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Review

Pneumonia Associated with Mechanical Ventilation: Management and Preventive Aspects

by
Álvaro Astasio-Picado
1,*,
Francisco Javier Perdones Jiménez
1,
Miriam López-Sánchez
2,
Jesús Jurado-Palomo
1 and
María del Carmen Zabala-Baños
1
1
Physiotherapy, Nursing and Physiology Department, Faculty of Health Sciences, University of Castilla-La Mancha, 45600 Toledo, Spain
2
Extremadura Health Service, 10300 Cáceres, Spain
*
Author to whom correspondence should be addressed.
Appl. Sci. 2022, 12(20), 10633; https://doi.org/10.3390/app122010633
Submission received: 30 August 2022 / Revised: 27 September 2022 / Accepted: 14 October 2022 / Published: 21 October 2022
(This article belongs to the Section Computing and Artificial Intelligence)
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Abstract

:
Introduction: Ventilator-associated pneumonia (VAP) constitutes a real iatrogenic health problem, which can lead to a higher rate of hospital admission days associated with the morbidity and mortality that it could cause. Objective: To study and learn about the different preventive measures used to reduce the incidence of VAP, as well as to study the microorganisms that most frequently cause VAP. To determine the nursing staff’s knowledge of this phenomenon and the social and health care costs derived from the disease. Methodology: The bibliographic search of the existing literature was carried out between November 2021 and June 2022. In order to gather all the necessary information, different databases were searched. For this purpose, a search strategy was developed using keywords included in “DeCS” and “MeSH” and using boolean operators such as “AND and OR”, and all articles meeting the chosen inclusion criteria were included. Results: After applying the article selection criteria and assessing the quality of the methodology, a total of 33 articles were finally included for systematic review. The results show the usefulness of various preventive measures against the micro-organisms that most frequently cause this type of pneumonia, as well as the true cost associated with this pathology and the still insufficient knowledge of healthcare personnel about it. Conclusion: Although many advances have reduced the incidence and mortality of this pathology, further research, training of healthcare personnel and implementation of new protocols are still required.

