Cairo: Pilbeam's Mechanical Ventilation, 7th Edition

Chapter 14: Ventilator-Associated Pneumonia

WorkBook Answer Key

KEY TERMS CROSSWORD PUZZLE

CHAPTER REVIEW QUESTIONS

1. Most often VAP is caused by bacterial infections; however, it can be caused by fungal
infections or may be associated with viral epidemics.

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WorkBook Answer Key 14-2

2. (a) Early onset pneumonia develops 48-72 hours after tracheal intubation. (b) Late onset
pneumonia develops later than 72 hours after intubation.
3. Pathogenic gram-negative aerobes commonly isolated from patients with nosocomial
pneumonias include the following:
Pseudomonas aeruginosa
Klebsiella pneumoniae
Escherichia coli
Enterobacter spp.
Serratia marcescens
Acinetobacter calcoaceticus
Proteus mirabilis
Haemophilus pneumoniae
4. Pathogenic gram-positive aerobes commonly isolated from patients with nosocomial
pneumonias include:
Staphylococcus aureus
Streptococcus pneumoniae
5. The development of VAP is associated with prolonged hospital stays, increased health care
costs, and mortality rates ranging from 25 to 50%.
6. Guidelines for the management of patients with VAP focus on early diagnosis, appropriate
antibiotic treatment, and various strategies to prevent the transmission of pathogenic organisms
to patients receiving mechanical ventilation.
7. Ventilator-associated pneumonia is the most common nosocomial infection encountered in the
intensive care unit (ICU).
8. The incidence of VAP ranges from 8 to 28% for all intubated patients.
9. Ventilator-associated pneumonia has been linked to (a) aspiration of oropharyngeal secretions
and esophageal/gastric contents; (b) direct inoculation of infectious material into the trachea and
lungs during endotracheal intubation; (c) inhalation of infected aerosols and embolization of the
biofilm that can be found in the endotracheal tubes of patients receiving prolonged mechanical
ventilation; (d) exogenous penetration from the pleural space; and (e) hematogenous spread of
extrapulmonary infections to the lung.
10. (any of the following) Conditions and risk factors predisposing to colonization and
ventilator-associated pneumonias include the following:
Alcoholism Malnutrition Immunosuppression
Antibiotic therapy Azotemia Radiation/scarring
Diabetes mellitus Preceding viral infection Malignancy
Hypoxemia Leukocytopenia Coma
Bronchoscopy Surgery Circuit/airway manipulation
Intubation Leukocytosis (72-hour circuit changes)
Tracheostomy Underlying illness Severe illness (Acute
Tube thoracostomy Underlying pulmonary Physiology and Chronic
Hypotension disease Health Evaluation
Nasogastric tubes/enteral Nasal intubation [APACHE] score ≥18)
feedings Gastric alkalinization
Acidosis Supine position
11. Patients who are being treated for trauma, burns, or multiorgan failure or those with an
impaired level of consciousness.

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WorkBook Answer Key 14-3

12. Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of
infection with Haemophilus pneumoniaee, S. pneumoniae, and Moraxella catarrhalis.
13. Patients with cystic fibrosis are susceptible to P. aeruginosa and S. aureus infections.
14. VAP is also recognized as a major complication of acute respiratory distress syndrome
(ARDS). It has been estimated that 35-70% of patients with ARDS develop pneumonia, which
can lead to sepsis and multiple organ failure. The mortality rate for patients with ARDS who
develop VAP is significantly higher than that for patients without VAP.
15. (any of the following) Common risk factors for multidrug-resistant infection include the
following:
Antimicrobial therapy in the preceding 90 days
Current hospitalization for 5 days or longer
High frequency of antibiotic resistance in the community or in the specific hospital unit
Presence of risk factors for health care-associated pneumonia
Hospitalization for 2 days or longer in the preceding 90 days
Residence in a nursing home or extended care facility
Home infusion therapy (including antibiotics)
Chronic dialysis within 30 days
Home wound care
Family member infected with a multidrug-resistant pathogen
Immunosuppressive disease and/or therapy
16. (any of the following) Non-pharmacological interventions associated with an increased risk
of VAP include use of an ET tube or a tracheostomy tube during mechanical ventilation (the
most important non-pharmacological risk factor); routine care of ventilator circuits, humidifiers,
and nebulizers; use of respirometers; use of reusable electronic ventilator probes and sensors; use
of bronchoscopes; and use of endoscopes.
17. (a) Concurrent steroid therapy, (b) inappropriate antimicrobial therapy, (c) overuse of
sedatives and paralytics for mechanically ventilated patients, and (d) use of type 2 (H2) histamine
antagonists and gastroprotective agents, such as antacids.
18. Colonization of the aerodigestive tract with pathogenic bacteria, aspiration of contaminated
secretions into the lower airways, colonization of the normally sterile lower airways, and lung
parenchyma with infectious microorganisms.
19. The CPIS includes six clinical assessments, and each item is given a score of 0-2 points. The
assessment criteria include (a) fever, (b) leukocyte count, (c) quantity and purulence of tracheal
secretions, (d) oxygenation status, (e) type of radiographic abnormality, and (f) results of a
tracheal aspirate culture and Gram stain.
20. There is a shift in the normal flora to gram-negative bacilli and S. aureus.
21. When all six criteria are used, a score higher than six is considered evidence of the presence
of VAP.
22. Numerous studies have shown that obtaining quantitative cultures of specimens from the
lower respiratory tract by conventional fiberoptic bronchoscopy or nonbronchoscopic techniques
can significantly improve the diagnosis of VAP and facilitate decision making regarding the
management of these patients.
23. Clinical assessment may result in inappropriate use of antibiotic therapy because the
causative microorganism remains unknown. Quantitative diagnosis allows identification of the
causative pathogen, and antibiotic therapy can be tailored to that organism.
24. Routine hand washing with soap and water and alcohol-based hand rubs is the most

