ClinicalArticle

Ventilator-Associated
Pneumonia
Risk Factors and
Prevention
Beth Augustyn, RN, MSN, ACNP, CCRN

P neumonia is the second most

common nosocomial infection in the
United States and is a leading cause
The incidence of VAP is 22.8% in
patients receiving mechanical venti-
lation,3 and patients receiving venti-
Interventions to prevent VAP
begin at the time of intubation and
should be continued until extubation.
of death due to hospital-acquired latory support account for 86% of With the extreme shortage of nurses
infections.1 Ventilator-associated the cases of nosocomial pneumonia.4 and the resultant increase in the
pneumonia (VAP) is a form of noso- Furthermore, the risk for pneumonia number of less experienced nurses
comial pneumonia that occurs in increases 3- to 10-fold in patients in the intensive care unit, education
patients receiving mechanical venti- receiving mechanical ventilation.5 on the prevention of VAP is essen-
lation for longer than 48 hours.2 VAP is associated with increases tial, because the occurrence of noso-
in morbidity and mortality, hospital comial infections is directly related
length of stay, and costs. The mor- to the adequacy of staff.8 Nurses
tality rate attributable to VAP is 27% need to understand the pathophysi-
and has been as high as 43% when the ology of VAP, risk factors for this
causative agent was antibiotic resist- type of pneumonia, and strategies
This article has been designated for CE credit. ant.6 Length of stay in the intensive that may prevent the disease.
A closed-book, multiple-choice examination
follows this article, which tests your knowledge care unit is increased by 5 to 7 days3
of the following objectives: and hospital length of stay 2- to 3- Pathophysiology
1. Describe the 2 main pathophysiology fold in patients with VAP.2 The cost The onset of VAP can be divided
processes of ventilator-associated pneumonia
(VAP) of VAP is estimated to be an addi- into 2 types: early and late. Early-
2. Identify risk factors for VAP tional $40000 per hospital admission onset VAP occurs 48 to 96 hours
3. Discuss timeframe interventions to prevent per patient with the disease1 and an after intubation and is associated
VAP estimated $1.2 billion per year.7 with antibiotic-susceptible organisms.
Late-onset VAP occurs more than 96
hours after intubation and is associ-
Author
ated with antibiotic-resistant organ-
Beth Augustyn is employed by Chest Medicine Consultants, Chicago, Illinois. isms2 (Table 1). Interventions to
Corresponding author: Beth Augustyn, Chest Medicine Consultants, 2800 N Sheridan Rd, Ste 301, Chicago,
IL 60657 (e-mail: bethaugustyn@hotmail.com). prevent VAP should begin at the
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. time of, or if possible, before intuba-
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. tion. The pathophysiology of VAP

32 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 http://ccn.aacnjournals.org


