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Am Nurse Today. Author manuscript; available in PMC 2018 June 01.
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Am Nurse Today. 2017 June ; 12(6): 42–43.

5 Nursing strategies to prevent ventilator-associated pneumonia

Emily Boltey, BSN, RN1, Olga Yakusheva, PhD1,2,3, and Deena Kelly Costa, PhD, RN1,3
1University
of Michigan School of Nursing, Department of Systems, Populations and Leadership,
Ann Arbor Michigan
2University
of Michigan School of Public Health, Department of Health Management and Policy,
Ann Arbor Michigan
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3Institute for Healthcare Policy and Innovation, University of Michigan Ann Arbor Michigan

Keywords
critical care nursing; evidence-based practice; VAP prevention; mechanical ventilation

Healthcare associated infections (HAI), such as ventilator-associated pneumonia (VAP), are

the most common and most preventable complication of a patient’s hospital stay. Their
frequency and potential adverse effects increase in critically ill patients because of impaired
physiology, including a blunted immune response and multi-organ dysfunction.

Traditionally, VAP rates have been measured as an indicator of quality of care. Despite
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recent initiatives to measure complications of mechanical ventilation and a decrease in

incidence over the past few years, VAP remains an issue for critically ill adults, with
mortality estimated as high as 10%.

This article reviews the top five evidence-based nursing practices for reducing VAP risk in
critically ill adults.

1. Minimize ventilator exposure

The most important evidence-based practice for lowering VAP risk is minimizing a patient’s
exposure to mechanical ventilation, which can be achieved in two ways.

First, you can encourage and advocate for the use of noninvasive ventilation approaches,
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such as bilevel positive airway pressure or continuous positive airway pressure. The face
masks used with these approaches can be uncomfortable for patients, but data from a small
randomized clinical trial suggests that similar benefits can be achieved using a helmet
instead. In addition to better patient comfort, helmets resulted in a significantly lower
intubation rate compared to face masks.

Corresponding author: Deena Kelly Costa PhD, RN, 400 North Ingalls St #4351, Ann Arbor MI, 48109, dkcosta@umich.edu, office:
734.764.2818, fax: 734.647.2416.
Visit www.americannursetoday.com/?p=XXXXX for a list of selected references.
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Second, when mechanical ventilation can’t be avoided, work to minimize its duration.
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Ventilator weaning protocols or evidence-based care bundles (for example, the Awakening,
Breathing Coordination, Delirium, and Early mobility (ABCDE) bundle) can be effective in
shortening mechanical ventilation duration. Nurse-led and respiratory therapist-led
ventilator-weaning protocols that include daily interruption of sedation and coordination
with a spontaneous breathing trial have been effective in removing patients from mechanical
ventilation quickly and appropriately. If a ventilator-weaning protocol doesn’t exist on your
unit, take the opportunity to design and develop one.

2. Provide excellent oral hygiene care

Oral health quickly deteriorates in mechanically ventilated patients. Some patients sustain
injuries to the oral mucosa during the intubation procedure, and after intubation, patients are
prone to dry mouth. These factors, in addition to a severely compromised immune system,
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can cause an increase in bacteria colonization in the oral mucosa, with the endotracheal tube
serving as a direct route to the lungs.

Adequate oral care can reduce bacterial overgrowth and reduce the risk for infection. In a
meta-analysis of more than 18 randomized controlled trials (RCTs), routine oral care with
chlorhexidine reduced the incidence of VAP. Currently, no guidelines exist for oral hygiene
frequency. A recent systematic review of 38 RCTs showed oral care being performed
anywhere from one to four times a day.

Making oral care a routine part of a patient’s assessment in the ICU is one way to enhance
its frequency. Consider developing a unit-specific protocol with clear articulation of roles
and responsibilities.
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3. Coordinate care for subglottic suctioning

Aspiration of secretions that accumulate around the endotracheal tube of mechanically
ventilated patients can lead to VAP. Subglottic secretion suctioning can be performed by
both the nurse and respiratory therapist and can aid in prevention. A recent meta-analysis of
20 RCTs found that subglottic suctioning reduced the risk for VAP by 45% compared to
patients who didn’t receive suctioning. Coordinating subglottic suctioning when conducting
oral care may be a good mechanism to cluster care and ensure both of these practices are
routinely delivered.

4. Maintain optimal positioning and encourage mobility

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Proper positioning (keeping the head of the bed between 30–45 degrees) and encouraging
early mobility of mechanically ventilated patients aid in the prevention of VAP. Gastric
reflux and aspiration can also lead to VAP in mechanically ventilated patients. Keeping the
head of the bed elevated between 30–45 degrees (semi-recumbent position) is recommended
to reduce reflux and subsequent risk for VAP.

