ORIGINAL ARTICLE

Talking about Prevention and Control Nursing of Ventila-

tor-Associated Pneumonia
Zhen Liu*
Rambo Medical Co., Ltd. E-mail: liuzhen@163.com

Abstract: Ventilator-associated pneumonia (VAP) refers to the infection of lung parenchyma in patients undergoing en-
dotracheal intubation or tracheotomy after receiving mechanical ventilation for 48 h, which is the most common co m-
plication of patients undergoing mechanical ventilation and has a high mortality rate (21.2%-43.2%). At present, the
main measures to prevent and control VAP are to strictly implement hand hygiene, strengthen oral care, raise the bed-
side, effectively remove secretions from the airbag, implement airbag management and ventilator circuit management,
carry out enteral nutrition and cluster intervention strategies according to the actual situation of hospitals. This article
reviews the characteristics, diagnosis, prevention and control of VAP, aiming to provide reference for better prevention
and control of VAP.
Keywords: Ventilator-Associated Pneumonia; VAP; Prevention; Control; Nursing

Ventilator-associated pneumonia (VAP) refers to the

infection of lung parenchyma in patients with endotra-
1. Characteristics of VAP
cheal intubation or tracheotomy after 48h of mechanical 1.1 Etiology and pathogenesis
ventilation and within 48 h of weaning and extubation. 1.1.1 Eharacteristics of pathogenic bacteria
VAP is the most common complication of patients with Gram-negative bacilli accounted for 80% of the
mechanical ventilation and the main type of nosocomial pathogens of VAP, and 20% were Gram-positive cocci,
infection in ICU. The morbidity of VAP in patients with and many of them were complicated with
mechanical ventilation is 9.7%-48.4%, and the fatality drug-resistant bacteria infection and multiple infections.
rate is 21.2%-43.2%. If the combined pathogenic bacte- In 2018, “Guidelines for Diagnosis and Treatment of
ria are multi-drug resistant bacteria, the fatality rate Acquired Pneumonia and Ventilator-associated Pneumo-
can be as high as 38.9%-60.0%. It can be seen that the nia in Chinese Adult Hospitals” (referred to as “Guide-
occurrence of VAP increases the fatality rate, makes it lines”) pointed out that the top 4 pathogens causing VAP
difficult to go offline, prolongs the hospital stay, in- in tertiary hospitals in China were Acinetobacter bau-
creases the medical expenses, etc. It plays a key role to mannii, Pseudomonas aeruginosa, Klebsiella pneumoni-
take effective preventive and nursing measures. This ae and Staphylococcus aureus.
article reviews the characteristics, diagnosis, prevention 1.1.2 Route of infection
and control of VAP, aiming to provide reference for bet- The pathogenic bacteria causing VAP mainly come
ter prevention and control of VAP. from endogenous (bacteria that suck secretions in oro-

Copyright © 2020 Zhen Liu

doi: 10.18686/jn.v9i3.182
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium,
provided the original work is properly cited.