Table 1 Bacteria associated with
ventilator-associated pneumonia
Early onset
Staphylococcus aureus
Streptococcus pneumoniae
Hemophilus influenzae
Proteus species
Serratia marcescens
Klebsiella pneumoniae
Escherichia coli
Late onset
Pseudamonas aeruginosa
Methicillin-resistant Staphylococcus
aureus
Acinetobacter species
Enterobacter species
involves 2 main processes: coloniza-
tion of the respiratory and digestive
tracts and microaspiration of secre-
tions of the upper and lower parts
of the airway.9
Colonization of bacteria refers to
the presence of bacteria without an
active host response.10 Bacterial col-
onization of the lungs can be due to
spread of organisms from many dif-
ferent sources, including the orophar-
ynx, sinus cavities, nares, dental
plaque, gastrointestinal tract, patient-
to-patient contact, and the ventilator
circuit.10 Inhalation of colonized bac-
teria from any of these sources can
cause an active host response and,
ultimately, VAP.
The presence of an endotracheal
tube provides a direct route for colo-
nized bacteria to enter the lower res-
piratory tract. Upper airway and oral
secretions can pool above the cuff of
an endotracheal tube and line the
tube, forming a biofilm. Starting as
early as 12 hours after intubation,
the biofilm contains large amounts
of bacteria that can be disseminated
into the lungs by ventilator-induced
breaths.10-12 In addition, the biofilm
may become dislodged by instillation
of saline into the endotracheal tube,
suctioning, coughing, or reposition-
ing of the endotracheal tube.12 Endo-
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tracheal tubes cause an abnormal
interruption between the upper air-
way and the trachea, bypassing the
structures in the upper airway and
providing bacteria a direct route into
the lower airway.10 Because the upper
airway is bypassed, a decrease occurs
in the body’s ability to filter and
humidify air.12 In addition, the cough
reflex is often eliminated and/or
decreased by the presence of an
endotracheal tube,2 and mucociliary
clearance can be impaired because
of mucosal injury during intubation.13
An endotracheal tube provides a
place for bacteria to bind in the tra-
chea, a situation that further increases
production and secretion of mucus.13
The impairment of these natural
host defense mechanisms increases
the likelihood of bacterial coloniza-
tion and subsequent aspiration of
the colonized organisms.
Aspiration of gastric contents is
another potential cause of VAP,
because the stomach serves as a reser-
voir for bacteria. Most patients receiv-
ing mechanical ventilation have a
nasogastric or an orogastric tube in
place for enteral feedings and admin-
istration of medications or for gastric
decompression. The presence of a
nasogastric or an orogastric tube
interrupts the gastroesophageal
sphincter, leading to increased gas-
trointestinal reflux and providing a
route for bacteria to translocate to the
oropharynx and colonize the upper
airway. Enteral feedings increase both
gastric pH and gastric volume,
increasing the risk of both bacterial
colonization and aspiration.14
Diagnosis
Because every patient who is intu-
bated and receiving ventilatory sup-
port is at risk for VAP, making an
accurate diagnosis of this disease and
CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 33
starting treatment is critical. Diagnos-
ing VAP remains difficult and contro-
versial. The diagnosis can be made on
the basis of radiographic findings,
clinical findings, results of microbi-
ological tests of sputum, or invasive
testing such as bronchoscopy.15 The
diagnosis is most often based on
visualization of a new or progressive
infiltrate on chest radiographs.16
However, findings on chest radi-
ographs are not reproducible and
should not be used alone for the
diagnosis of VAP.13 Other causes of
pulmonary infiltrates visualized on
chest radiographs of patients receiv-
ing mechanical ventilation include
atelectasis, aspiration, pulmonary
embolism, pulmonary edema, alveo-
lar hemorrhage, pulmonary infarc-
tion, and acute respiratory distress
syndrome. The likelihood of VAP
increases if a patient has clinical
signs and symptoms such as fever,
leukocytosis, and purulent sputum
in addition to abnormal findings on
chest radiographs.16 The results of
microbiological tests of sputum spec-
imens obtained by either invasive or
noninvasive methods are not suffi-
cient for the diagnosis of VAP, but
culture and sensitivity results can be
helpful for choosing an antibiotic.17
Risk Factors
Although any patient with an
endotracheal tube in place for more
than 48 hours is at risk for VAP, cer-
tain patients are at higher risk. The
risk factors for VAP can be divided
into 3 categories: host related, device
related, and personnel related
(Table 2). Host-related risk factors
include preexisting conditions such
as immunosuppression, chronic
obstructive lung disease, and acute
respiratory distress syndrome. Other