Early mobility can be challenging, but it results in more ventilator-free days. Evidence
supports the feasibility of early mobilization for critically ill patients, even shortly after

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intubation, as long as the patient isn’t sedated. Early mobility protocols include a
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progressive approach that transitions from dangling at the edge of the bed, to standing at the
edge of bed, to marching in place and then, for patients who can tolerate a higher level of
activity, ambulating. For the best patient outcomes, coordinate exercise and mobilization
with physical and occupational therapists.

5. Ensure adequate staffing

Adequate nurse staffing in the ICU, especially for mechanically ventilated patients, can help
minimize VAP risk. It provides nurses with the time, opportunity, and resources to
implement care practices that reduce risk, and it allows them to spend more time with their
patients, which may lead to early identification of VAP and prompt treatment.

Healthy work environments and interprofessional collaboration also have been associated
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with lowering the risk for VAP. Two studies found that better nurse work environments, in
conjunction with physician staffing, have implications for VAP risk. For example, in open
ICUs where patients are managed by general physicians instead of specially trained critical
care physicians, having better nurse work environments can reduce VAP rates for
mechanically ventilated patients.

Similarly, prior work identified that when nurses work in environments that support
professional nursing practice (i.e. healthy nurse work environments), nurses are significantly
less likely to report frequent VAP. These data provide support for you to work with other
nurses to ensure your work environment supports professional nursing practice. Ways to do
this include developing shared governance models, engaging in quality improvement
activities to enhance high quality care and encouraging positive team interactions. Partnering
with ICU physician and the rest of the interprofessional team, especially respiratory therapy,
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are two key ways to continue to encourage positive team interactions and reduce VAP risk.

/H1/Nurses perfectly positioned

Nurses are particularly well positioned to lead the healthcare team in VAP prevention. You
can help minimize patients’ exposure to mechanical ventilation, work collaboratively to
develop a ventilator weaning protocol, and ensure implementation of evidence-based care
that minimizes VAP risk.

Acknowledgments
All of the authors work at the University of Michigan in Ann Arbor. Emily Boltey is a doctoral (PhD) student in the
Department of Systems, Populations and Leadership at the School of Nursing; Olga Yakusheva is an Associate
Professor in the Department of Systems, Populations and Leadership at the School of Nursing and Department of
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Health Management & Policy in the School of Public Health, a member of the Institute for Healthcare Policy &
Innovation; and Deena Kelly Costa is an Assistant Professor in the Department of Systems, Populations and
Leadership at the School of Nursing and a member of the Institute for Healthcare Research and Quality. Funding
for this work was provided by the Agency for Healthcare Research & Quality (K08 HS024552, PI Costa).

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Selected references
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1. Patel BK, Wolfe KS, Pohlman AS, et al. Effect of noninvasive ventilation delivered by helmet vs
face mask on the rate of endotracheal intubation in patients with acute respiratory distress
syndrome: A randomized clinical trial. JAMA. 2016; 315(22):2435–41. [PubMed: 27179847]
2. Blackwood B, Alderdice F, Burns K, et al. Use of weaning protocols for reducing duration of
mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis.
BMJ. 2011; 342:c7237. [PubMed: 21233157]
3. Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and
breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit
Care Med. 2014; 42(5):1024–36. [PubMed: 24394627]
4. Ely EW, Meade MO, Haponik EF, et al. Mechanical ventilator weaning protocols driven by
nonphysician health-care professionals. CHEST. 2001; 120(6 Suppl):454S–63S. [PubMed:
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pneumonia prevention bundle. Am J Infect Control. 2016; 44(6):652–6. [PubMed: 26874407]
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6. Hua F, Xie H, Worthington HV, et al. Oral hygiene care for critically ill patients to prevent
ventilator-associated pneumonia. Cochrane Database of Syst Rev. 2016; 10
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[PubMed: 27181221]
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Key points
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1. Ventilator-associated pneumonia (VAP) is a healthcare associated infection

that can complicate care of mechanically ventilated patients in the intensive
care unit.

2. To reduce risk for VAP, the following nurse-led evidence-based practices are
recommended: reduce exposure to mechanical ventilation, provide excellent
oral care and subglottic suctioning, promote early mobility, and advocate for
adequate nurse staffing and a healthy work environment.

3. Nurses can lead the commitment to reducing VAP and improving quality of
care for mechanically ventilated patients by coordinating and implementing
these evidence-based practices.
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Am Nurse Today. Author manuscript; available in PMC 2018 June 01.