52 | Zhen Liu Journal of Nursing

pharynx and subglottal or reflux through gastric juice, lungs have new or progressive consolidation, infiltration
etc.) and exogenous (hands of medical staff and medical or ground glass-like imaging compared with the latest
facilities related to ventilators, etc.). Among them, the lung imaging and two of the following three articles are
colonization and translocation of endogenous potential combined, the clinical diagnosis can be established: (1)
pathogenic bacteria are the main infection routes causing Peripheral blood leukocytes > 10×109/L or < 4 × 109. (2)
VAP, and inhalation transmission is the main transmis- Body temperature > 38℃; (3) Purulent secretion.
sion route. 2.2 Etiological diagnosis
1.1.3 Pathogenesis
The main mechanism of VAP is that oropharynx se- On the basis of clinical diagnosis, pathogenic bacte-
cretion and gastrointestinal reflux enter the lung, bacteri- ria were cultured by bronchoscope anti-pollu-
al biofilm on the tracheal wall falls off, damaged oro- tion brush, bronchoalveolar lavage fluid, lung tissue or
pharynx and respiratory defense system, respiratory sterile body fluid. There are purulent respiratory secre-
loop bacteria and environmental pollution bacteria enter tions from one or more samples: sputum culture ≥ 105
the lower respiratory tract, etc. There are two main ways cfu/ml; Bronchoalveolar lavage culture ≥ 104 cfu/ml;
for bacteria to invade the lower respiratory tract, one is Lung tissue culture ≥ 104 cfu/ml; Protective brush
endogenous VAP: Accidentally inhaled oropharyngeal culture ≥103 CFU/ml. And it was consistent with clin-
secretions, gastrointestinal reflux and bacterial biofilm ical manifestations.
shedding cause VAP through endogenous ways; The oth-
er type is exogenous VAP, which is mainly triggered by 3. VAP prevention and control
the following exogenous factors, such as high bacterial nursing
concentration in ICU ward, inadequate implementation
3.1 Basic measures
of respiratory loop management and hand hygiene of
medical staff, and lax implementation of visiting system 3.1.1 Strict hand hygiene
and aseptic operation technology in ICU ward. Hand hygiene is the most economical and conven-
ient way to prevent VAP. Proper use of alcohol disin-
1.2 Risk factors of VAP fectant to wash hands can reduce the incidence of noso-
VAP is caused by many factors, mainly including comial infection by 40%, and strict hand hygiene can
the following risk factors: First, the patient’s own factors, reduce the incidence of VAP. The US Centers for Disease
such as the patient’s advanced age, impaired immune Control and Prevention recommends that medical staff
function, combined with diabetes, malignant tumors and should carry out strict hand hygiene, including hand
other basic diseases; The second is iatrogenic factors, washing and alcohol disinfection. Five opportunities for
such as medical operation technology, treatment and hand hygiene in clinic are: (1) Before contacting patients.
nursing methods and drug factors; Third, the mechanical (2) Before cleaning or aseptic procedure. ① Before
ventilation time is long, the balloon pressure of balloon nursing patients with oral and nasal cavity, endotracheal
catheter is low, as well as the use of sedative muscle re- intubation and gas cutting sleeve (before wearing clean
laxants, endotracheal intubation after weaning failure, gloves); ② Before sputum aspiration through artificial
antibiotics used, nasogastric tube indwelling, long-term airway or bronchoalveolar lavage (before wearing sterile
total parenteral nutrition, long-term supine position, etc. gloves). (3) After contact with body fluids of patients.
① After oral and nasal care, endotracheal intubation and
2. Progress in diagnosis of VAP tracheotomy; ② After aspiration in airway, respiratory
sampling or other articles contaminated by respiratory
2.1 Clinical diagnosis
mucosa and respiratory secretions; ③ Patients were
At present, there is no clear gold standard for VAP given tracheal intubation or tracheal intubation removal
diagnosis at home and abroad. China’s 2018 guidelines operation. (4) After contacting with patients. (5) After
point out that when mechanical ventilation is ≥ 3 days, contacting the patient’s surroundings (before leaving the
if imaging (including X-ray and CT) shows that the patient bed unit).