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WorkBook Answer Key 14-4

important prevention strategy for reducing the risk that clinicians will transmit infectious
microorganisms from one patient to another or from a contaminated site to a clean site on the
same patient.
25. Aspiration of gastric contents can be reduced by following some basic guidelines. Routine
verification of the proper placement of the enteral feeding tube is important. Intermittent
feedings may be preferable to feeding continuously, because the former may prevent
overdistention of the stomach and limit gastropulmonary colonization. Aspiration occurs more
often in patients placed in the supine position than in patients in the semirecumbent position (i.e.,
30-45 degrees from the horizontal position). When feasible and if the patient can tolerate it,
placing a patient in the semirecumbent position is a low-cost, low-risk procedure that is effective
in reducing the aspiration of gastric contents compared with the supine position.
26. A common pathogen associated with percutaneous tracheotomy is P. aeruginosa.
27. Most clinicians agree that reducing ventilator circuit changes is cost-effective and, more
important, lessens the risk of VAP. Circuits do not need to be changed unless they are
nonfunctional or have become visibly soiled with secretions or blood.
28. (a) The CDC currently recommends the development and implementation of an oral hygiene
program for patients in acute care and long-term care facilities who are at high risk for
nosocomial pneumonias. Although the benefits of oral hygiene in preventing VAP continue to be
the subject of debate, recent studies have demonstrated that using an oral cleansing agent, such
as chlorhexidine, can modulate oropharyngeal colonization and ultimately decrease the incidence
of VAP.
(b) Use of prophylactic treatment, such as H2-antagonists and antacids, may reduce the risk of
stress ulcers.
(c) Substantial interest has developed in topically treating the oropharynx and stomach of
patients on mechanical ventilation with antibiotics. The goal is to reduce the number of
potentially pathogenic organisms that may colonize the stomach. This, in turn, may reduce the
incidence of VAP. Selective digestive tract decontamination may reduce VAP and ICU mortality
when a combination of topical and intravenous prophylactic antibiotics is used. However, this is
not without the long-term risk of development of antibiotic-resistant organisms.
(d) The use of both topical and systemic prophylactic antibiotics may reduce respiratory
infections and overall mortality rates in critically ill patients.
29. (a) Fiberoptic bronchoscopy, bronchial alveolar lavage (BAL); (b) mini BAL; (c) blinded
bronchial sampling (BBS); and (d) blinded protective specimen brush (BPSB).
30. (a) Serial clinical and (b) microbiological assessments
31. 30-45 degrees from horizontal.
32. Nasal intubation increases the risk of the development of sinusitis, which is associated with
VAP.
33. Ventilator bundles

CRITICAL THINKING QUESTIONS

1. Older patients are at greater risk for developing VAP than are younger patients. Patients
treated for trauma, burns, multiorgan failure, or impaired levels of consciousness typically have
the highest risk of developing VAP. The patient is intubated and receiving mechanical
ventilation, which also puts the person at risk for developing VAP. Ventilator bundles are
practices that can significantly reduce the incidence of VAP.
2. Comorbidities may predispose patients to infection with specific organisms.

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WorkBook Answer Key 14-5

CASE STUDY

1. VAP that develops more than 72 hours after tracheal intubation is considered late onset
pneumonia.
2. Patients with cystic fibrosis are susceptible to P. aeruginosa and S. aureus infections.
3. Obtaining quantitative specimens from the lower respiratory tract by conventional fiberoptic
bronchoscopy or nonbronchoscopic techniques can improve the diagnosis for VAP and facilitate
decisions making regarding the management of the patient.

NBRC-STYLE QUESTIONS

1. C
2. A
3. A
4. C
5. B
6. B
7. B
8. D
9. A
10. A

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