host-related factors include patients’
 Table 2 Risk factors for ventilator-
associated pneumonia
Host related
Underlying medical conditions
Immunosuppression
Chronic obstructive lung disease
Adult respiratory distress syndrome
Patients’ body position
Level of consciousness
Number of intubations
Medications
Device related
Endotracheal tube
Ventilator circuit
Nasogastric or orogastric tubes
Personnel related
Improper hand washing
Failure to change gloves between
contacts with patients
Not wearing personal protective
equipment when antibiotic resistant
bacteria have been identified
body positioning, level of conscious-
ness, number of intubations, and
medications, including sedative
agents and antibiotics. In one study,18
bacterial contamination of endotra-
cheal secretions was higher in patients
in the supine position than in patients
in the semirecumbent position.
Whether due to a pathophysiologi-
cal process, medication, or injury,
decreased level of consciousness
resulting in the loss of the cough and
gag reflexes contributes to the risk of
aspiration and therefore increased
risk for VAP.19 Reintubation and sub-
sequent aspiration can increase the
likelihood of VAP 6-fold.20
Device-related risk factors include
the endotracheal tube, the ventilator
circuit, and the presence of a nasogas-
tric or an orogastric tube. Secretions
pool above the cuff of an endotra-
cheal tube, and low cuff pressures can
lead to microaspiration and/or leak-
age of bacteria around the cuff into
the trachea.14 As mentioned earlier,
nasogastric and orogastric tubes dis-
rupt the gastroesophageal sphincter,
leading to reflux and an increased
34 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007
risk for VAP. The question of whether
placement of nasogastric or orogas-
tric tubes distal to the pylorus
decreases the risk of aspiration and
VAP remains unanswered. The results
of studies on the relationship between
use of small-bore feeding tubes and
the incidence of VAP have been
inconclusive. The Centers for Disease
Control and Prevention makes no
recommendations about routine use
of postpyloric feeding tubes or small-
bore feeding tubes, because these
issues remain controversial and fur-
ther research is needed.1
Improper hand washing resulting
in the cross-contamination of patients
is the biggest personnel-related risk
factor for VAP. Patients who are
intubated and receiving mechanical
ventilation often need interventions
such as suctioning or manipulation
of the ventilator circuit. These inter-
ventions increase the likelihood of
cross-contamination between patients
if healthcare staff do not use proper
hand-washing techniques. Failure to
wash hands and change gloves
between contaminated patients has
been associated with an increased
incidence of VAP.21 In addition, fail-
ure to wear proper personal protec-
tive equipment when antibiotic-
No or
Has the person been unsure
vaccinated previously?
Yes
Was the person aged No
>65 years at the time
of last vaccination?
Yes*
Vaccination not indicated
Figure 1 Algorithm for giving pneumococcal vaccine.
*Note: For any person who has received a dose of pneumococcal vaccine at age >65 years, revaccination is
not indicated.
Reprinted from Centers for Disease Control and Prevention.22
Table 3 Strategies to prevent
ventilator-associated pneumonia
Prevent colonization
Follow protocol for hand washing
Use oral decontamination
Use stress ulcer prophylaxis
Avoid saline lavage with suctioning
Turn patients at least every 2 hours
Change ventilator circuit no more
than every 48 hours
Prevent aspiration
Position the head of the bed >30º
Minimize the use of narcotic and
sedative agents
Thoroughly suction the oropharynx
Use endotracheal tubes that have
continuous subglottic suction ports
Monitor gastric residual volumes for
overdistention
Maintain adequate endotracheal tube
cuff pressures of at least 20 cm H2O
resistant organisms have been iden-
tified increases the risk of cross-
contamination between patients.1
Prevention
Although VAP has multiple risk
factors, many nursing interventions
can reduce the incidence of this dis-
ease (Table 3). Prevention of pneu-
monia, both in and outside of the
hospital, begins with vaccination
(Figure 1).22 Nurses are the first line
of defense in preventing bacterial
colonization of the oropharynx and
the gastrointestinal tract. Meticulous
Vaccination indicated
Yes
Have >5 years elapsed
since the first dose?
No
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hand washing for 10 seconds should
be performed before and after all
contact with patients.1 In addition,
gloves should be worn when contact
with oral or endotracheal secretions
is possible. Strategically placing a sign
on a patient’s door to remind health-
care workers to wash their hands
and wear gloves is an easy and cost-
effective measure that can help mini-
mize transmission of bacteria between
patients. The use of protective gowns