Journal of Nursing Volume 9 Issue 3 | 2020 | 53

3.1.2 Raising the head of a bed standards, and have not issued relevant guidelines on the
The supine position is an independent risk factor for definition of negative pressure range. The greater the
VAP. In the relevant guidelines, raising the bedside by suction negative pressure value, the more complications
30°to 45°is regarded as a basic measure to prevent such as airway mucosa damage, bleeding and even
VAP. In the process of clinical implementation, we can choking cough. Subglottic secretion suction includes
improve the compliance of bedside elevation through continuous subglottic suction and intermittent subglottic
standardized doctor’s advice, reminding, supervision and suction. To prevent mucosal injury, it is recommended to
feedback, education and training, and quality control use intermittent subglottic suction to intermittently suck
circle. the secretion on the balloon with constant negative pres-
3.1.3 Oral care sure, which can be sucked by 10 ml syringe every hour
Patients after endotracheal intubation should receive or intermittent central negative pressure of 100~150ml
oral care in time, but there is no evidence to clearly sup- every 2 hours.
port the frequency of oral care for critically ill patients. 3.2.2 Monitoring airbag pressure
Patients with mechanical ventilation through endotra- The residue on air bag is an important source of
cheal intubation should be given oral care by washing VAP pathogen, and managing air bag is one of the im-
and scrubbing. After oral care, they should be sucked in portant means to reduce VAP. In 2014, the expert con-
the mouth in time. Patients with endotracheal intubation sensus of artificial airway airbag recommended that the
should be given oral care by two persons. The depth of airbag pressure should be maintained at 25-30 cm H2O.
endotracheal intubation should be evaluated before and The research shows that by comparing the finger touch
after operation. The bedside should be raised by 30°to method with the pressure gauge method, it is found that
45°before operation, and the air bag pressure should be the finger touch method has inaccurate pressure and
maintained at 25-30 cm H2O after operation. Compound many complications. Therefore, it is suggested that the
chlorhexidine gargle can inhibit the adhesion and growth finger touch method based on experience should not be
of bacteria in oral cavity, and reduce the formation of used to inflate the airbag in clinic, but should be moni-
dental plaque. However, oral care with glucose chlor- tored by pressure devices, such as hand-held manometer
hexidine solution is still controversial, and further clini- method, traditional pressure gauge, automatic continuous
cal practice and research are needed. monitoring and control device, etc., especially the auto-
3.2 Effectively removal secretions from matic inflator keeps the best airbag pressure. When using
air bags the balloon manometer to monitor the intermittent bal-
loon pressure, it should be re-measured every 6-8 h, and
3.2.1 Aspiration of subglottic secretion
the inflation pressure should be higher than the ideal
The retention in the balloon of patients with endo-
value of 2 cm H2O every time. It should be re-measured
tracheal intubation enters the lung and causes VAP.
after sputum suction with cleaning up the accumulated
Studies have confirmed that subglottic suction can sig-
water in the pressure tube and changing the patient’s
nificantly reduce the occurrence of VAP. It is recom-
position.
mended to use a catheter with subglottic secretion drain-
age for patients whose expected endotracheal intubation 3.3 Enteral nutrition
time may exceed 48 h or 72 h. The purpose of subglottic In “Guidelines for Prevention of Ventila-
secretion suction is to remove the retention on the bal- tor-associated Pneumonia” issued by CDC in 2015, en-
loon, which is mainly through continuous or intermittent teral nutrition is clearly regarded as one of the important
negative pressure drainage of the retention on the bal- measures to prevent VAP clustering strategy. Scientific
loon by using the drainage tube attached to the endotra- and standardized enteral nutrition nursing is an important
cheal tube wall. It can shorten the mechanical ventilation measure to prevent VAP in critically ill patients, which
time and effectively reduce the occurrence of VAP. mainly includes: (1) Selection of feeding route. For
However, at present, domestic experts have not formu- medical institutions with high feasibility of opening
lated standardized and unified operation procedures and small intestine access, or those with certain difficulties, it

