Journal of Clinical Monitoring and Computing

, Volume 24, Issue 2, pp 161–168 | Cite as

Ventilator-associated pneumonia: current status and future recommendations

  • Shai EfratiEmail author
  • Israel Deutsch
  • Massimo Antonelli
  • Peter M. Hockey
  • Ronen Rozenblum
  • Gabriel M. Gurman



Ventilator-associated pneumonia (VAP) is a common hazardous complication in ICU patients. The aim of the current review is to give an update on the current status and future recommendations for VAP prevention.


This article gives an updated review of the current literature on VAP. The first part briefly reviews pathogenesis and epidemiology while the second includes an in-depth review of evidence-based practice guidelines (EBPG) and new technologies developed for prevention of VAP.


VAP remains a frequent and costly complication of critical illness with a pooled relative risk of 9–27% and mortality of 25–50%. Strikingly, VAP adds an estimated cost of more than $40,000 to a typical hospital admission. An important aetiological mechanism of VAP is gross or micro-aspiration of oropharyngeal organisms around the cuff of the endotracheal tube (ETT) into the distal bronchi. Prevention of VAP is preferable. Preventative measures can be divided into two main groups: the implemen- tation of EBPGs and use of device-based technologies. EBPGs have been authored jointly by the American Thoracic Society and the Infectious Diseases Society of America. The Canadian Critical Care Trials group also published VAP Guidelines in 2008. Their recommendations are detailed in this review. The current device-based technologies include drainage of subglottic secretions, silver coated ETTs aiming to influence the internal bio-layer of the ETT, better sealing of the lower airways with ultrathin cuffs and loops for optimal cuff pressure control.


EBPG consensus includes: elevation of the head of the bed, use of daily “sedation vacations” and decontamination of the oropharynx. Technological solutions should aim to use the most comprehensive combination of subglottic suction of secretions, optimization of ETT cuff pressure and ultrathin cuffs. VAP is a type of hospital-acquired pneumonia that develops more than 48 h after endotracheal intubation. Its incidence is estimated to be 9–27%, with a mortality of 25–50% [Am J Respir Crit Care Med 171:388–416 (2005), Am J Med 85:499–506 (1988), Chest 122:2115–2121 (2002), Intensive Care Med 35:9–29 (2009)]. The most important target in VAP handling is its prevention. The aim of this article is to review the pathogenesis, epidemiology and the different strategies/technologies for prevention of VAP.