is not recommended as routine prac-
tice, but gowns should be used when
antibiotic-resistant pathogens have
been isolated and identified.1
Oral decontamination, by reduc-
ing the amount of bacteria within a
patient’s oral cavity, can be accom-
plished by both mechanical and
pharmacological interventions.
Mechanical interventions include
tooth brushing and rinsing of the
oral cavity to remove dental plaque;
pharmacological interventions
involve the use of antimicrobial
agents.23 Bacteria in dental plaque
can be removed by brushing the teeth
and thoroughly suctioning secre-
tions from the mouth. Both of these
interventions decrease the likelihood
of colonization of the oropharynx.
Pharmacological interventions
include twice-a-day use of chlorhexi-
dine oral rinse. In a study24 of patients
undergoing cardiac surgery, use of
chlorhexidine decreased the inci-
dence of VAP by decreasing coloniza-
tion. In another study,7 use every 6
hours of a solution containing gen-
tamicin, colistin, and vancomycin
decreased the incidence of VAP by
16% and resulted in an estimated cost
savings of $13000 for every case of
VAP prevented. Unfortunately, except
for patients undergoing cardiac sur-
gery, no evidence-based protocols for
oral care have been tested and con-
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firmed to decrease the incidence of
VAP in patients receiving mechani-
cal ventilation.
Bacterial colonization of the
stomach can lead to aspiration and
colonization of the respiratory tract.
Most patients receiving mechanical
ventilation are given stress ulcer
prophylaxis, often with medications
that increase the gastric pH. A study25
in the 1980s indicated that pathogens
multiply in an alkaline gastric envi-
ronment. In the largest study26 on the
risk for VAP with stress ulcer pro-
phylaxis, ranitidine, an H2-receptor
blocker, significantly reduced the
risk of clinically important bleeding
without increasing the risk of VAP
or mortality. In another large study,27
mechanical ventilation for greater
than 48 hours was associated with a
16-fold increase in the risk for gas-
trointestinal bleeding. In research28
conducted in a pediatric intensive
care unit, VAP rates did not differ
between patients receiving ranitidine,
omeprazole, or sucralfate for stress
ulcer prophylaxis. Unfortunately, as
the use of proton pump inhibitors
for stress ulcer prophylaxis has
increased, few studies have been con-
ducted in adults to address whether
the incidence of VAP is affected by the
use of these inhibitors. In summary,
according to the studies done so far,
stress ulcer prophylaxis does not
play a significant role in the devel-
opment of VAP but may prevent the
serious complication of gastrointesti-
nal bleeding.
Mucus in the airways can become
stagnant and serve as a medium for
bacterial growth. Maintenance of
aseptic technique when performing
endotracheal suctioning is essential
to prevent contamination of the air-
ways. No difference has been found
in the incidence of VAP with open
CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 35
versus closed suction systems.29 When
a closed system is used, the suction
catheter should be rinsed free of
secretions away from the patient.
Furthermore, saline lavage of
endotracheal tubes before suction-
ing dislodges bacteria from the
endotracheal tube into the lower air-
ways, increasing the risk for VAP.30
Saline lavage has long been consid-
ered a means to liquefy secretions
and prevent plugs of mucus in
endotracheal tubes. However, in
one study,31 saline instillation did
not thin secretions; rather it reduced
the amount of oxygen that reached
the lungs and increased blood pres-
sure, heart rate, intracranial pressure,
and the risk for VAP. Maintaining
adequate hydration, ensuring proper
humidification of the ventilatory
circuit, and using nebulizer or
mucolytic agents can help decrease
the viscosity of secretions and elimi-
nate the need for saline lavage.30,31
Prophylactic use of systemic antibi-
otics does not decrease the incidence
of VAP and when the agents are used
inappropriately, antibiotic resistance
can develop.32
Routine turning of patients a min-
imum of every 2 hours can increase
pulmonary drainage and decrease
the risk for VAP. Use of beds capable
of continuous lateral rotation can
decrease the incidence of pneumo-
nia but do not decrease mortality or
duration of mechanical ventilation.33
These beds are costly and are not
necessary for routine use in the pre-
vention of VAP,1 although the use of
specialty beds may be cost-effective
and therapeutic for patients with
poor oxygenation or impaired
wound healing.
Colonization of the ventilator
circuit can also play a role in the
development of VAP. Daily changes
of the ventilator circuit do not seem
to decrease the incidence of VAP.34
The Centers for Disease Control and
Prevention does not recommend
changing the ventilator circuit more
than once every 48 hours,1 and