1. Introduction

Nosocomial pneumonia is one of the most frequent nosocomial infections among hospitalized patients. Among nosocomial pneumonias (NN), nosocomial pneumonia associated with mechanical ventilation (VAP) is the most frequent infectious complication among patients hospitalized in intensive care units, constituting a significant problem of morbidity and mortality (often caused by multi-resistant microorganisms), as well as an increase and overload of health resources and the high socioeconomic and health cost that this entails [1,2].
VAP constitutes, in most cases, a real in-hospital health problem and an increase in the hospital stay of patients who suffer from it. These factors lead to the need to establish therapeutic and preventive strategies that lead to a reduction in the complications and incidences of said pathology [3].
Ventilator-associated pneumonia, a subtype of pneumonia, accounts for 80% of all pneumonias acquired in intensive care units. The incidence of VAP has experienced a significant decline in recent years, possibly due to the general implementation of preventive therapeutic measures [4,5,6,7,8].
The risk of presenting an NN is multiplied by more than 20 times in patients who are receiving Invasive mechanical ventilation (IMV). It has been estimated that during the first week of IMV, the risk is 3%, decreases to 2% in the second week, and remains around 1% in the third week and later. Around 10% of patients who require IMV end up developing VAP [4,6].
The initial mortality associated with VAP was between 33–50%, however, recent studies have estimated a decrease to show parameters of around 9–13% [3]. The clinical guidelines published by the “Infectious Diseases Society of America (IDSA)” and the “American Thoracic Society (ATS)” reported that the mortality rate of VAP in the US in the year 2016 reached 13%. While in Europe, a study determined that the mortality rate of early VAP was 19.2% and the mortality rate of late VAP was 31.4% [8,9,10,11,12,13,14].
The microorganisms that cause pneumonia in general can reach the lower respiratory tract by some of the following routes: [15,16,17]
(a)
By inhalation through the respiratory tract or the ETT if the patient is intubated and connected to MV (via circuits and/or tubing).
(b)
By aspiration of colonized secretions from the oropharynx.
(c)
Hematogenously from foci of infection distant from the lung or from the intestinal flora itself, from the phenomenon of bacterial translocation.
(d)
By contiguity from infections close to the lungs.
Therefore, although these four possible pathogenic pathways for the development of VAP have traditionally been distinguished, it has been possible to verify that, currently, the aspiration of colonized secretions from the oropharynx is the majority pathway and, in part, almost the only one [15,16,17].
In patients connected to MV, either by ETT or tracheostomy, the pneumotamponade performs the essential function of isolating the airway. This prevents air loss to the outside and the supposed entry of material into the lungs, although this is not completely the case, so the sterility of the lower airways is compromised. A poorly inflated balloon, insufficient pressure or poor handling can cause contaminated secretions from the oropharynx that have descended through the airway to penetrate around the pneumotamponade and reach the lower airway. When these secretions reach the lung parenchyma and alter the integrity of the respiratory system and, in turn, exceed the host’s defense capacity, an inflammatory response will occur, giving rise to VAP [15,16,17].
Microorganisms that usually do not require difficulties in choosing antibiotic treatment usually cause early VAP and most empiric antibiotic therapy guidelines are made up of drugs that are sensitive to them. Among the pathogens included here we can mainly highlight: Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus sensitive to methicillin (SASM) [2,4,18,19].
Late VAPs are usually caused by another profile of different pathogens, in many cases with resistance to different families of antibiotics and associated with higher mortality, so we would be talking about multi-resistant microorganisms (MDRO). Among them, we find pathogens such as Pseudomonas aeruginosa, Acinetobacter baumannii or methicillin-resistant Staphylococcus aureus (MRSA) [2,4,18,19].
The rapid diagnosis of the disease in order to establish the appropriate treatment is crucial for the evolution and prognosis of the patient [20,21].
The joint diagnosis of VAP can be made based on non-invasive or invasive strategies. Non-invasive strategies include criteria and clinical, radiological and laboratory symptoms such as: [2]
−
Fever > 38° with no other possible origin.
−
Leukopenia (<4000 mm3) or leukocytosis (>12,000/mm3).
−
Purulent secretions from the lower airway.
−
Impaired gas exchange and ventilatory function (episodes of desaturation or increased oxygen requirements).
−
Radiological tests (X-ray or chest CT) showing the beginning of pulmonary infiltrates or progression in existing ones.
−
Increase in inflammatory biomarkers such as C-Reactive Protein (CRP).
−
Pulmonary auscultation suggestive of disease.
However, these clinical data are insufficient and non-specific when it comes to establishing the final diagnosis with certainty, and must be combined with other types of complementary tests [2].
In comparison with the empiric treatment of VAP, we find the specific therapy for each pathogen. The main clinical goal will be to avoid prolonged and unnecessary use of antibiotics. In fact, on many occasions, VAPs are misdiagnosed and, in this case, the antibiotic treatment should be suspended as soon as it is known [22,23,24]. Similarly, antibiotics should be reduced once the results of the culture and susceptibility tests are available, where the final and specific treatment will be definitively chosen [24,25,26,27,28,29,30,31].
The objective of this study is to analyze the scientific evidence of the effectiveness of the preventive measures used to reduce the incidence of pneumonia associated with mechanical ventilation.

2. Materials and Methods

The preparation of this work was carried out through a systematic bibliographic review of the articles found by searching the following databases: Medline/Pubmed, WOS, Scielo, Scopus and Google Scholar. To find the best possible scientific evidence, a series of inclusion and exclusion criteria were applied.
The keywords for this review are: ventilator-associated pneumonia; nosocomial; nursing; prevention; preventive measures; microorganisms; knowledge. To carry out the bibliographic search, different keywords in English were used, such as: “ventilator-associated pneumonia”, “nursing”, “prevention”, “microorganisms”, “costs”, Ventilator-associated pneumonia “NAV”, “ventilator-associated pneumonia”, “nursing”, “prevention”, “microorganisms”. These have been validated by the DeCS and MeSH. Once selected, the corresponding Boolean operators were used: AND/OR, as well as the necessary parentheses and quotation marks. The final search string is as follows: (“ventilator”) AND (“associated”) AND (“nosocomial”) AND (“pneumonia”) AND (“nursing”) AND (“prevention”) AND (“microorganisms”) OR (“ventilator-associated pneumonia”) OR (“VAP”). The criteria that were taken into account for the selection of the relevant studies were the following. Inclusion criteria: the period between 2015 and 2022; article type: article review and article research; field: medicine; English language; sample in an adult population; and studies that provide scientific evidence justified by the level of indexing of articles in journals according to the latest certainties. Exclusion criteria: articles prior to 2015; language: not English; studies in which the population was minors; studies that do not provide scientific evidence justified by the level of indexing of articles in journals according to the latest certainties.
For the methodological evaluation of the individual studies and the detection of possible biases, the evaluation was carried out using the PEDro Evaluation Scale. This scale consists of 11 items, providing one point for each element that is fulfilled. The articles that obtained a score of 9–10 points have excellent quality, those between 6 and 8 points have good quality, those that obtained 4–5 points have an intermediate quality, and, finally, those articles that obtained less than 4 points have a poor methodological quality [22].
The Scottish Intercollegiate Guidelines Network classification was used in the data analysis and assessment of the levels of evidence, which focused on the quantitative analysis of systematic reviews and the reduction of systematic error. Although it took into account the quality of the methodology, it did not assess the scientific or technological reality of the recommendations [23].

