Reduce duration of intubation and mechanical ventilation through protocols to improve the use of sedation and to accelerate weaning II       x   x
Staff education and involvement I 1A     x   x
Surveillance of ICU infections II 1B     x    
Tight glycemic control I            

 

ATS/IDSA Guidelines CDC Guidelines AACN Guidelines
Evidence Level Definition
Level I (high) Evidence comes from well-conducted, randomized controlled trials.
Level II (moderate) Evidence comes from well-designed, controlled trials without randomization or large case series with systematic analysis of disease patterns and/or microbial etiology.
Level III (low) Evidence comes from case studies and expert opinion.
Evidence Level Definition
Category IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical or epidemiologic studies.
Category IB Strongly recommended for implementation and supported by some clinical or epidemiologic studies and by strong theoretical rationale.
Category IC Required for implementation, as mandated by federal or state regulation or standard.
Category II Required for implementation, as mandated by federal or state regulation or standard.
No Recommendation; Unresolved Practices for which insufficient issue evidence or no consensus exists about efficacy.
Evidence Level Definition
Level VI Clinical studies in a variety of patient populations and situations to support recommendations.
Level V Clinical studies in a variety of patient populations and situations to support recommendations.
Level IV Limited clinical studies to support recommendations.
Level III Laboratory or bench data only; no clinical data to support recommendations.
Level II Theory based; no research data to support recommendations. Recommendations from expert consensus group may exist.
Level I Manufacturer recommendation only.
CCCS/CCCTG – AHRQ/IHI/SHN
x Denotes intervention recommended by guideline.
x (Consider) Denotes intervention marked as to be considered in guideline.

1. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388-416. [ View Abstract ]

2. Guidelines for preventing health-care-associated pneumonia, 2003 recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Respir Care. 2004;49(8):926-939. [ View Abstract ]

3. Dodek P, Keenan S, Cook D, et al; Canadian Critical Care Trials Group; Canadian Critical Care Society. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004;141(4):305-313. [ View Abstract ]

4. Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ). 2001;(43):i-x, 1-668.

5. Prevent Ventilator-Associated Pneumonia. Institute for Healthcare Improvement. 100,000 Lives Campaign. Available at: http://www.ihi.org/topics/VAP/Pages/default.aspx.

6. American Association of Critical Care Nurses. Practice Alert: Ventilator Associated Pneumonia. January 2008. http://www.aacn.org/WD/Practice/Docs/Ventilator_Associated_Pneumonia_1-2008.pdf.

7. Safer Healthcare Now! Campaign April 2009 How-to Guide: Prevention of VAP. Available at:http://www.patientsafetyinstitute.ca/en/Topic/Pages/Ventilator-Associated-Pneumonia-(VAP).aspx?k=Ventilator-Associated%20Pneumonia%20(VAP) . Accessed October 21, 2013. [ View Abstract ]