research35 has indicated that chang-
ing the ventilator circuit as infre-
quently as once a week does not
increase the risk for VAP. It is rec-
ommended that the ventilator circuit
be changed when visibly soiled.1
Many investigators have compared
the impact of heat and moisture
exchangers on the incidence of VAP
with the impact of heated humidifiers.
The results were inconclusive as to
which form of humidity is associated
with a higher incidence of VAP.
In addition to strategies to prevent
colonization, strategies to prevent
aspiration can also be used to decrease
the risk for VAP. Because the pres-
ence of an endotracheal tube predis-
poses patients to VAP, patients should
be assessed on a daily basis for
potential weaning and extubation
from mechanical ventilation. Several
methods of assessing readiness for
extubation exist. These include T-
piece trials, weaning intermittent
mandatory ventilation, and pressure-
support ventilation.36
Positioning patients in a semi-
recumbent position with the head of
the bed elevated 30º to 45º prevents
reflux and aspiration of bacteria from
the stomach into the airways. Sim-
ply elevating the head of the bed 30º
can decrease VAP by 34%.37 Impaired
gastric emptying can lead to overdis-
tention, or increased gastric residual
volume, of the stomach and the poten-
tial for regurgitation and aspiration.
Minimizing the use of narcotic agents
can help prevent aspiration of gastric
and/or oral contents.2 Decreasing
use of narcotic and/or sedative
36 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007
agents in the intensive care unit
must be done cautiously, because
pain can limit deep breathing and
impair oxygenation. Daily interrup-
tions of continuous sedative infu-
sions can shorten the duration of
mechanical ventilation by more
than 2 days and length of stay in the
intensive care unit by 3.5 days.38
Monitoring gastric residual volumes
and administering agents to increase
gastric motility have been suggested
as ways to prevent gastric overdis-
tention.2 Although the effectiveness
of these interventions in reducing
VAP has not been tested in clinical
trials, it is reasonable to avoid gas-
tric overdistention in an attempt to
prevent aspiration.
Because secretions tend to pool
above the cuffs of endotracheal tubes,
the oropharynx should be thoroughly
suctioned to prevent aspiration of
the pooled secretions before an
endotracheal tube is replaced. Pres-
sure in the cuff should be measured
and should be maintained at no less
than 20 cm H2O.39 Maintaining ade-
quate cuff pressures decreases the
likelihood that secretions will leak
around the cuff or be aspirated. Use
of tubes with ports for continuous
subglottic suctioning can decrease
the incidence of VAP by 50%,40 and
costs per episode of VAP have been
reduced as much as $18000 when
endotracheal tubes with continuous
subglottic suctioning are used rather
than traditional endotracheal tubes.41
Studies are also being conducted
with endotracheal tubes coated with
silver nitrate. Use of urinary catheters
coated with silver nitrate has been
associated with a decreased incidence
of urinary tract infections; therefore,
it is thought that endotracheal tubes
coated with silver nitrate might
decrease the incidence of VAP. It is
hypothesized that silver nitrate
interferes with the ability of bacteria
to line the endotracheal tube and
form a biofilm. In a study11 of dogs
receiving mechanical ventilation,
endotracheal tubes coated with sil-
ver nitrate were less likely to become
colonized with bacteria than were
traditional endotracheal tubes. Fur-
ther studies are needed to determine
the cost-effectiveness of these coated
tubes in preventing VAP.
Role of Nurses
The effects of VAP on morbidity,
mortality, length of hospital stay,
and cost are immense. Education
plays a key role in the management
of patients with VAP. Use of self-study
education modules on the nursing
care of patients at risk for VAP can
decrease the rate of this type of
pneumonia, the number of days of
mechanical ventilation, and the cost
of the disease.8
Healthcare systems can also play
a role in preventing VAP by employ-
ing outcome managers to provide a
more comprehensive approach to VAP
prevention. In one study,42 the dura-
tion of mechanical ventilation, hos-
pital and intensive care unit lengths
of stay, and mortality decreased
when an outcome manager was used.
Outcome managers can be responsi-
ble for ensuring that protocols to
prevent VAP and other complica-
tions of intubation and mechanical
ventilation are developed and are
being followed appropriately. The
use of ventilator pathways and/or
protocols with preprinted order sets
(Figure 2) can also lead to improved
outcomes for patients. A simple, yet
cost-effective way to ensure compli-
ance with elevating the head of the
bed is random daily audits. The
rationale for why a patient cannot
http://ccn.aacnjournals.org
 Adult Ventilator Pathway / Critical Care