54 | Zhen Liu Journal of Nursing

is recommended that people with poor tolerance to The ventilator cluster prevention and control strat-
stomach nutrition (such as continuous application of egy refers to the implementation of some evidence-based
sedatives, anesthetics and large amount of stomach re- treatment and nursing measures, which is the most
tention) and high risk of reflux (such as prone position) widely used intervention strategy in clinical VAP nursing
should first choose small intestine nutrition; In medical practice at present, mainly including: (1) Using
institutions where the opening of small intestine is not non-invasive respiratory support treatment technology as
feasible, early feeding can be done through stomach. much as possible; (2) Daily wake-up and offline assess-
Continuous feeding can reduce the risk of gastric reflux ment; (3) It is suggested to use a catheter with subglottic
and aspiration more than intermittent feeding. (2) Con- secretion suction for patients whose expected tracheal
tinuous feeding position. During nasal feeding, the low- intubation time may exceed 48 h or 72 h; (4) The pres-
er bed was allowed to be raised by 30°or higher, and the sure of the airbag should be maintained at 25-30 cm H2O
left lateral position was adopted. After nasal feeding, it after inflation; (5) If there is no contraindication,
was kept in the half position for 30-60 min. (3) Monitor- the bedside is raised by 30°to 45°; (6) Strengthen oral
ing of gastric residual volume and gastric tolerance. For care; (7) When carrying out operations related to airway,
the incidence of VAP, duration of mechanical ventilation the aseptic technical operation procedures should be
and mortality, monitoring gastric reflux and vomiting strictly observed; (8) Encourage and assist patients with
alone is as effective as monitoring gastric reflux, vomit- mechanical ventilation to take early activities and start
ing and residual stomach volume. Routine monitoring of rehabilitation exercise as soon as possible. At present,
gastric residual volume is not recommended for asymp- there is no standard clustering strategy. The Guidelines
tomatic patients receiving enteral nutrition. Gastrointes- for Prevention, Diagnosis and Treatment of Ventila-
tinal tolerance should be monitored every day in criti- tor-associated Pneumonia issued by China in 2013 rec-
cally ill patients, and attention should be paid to ab- ommended that all medical institutions should carry out
dominal pain, bloating, exhaustion and defecation. clustering intervention nursing to prevent VAP according
to their own situation on the basis of evidence.
3.4 Ventilator circuit management
Respiratory circuit is an important place where bac-
4. Summary and prospect
teria inhabit and migrate, so it is particularly important to
manage the ventilator circuit. The main measures are as In recent years, there have been more and more re-
follows: (1) The frequency of ventilator pipeline re- searches on VAP from clinical, microbiology and pre-
placement. In China’s Guidelines for Clinical Applica- vention and control measures at home and abroad, and
tion of Mechanical Ventilation (2006) and the Prediction some achievements have been made, but VAP still occurs.
Strategy of Ventilator-associated Pneumonia in American Therefore, medical staff at all levels of medical institu-
SHEA Acute Hospital in 2014, it is recommended to tions and hospital infection professionals should pay
replace the ventilator pipeline only when there is visible attention to and control the management of VAP patho-
pollution or failure. (2) Condensate water management. genic factors, strengthen the concept of sterility of med-
Studies at home and abroad show that the ventilator ical staff, and attach importance to the training of VAP
condensed water collecting cup should be placed at the related knowledge. Meanwhile, we should strengthen the
lowest point of the pipeline system, and the condensed supervision of VAP prevention and control measures and
water in the pipeline should be removed in time, when carry out continuous quality improvement, so as to pro-
the condensed water is larger than 1/2 of the volume of mote the implementation of VAP prevention and nursing
the collecting cup. In addition, in order to prevent or measures and reduce the occurrence of VAP.
reduce the generation of condensed water, it is suggested
that patients with mechanical ventilation should be hu- References
midified by a humidifier with heating wires. 1. Hu C, Du J, Li S. Analysis of risk factors of venti-
lator-associated pneumonia in children patients with
3.5 Cluster prevention and control strategies severe mechanical ventilation and its nursing coun-
termeasures. Nursing Practice and Research 2020;

Journal of Nursing Volume 9 Issue 3 | 2020 | 55

 17(17): 53–55. tor-associated pneumonia in children with respira-
2. Zhang L, Cai L, Cai X, et al. Effect of comprehen- tory failure. Medical Innovation of China 2020;
sive airway intervention on prevention of ventila- 17(25):161–165.

56 | Zhen Liu Journal of Nursing