Ventilator-associated Pneumonia: The Potential Critical Role of Emergency Medicine in Prevention

Grap, Mary Jo; Munro, Cindy L.; Unoki, Takeshi; Hamilton, V. Anne; Ward, Kevin R.

doi:10.1016/j.jemermed.2010.05.042

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Ventilator-associated Pneumonia: The Potential Critical Role of Emergency Medicine in Prevention

Mary Jo Grap, RN, PhD, ACNP, FAAN
- School of Nursing, Virginia Commonwealth University, Richmond, Virginia
- Department of Emergency Medicine, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
- Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES), Virginia Commonwealth University, Richmond, Virginia
- Reprint Address: Mary Jo Grap, rn, phd, acnp, faan, School of Nursing, Virginia Commonwealth University, PO Box 980567, 1100 East Leigh St., Richmond, VA 23219
Cindy L. Munro, RN, PhD, ANP, FAAN
- School of Nursing, Virginia Commonwealth University, Richmond, Virginia
- Department of Emergency Medicine, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
- Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES), Virginia Commonwealth University, Richmond, Virginia
Takeshi Unoki, RN, PhD
- School of Nursing, St Luke’s College of Nursing, Tokyo, Japan
V. Anne Hamilton, RN, MS, FNP
- School of Nursing, Virginia Commonwealth University, Richmond, Virginia
Kevin R. Ward, MD
- Department of Emergency Medicine, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
- Virginia Commonwealth University Reanimation Engineering Shock Center (VCURES), Virginia Commonwealth University, Richmond, Virginia

Received 28 August 2009; received in revised form 11 December 2009; accepted 9 May 2010. published online 09 August 2010.
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Abstract

Background

Delivery of critical care within a certain window of opportunity is paramount in many disease states, and providing the right care to these patients at the right time in the Emergency Department (ED) can significantly reduce mortality. However, aggressive treatment of these patients often requires endotracheal intubation and mechanical ventilation either in the pre-hospital or ED phase of care. Care of mechanically ventilated patients in the ED is not trivial or without potential complications, including ventilator-associated pneumonia (VAP).

Objective/Discussion

This article summarizes the epidemiology, pathophysiology, and specific risk factors associated with VAP and provides evidence-based recommendations for its prevention. We emphasize practices that are particularly important in the early stages of care of intubated, mechanically ventilated patients; thus, they should be instituted in the ED.

Conclusion

Specifically, we recommend continuous backrest elevation of 30–45°, chlorhexidine application to the oral cavity after intubation and every 12h thereafter, orotracheal intubation with a tube that enables continuous subglottic suctioning, and cuff pressure assessments after intubation and every 4h thereafter to maintain pressure between 20 and 30cm H₂O.