(Use ballpoint pen only)

Date Date
Hour Orders Hour Nurse
1. Initiate Adult Ventilator Management Pathway.

2. Ventilator to be managed by:

3. Ventilator settings:
FiO2 _______ Rate _______ PEEP _______
Tidal volume _______ Mode _______ Pressure support _______

4. Complete daily weaning parameter and document in EMTEK by 0900.

5. Initiate Rapid Wean Protocol when stability criteria are met. If Rapid
Wean Protocol fails, initiate Ventilator Extended Weaning Protocol.

6. Initiate diuretic regimen for patients in CHF or pulmonary edema.

7. Nutrition consult on admission.

8. Place on appropriate bed/overlay per skin care guidelines.

9. Daily CXR while in ICU.

10. Initiate Continuous Lateral Rotation Therapy if P/F Ratio < 250 after
twelve hours in ICU.

11. Initiate prophylactic oral hygiene.

12. Keep head of bed > 45º unless contra-indicated.

13. PT/OT evaluation and treatment. Pt. activity level: ____________________________

Place L’nard boots.

14. Prealbumin Monday/Thursday

15. Sedation/analgesia per ventilation sedation order sheet to keep Riker

score between -1 and +1.

16. Schedule care conference during acute phase of mechanical ventilation.

91-4642 12/02 © 2003 Advocate Health Care

Figure 2 Adult ventilator pathway/critical care.

Abbreviations: CHF, congestive heart failure; CXR, chest radiograph; FiO2, fraction of inspired oxygen; ICU, intensive care unit; OT, occupational therapy; PEEP, positive
end-expiratory pressure; P/F ratio, ratio of PaO2 to fraction of inspired oxygen; Pt, patient; PT, physical therapy.
Reprinted with permission from Advocate Lutheran General Hospital, Park Ridge, IL.

38 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 http://ccn.aacnjournals.org

have the head of the bed elevated
should be documented.3 Standard-
ized orders or pathways can be a
friendly reminder to healthcare
providers about the importance of
interventions to prevent VAP.
Summary
VAP, although often preventable,
has a large impact on morbidity and
mortality. Together with other health-
care providers, nurses play a key role
in preventing VAP. Many of the inter-
ventions are part of routine nursing
care. Education for all healthcare
providers should focus on the risk
factors for VAP and on preventive
measures. In order to further decrease
the incidence of VAP, protocols and
monitoring tools must be developed.
VAP is not a new diagnosis, but edu-
cation and research on the preven-
tion of this life-threatening problem
are ongoing.
Financial Disclosures
None reported.
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CE Test Test ID C0742: Ventilator-Associated Pneumonia: Risk Factors and Prevention
Learning objectives: 1. Describe the 2 main pathophysiology processes of ventilator-associated pneumonia (VAP)
2. Identify risk factors for VAP 3. Discuss timeframe interventions to prevent VAP