3. Results

The research question was constructed following the PICO format (Population/patient, Intervention, Comparator and Outcomes/Outcomes). Detailed as P (Patients): Patients with pneumonia associated with mechanical ventilation, I (Intervention): Preventive measures/microorganisms/nursing knowledge/costs, C (Comparison): Not compared/Not precise/Find the answer/No intervention, O (Outcomes, Results): Decrease in VAP incidence. (Scheme 1).
Below is a table that shows the search strategy used to select the 33 articles selected from the five databases, following the criteria of identified studies, duplicate studies, titles, abstracts, full texts and valid studies of a definitive nature (Table 1). The total number of valid articles is summarized in Appendix A.

3.1. Preventive Measures Used to Prevent VAP and Their Effectiveness According to Various Studies

There are many different preventive measures that can be applied when trying to reduce the incidence and prevalence of VAP. For this, a package of measures has been searched for and their usefulness and effectiveness have been compared according to various studies and authors [32,33,34,35]. All the authors, without exception, are in favor of washing hands with soap and water in the five moments of patient care [36,37,38,39,40,41,42,43]. Some of them, such as Álvarez et al. [36], Moreno et al. [37], Villamón et al. [40], Cornistein et al. [41] and González et al. [43], also consider the introduction of 70% alcoholic solutions to be important during hand hygiene.
Regarding oropharyngeal hygiene and oral care, all agree on the use of chlorhexidine in different concentrations to avoid colonization by microorganisms of the oropharynx and thus carry out oral and oral cleaning [44,45]. Authors such as Wanda et al. [42] and Natesia et al. [45], estimate that 0.12% chlorhexidine is the most suitable concentration. The rest of the authors who mention this measure propose chlorhexidine concentrations of 0.12% or 0.2%.
Neutral tamponade cuff pressure from either the ETT or tracheostomy device is essential. They all agree that values below 20 cm H2O are not recommended. Authors such as Coppadoro et al. [32], Lau et al. [35], Álvarez et al. [36], Carrera et al. [43], etc. are in favor of pressures ranging between 20–30 cm H2O. Other authors, such as Li Bassi et al. [38] and Natasia et al. [45], determine that the pressure should be maintained between 20–35 cm H2O.
Regarding the aspiration of secretions, all the authors determine that this must be done in a sterile manner and only when necessary and not routinely. As for the different types of suction systems, we find open or closed systems. Authors such as Coppadoro et al. [35], Burja et al. [36] and Carrera et al. [43] are in favor of the use of closed suction systems. No results were found in favor of the use of open systems. The rest of the authors do not show a clear difference between the use of one or another type of system.
The authors who cite this measure are in favor of keeping the patient in bed in a Fowler’s or Semi-Fowler’s position with a headrest tilt of between 30–45°, always avoiding SD.
All the studies and authors that evaluate this measure are in favor of the use of ETT with a suction system for subglottic secretions. The authors who comment on the use of the DDS and the DOS in their studies are in favor of these. The different authors are in favor of carrying out sedation windows and minimizing them. Other authors, such as Villamón et al. [40] and Natasia et al. [45], propose scales for assessing the level of sedation such as the Ramsey and Rass scales, respectively.