ventilator-associated pneumonia pathogenesis epidemiology clinical practice guidelines prevention technologies 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Andrews CP, Coalson JJ, Smith JD, Johanson WG Jr. Diagnosis of nosocomial bacterial pneumonia in acute, diffuse lung injury. Chest. 1981;80:254–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Fagon JY, Chastre J, Hance AJ, Domart Y, Trouillet JL, Gibert C. Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients. Chest. 1993;103:547–53.PubMedCrossRefGoogle Scholar
  3. 3.
    Fagon JY, Chastre J, Hance AJ, Guiguet M, Trouillet JL, Domart Y, et al. Detection of nosocomial lung infection in ventilated patients. Use of a protected specimen brush and quantitative culture techniques in 147 patients. Am Rev Respir Dis. 1988;138:110–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Wood AY, Davit AJ II, Ciraulo DL, Arp NW, Richart CM, Maxwell RA, et al. A prospective assessment of diagnostic efficacy of blind protective bronchial brushings compared to bronchoscope-assisted lavage, bronchoscope-directed brushings, and blind endotracheal aspirates in ventilator-associated pneumonia. J Trauma. 2003;55:825–34.PubMedCrossRefGoogle Scholar
  5. 5.
    America ATSIDSo. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388–416.CrossRefGoogle Scholar
  6. 6.
    Chastre J, Fagon JY, Soler P, Bornet M, Domart Y, Trouillet JL, et al. Diagnosis of nosocomial bacterial pneumonia in intubated patients undergoing ventilation: comparison of the usefulness of bronchoalveolar lavage and the protected specimen brush. Am J Med. 1988;85:499–506.PubMedCrossRefGoogle Scholar
  7. 7.
    Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122:2115–21.PubMedCrossRefGoogle Scholar
  8. 8.
    Torres A, Ewig S, Lode H, Carlet J. Defining, treating and preventing hospital acquired pneumonia: European perspective. Intensive Care Med. 2009;35:9–29.PubMedCrossRefGoogle Scholar
  9. 9.
    IHI Ifhci-. Implement the Ventilator Bundle. 2008.Google Scholar
  10. 10.
    Estes RJ, Meduri GU. The pathogenesis of ventilator-associated pneumonia: I. Mechanisms of bacterial transcolonization and airway inoculation. Intensive Care Med. 1995;21:365–83.PubMedCrossRefGoogle Scholar
  11. 11.
    Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention. Respir Care. 2005;50:725–39. discussion 39–41.PubMedGoogle Scholar
  12. 12.
    Alcon A, Fabregas N, Torres A. Hospital-acquired pneumonia: etiologic considerations. Infect Dis Clin North Am. 2003;17:679–95.PubMedCrossRefGoogle Scholar
  13. 13.
    Bone DK, Davis JL, Zuidema GD, Cameron JL. Aspiration pneumonia. Prevention of aspiration in patients with tracheostomies. Ann Thorac Surg. 1974;18:30–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Gal TJ. Effects of endotracheal intubation on normal cough performance. Anesthesiology. 1980;52:324–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Klainer AS, Turndorf H, Wu WH, Maewal H, Allender P. Surface alterations due to endotracheal intubation. Am J Med. 1975;58:674–83.PubMedCrossRefGoogle Scholar
  16. 16.
    Levine SA, Niederman MS. The impact of tracheal intubation on host defenses and risks for nosocomial pneumonia. Clin Chest Med. 1991;12:523–43.PubMedGoogle Scholar
  17. 17.
    Kollef MH. Ventilator-associated pneumonia. A multivariate analysis. JAMA. 1993;270:1965–70.PubMedCrossRefGoogle Scholar
  18. 18.
    de Latorre FJ, Pont T, Ferrer A, Rossello J, Palomar M, Planas M. Pattern of tracheal colonization during mechanical ventilation. Am J Respir Crit Care Med. 1995;152:1028–33.PubMedGoogle Scholar
  19. 19.
    Ewig S, Torres A, El-Ebiary M, Fabregas N, Hernandez C, Gonzalez J, et al. Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury. Incidence, risk factors, and association with ventilator-associated pneumonia. Am J Respir Crit Care Med. 1999;159:188–98.PubMedGoogle Scholar
  20. 20.
    Meduri GU, Estes RJ. The pathogenesis of ventilator-associated pneumonia: II. The lower respiratory tract. Intensive Care Med. 1995;21:452–61.PubMedCrossRefGoogle Scholar
  21. 21.
    Hamill RJ, Houston ED, Georghiou PR, Wright CE, Koza MA, Cadle RM, et al. An outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection associated with nebulized albuterol therapy. Ann Intern Med. 1995;122:762–6.PubMedGoogle Scholar
  22. 22.
    Kollef MH, Morrow LE, Baughman RP, Craven DE, McGowan JE Jr, Micek ST, et al. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes—proceedings of the HCAP summit. Clin Infect Dis. 2008;46(Suppl 4):S296–334. quiz 5–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention. J Crit Care. 2008;23:126–37.PubMedCrossRefGoogle Scholar
  24. 24.
    Rouby JJ, Laurent P, Gosnach M, Cambau E, Lamas G, Zouaoui A, et al. Risk factors and clinical relevance of nosocomial maxillary sinusitis in the critically ill. Am J Respir Crit Care Med. 1994;150:776–83.PubMedGoogle Scholar
  25. 25.
    Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999;354:1851–8.PubMedCrossRefGoogle Scholar
  26. 26.