1. Ventilator-associated pneumonia (VAP) can occur in patients who 7. Enteral feedings increase the risk of which of the following?
have received mechanical ventilation for longer than how many hours? a. Bacterial colonization and growth
a. 72 hours b. VAP and infection
b. 24 hours c. Bacterial colonization and aspiration
c. 96 hours d. Bacteria translocation and colonization
d. 48 hours
8. Which of the following clinical signs and symptoms indicate the likelihood
2. Increases in which of the following are associated with VAP? of VAP?
a. Morbidity, mortality, hospital length of stay, and costs a. Fever and purulent sputum
b. Ventilator time, length of stay, time in intensive care unit (ICU), and costs b. Fever, leukocytosis, and purulent sputum
c. Morbidity, mortality, ventilator time, and time in ICU c. Leukocytosis and purulent sputum
d. Length of stay, costs, ventilator time, and time in ICU d. Positive sputum culture, fever, and leukocytosis

3. Interventions to prevent VAP should begin at what time? 9. What is the biggest personnel-related risk factor for VAP development?
a. When the patient is admitted to the ICU a. Improper hand washing
b. When the patient is intubated b. Changing gloves between contaminated patients
c. When the patient receives oxygen c. Wearing personal protective equipment
d. When the patient has decreased oxygenation d. Improper room cleaning between patient admissions

4. Early onset of VAP occurs after how many hours of intubation? 10. Which of the following interventions decrease
a. 48 to 96 hours the likelihood of colonization of the oropharynx?
b. 24 to 72 hours a. Thoroughly suctioning secretions from the nose and mouth
c. 48 to 72hours b. Thoroughly suctioning the nose and brushing the teeth
d. 72 to 96 hours c. Thoroughly suctioning the mouth and brushing the gums
d. Thoroughly suctioning the secretions from the mouth and brushing the teeth
5. Where does colonization of bacteria occur in VAP?
a. Respiratory system 11. VAP can be decreased by 34% by simply elevating the head of bed how
b. Digestive system many degrees?
c. Upper and lower parts of the airway a. 30°
d. Respiratory and digestive system b. 40°
c. 45°
6. Biofilm can be disseminated into the lungs by ventilator-induced d. 35°
breaths or can be dislodged by which of the following?
a. Instillation of saline into the endotracheal tube and intubation for more than 12. The use of tubes with ports for continuous subglottic
12 hours suctioning can decrease the incidence of VAP by what percentage?
b. Warm humidified air through the ventilator circuit and suctioning a. 27%
c. Intubation for more than 12 hours and repositioning of the endotracheal tube b. 75%
d. Instillation of saline into the endotracheal tube, suctioning, coughing, and c. 50%
repositioning of the endotracheal tube d. 45%

Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. K a 2. K a 3. K a 4. K a 5. K a 6. K a 7. K a 8. K a 9. K a 10. K a 11. K a 12. K a
Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb
Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc
Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd
Test ID: C0742 Form expires: August 1, 2009 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: A,
Synergy CERP A Test writer: Brenda K. Hardin-Wike, RN, CNS, MSN, CCNS
Program evaluation Name Member #
Yes No
Objective 1 was met K K Address
Objective 2 was met K K City State ZIP
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Content was relevant to my Country Phone
Mail this entire page to: nursing practice K K
My expectations were met K K E-mail
AACN This method of CE is effective RN Lic. 1/St RN Lic. 2/St
101 Columbia for this content K K
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Aliso Viejo, CA 92656 K easy K medium K difficult
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(800) 899-2226 it took me hours/minutes. Signature

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