    van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, Joore HC, van Schijndel RJ, van der Tweel I, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med. 2006;34:396–402.PubMedCrossRefGoogle Scholar
  27. 27.
    Prod’hom G, Leuenberger P, Koerfer J, Blum A, Chiolero R, Schaller MD, et al. Nosocomial pneumonia in mechanically ventilated patients receiving antacid, ranitidine, or sucralfate as prophylaxis for stress ulcer. A randomized controlled trial. Ann Intern Med. 1994;120:653–62.PubMedGoogle Scholar
  28. 28.
    Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, 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;338:791–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342:1471–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ. 2007;334:889.PubMedCrossRefGoogle Scholar
  31. 31.
    Smulders K, van der Hoeven H, Weers-Pothoff I, Vandenbroucke-Grauls C. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest. 2002;121:858–62.PubMedCrossRefGoogle Scholar
  32. 32.
    Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest. 1999;116:1339–46.PubMedCrossRefGoogle Scholar
  33. 33.
    Bouza E, Perez MJ, Munoz P, Rincon C, Barrio JM, Hortal J. Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery. Chest. 2008;134:938–46.PubMedCrossRefGoogle Scholar
  34. 34.
    Dezfulian C, Shojania K, Collard HR, Kim HM, Matthay MA, Saint S. Subglottic secretion drainage for preventing ventilator-associated pneumonia: a meta-analysis. Am J Med. 2005;118:11–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Berra L, Panigada M, De Marchi L, Greco G, ZX Y, Baccarelli A, et al. New approaches for the prevention of airway infection in ventilated patients. Lessons learned from laboratory animal studies at the National Institutes of Health. Minerva Anestesiol. 2003;69:342–7.PubMedGoogle Scholar
  36. 36.
    Kollef MH, Afessa B, Anzueto A, Veremakis C, Kerr KM, Margolis BD, et al. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA. 2008;300:805–13.PubMedCrossRefGoogle Scholar
  37. 37.
    Asai T, Shingu K. Leakage of fluid around high-volume, low-pressure cuffs apparatus A comparison of four tracheal tubes. Anaesthesia. 2001;56:38–42.PubMedCrossRefGoogle Scholar
  38. 38.
    Dullenkopf A, Schmitz A, Gerber AC, Weiss M. Tracheal sealing characteristics of pediatric cuffed tracheal tubes. Paediatr Anaesth. 2004;14:825–30.PubMedCrossRefGoogle Scholar
  39. 39.
    Lorente L, Lecuona M, Jimenez A, Mora ML, Sierra A. Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am J Respir Crit Care Med. 2007;176:1079–83.PubMedCrossRefGoogle Scholar
  40. 40.
    Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med. 1981;70:65–76.PubMedCrossRefGoogle Scholar
  41. 41.
    Lewis FR Jr, Schiobohm RM, Thomas AN. Prevention of complications from prolonged tracheal intubation. Am J Surg. 1978;135:452–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Spray SB, Zuidema GD, Cameron JL. Aspiration pneumonia; incidence of aspiration with endotracheal tubes. Am J Surg. 1976;131:701–3.PubMedCrossRefGoogle Scholar
  43. 43.
    Ferdinande P, Kim DO. Prevention of postintubation laryngotracheal stenosis. Acta Otorhinolaryngol Belg. 1995;49:341–6.PubMedGoogle Scholar
  44. 44.
    Rello J, Sonora R, Jubert P, Artigas A, Rue M, Valles J. Pneumonia in intubated patients: role of respiratory airway care. Am J Respir Crit Care Med. 1996;154:111–5.PubMedGoogle Scholar
  45. 45.
    Valencia M, Ferrer M, Farre R, Navajas D, Badia JR, Nicolas JM, et al. Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trial. Crit Care Med. 2007;35:1543–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Kearl RA, Hooper RG. Massive airway leaks: an analysis of the role of endotracheal tubes. Crit Care Med. 1993;21:518–21.PubMedCrossRefGoogle Scholar
  47. 47.
    Guyton DC, Barlow MR, Besselievre TR. Influence of airway pressure on minimum occlusive endotracheal tube cuff pressure. Crit Care Med. 1997;25:91–4.PubMedCrossRefGoogle Scholar
  48. 48.
    Efrati S, Leonov Y, Oron A, Siman-Tov Y, Averbukh M, Lavrushevich A, et al. Optimization of endotracheal tube cuff filling by continuous upper airway carbon dioxide monitoring. Anesth Analg. 2005;101:1081–8. table of contents.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Shai Efrati
    • 1
    Email author
  • Israel Deutsch
    • 1
  • Massimo Antonelli
    • 2
  • Peter M. Hockey
    • 3
  • Ronen Rozenblum
    • 4
  • Gabriel M. Gurman
    • 5
  1. 1.Research & Development Unit, Assaf Harofeh Medical Center, Affiliated with the Sackler School of MedicineTel-Aviv UniversityZerifinIsrael
  2. 2.Department of Intensive Care and AnesthesiologyPoliclinico Universitario A. GemelliRomeItaly
  3. 3.General and Respiratory MedicineHampshire Community Health CareHampshireUK
  4. 4.The Center for Patient Safety Research and Practice, Division of General MedicineBrigham & Women’s Hospital and Harvard Medical SchoolBostonUSA
  5. 5.Faculty of Health Sciences, Beer-Sheva, and Myney Hayesuah Medical CenterBen-Gurion University of the NegevBnei BrakIsrael

Personalised recommendations