3.2. Main Microorganisms That Cause VAP According to Various Studies

The table below shows the results of the microbiology causing VAP according to the studies carried out by the different authors (Table 2).
Many authors have tried to determine the microbiology responsible for cases of pneumonia associated with mechanical ventilation [46].
Table
Table 2. Main results microorganisms causing VAP according to various studies.
Table 2. Main results microorganisms causing VAP according to various studies.
Cilloniz, C. (2016) [47]Rebellón, D. (2015) [48]Al Zahraa, M. (2021) [49]Luyt, C. (2018) [50]De León, M. (2019) [51]Huang, Y. (2018) [52]
Gram-positive (%)
Staphylococcus aureus30%28% 13.9% 7%
SASM 7.7%
SARM 6.2%
Streptococcus pneumoniae3%2.9% 21%
Gram negative (%)
Pseudomonas aeruginosa24%21.8%3%9.7%12.5%19.8%
Acinetobacter species7%6.8%12%8.6%7%33.9%
Klebsiella species11%9.8%45% 24.5%23.6%
Escherichia species8%6.9% 15%3.4%
Enterobacter species7%6.3%5%18.4%18%4%
Haemophilus influenza3%2.7%
Polymicrobial (%) 13.7%
Others (%)7%6.6%35%8.2% 8.3%
Unknown origin (%) 13.1%2%
Cilloniz et al. [47] determined that early-onset VAPs are usually caused by community pathogens with a better prognosis. However, late VAPs have a worse prognosis when associated with MDROs. Gram-negative pathogens would be the most frequently present (between 50% and 80% of cases).
For their part, Rebellón et al. [48] stated that Gram-negative organisms are the main cause of VAP and that resistant strains may be present in half of the cases, associating this with an increase in mortality.
Al Zahraa et al. [49] observed in their study that Gram-negative organisms were the most commonly isolated and, on the contrary, they did not find infections by Gram-positive pathogens.
Luyt et al. [50] observed that 70% of the isolated microorganisms were Gram-negative and that within the Gram-positive microorganisms, Staphylococcus aureus was the most predominant.
Maricela de León et al. [51] establish that Gram-negative pathogens were the most prevalent, and Streptococcus pneumoniae stands out among the Gram-positive ones.
Finally, Huang et al. [52] found that Gram-negative bacteria were present in more than 80% of cases and that Staphylococcus aureus was the most common Gram-positive bacteria.

3.3. Adherence and Knowledge of Nursing Staff about Preventive Measures against VAP

Several studies have been reviewed in order to assess the adherence and knowledge of the nursing staff about the preventive measures against VAP. In the study carried out by Shajaeimotlagh et al. [53], the nurses achieved a score of 48.31% in a test carried out on the different preventive measures, which indicates less than half of the total score. Hassan et al. [54] determined through several tests that more than ¾ of the nurses had a low level of knowledge about pathophysiology, risk factors and preventive measures, this could be due to a lack of time and lack of knowledge of standardized protocols. Pujante-Palazón et al. [55] obtained better results with a medium-high degree of knowledge. For their part, Rafiei et al. [56] showed that there was a group of nurses who were more familiar with the prevention guidelines and the training workshops who had more knowledge than those who had not received any training and who had inadequate knowledge. Miranda da Cruz et al. [57] were able to verify that there was no relationship between the time worked in the ICU and the level of knowledge, and that the nursing staff had a great adherence of 80% to preventive measures. Okgün Alcan et al. [58] confirmed that adherence and knowledge of the package of prevention measures improved after education from 10.8% to 89.8%. Finally, Jam R et al. [59] found that the knowledge of the nursing staff about these measures is not necessarily transferred to clinical practice due to contextual factors (Figure 1).

3.4. Average Health Cost Per Case of VAP Additional to Medical Care According to Various Studies

There are several studies that try to evaluate the average additional cost per case of VAP. Ladbrook et al. [60] estimated that the average hospital costs per case of VAP represented an additional annual cost for the health system of USD 1.45 billion. For their part, Véliz et al. [61] came to show a health cost 7 times higher than those who did not develop this pathology (Figure 2).

4. Discussion

The studies used in this systematic review show us information and results on various aspects of VAP.
Regarding the use and effectiveness of the different preventive measures, we can find different results depending on each measure:
All the authors that make up the review shared measures such as hand hygiene with soap and water and the introduction of 70% alcoholic solutions. Handwashing would thus help prevent the spread of infection and remove microbes from the hands.
Oropharyngeal hygiene and oral care with chlorhexidine is one of the most important and widely used measures. All authors agree that concentrations such as 0.12%, 0.2% or 2% chlorhexidine should be used. Chlorhexidine would thus be considered the most evaluated antiseptic in clinical trials and the one that most frequently helps reduce microbial colonization of the oral cavity and therefore reduce the incidence of VAP. Authors such as Mehta et al. [34] and Li Bassi et al. [38] report that the use of toothbrushing presents controversy and little proven evidence. On the other hand, Hellyer et al. [46] comment that the use of dental brushing does not seem to be harmful, so it could be used during oral hygiene. Regarding the frequency of hygiene of the oral cavity, authors such as Moreno et al. [37], Álvarez Lerma et al. [36], Villamón Nevot et al. [40] and Carrera et al. [43] agree that this should be done every 8h or once per shift.
The pressure of the cuff will be one of the main factors involved in the etiology of VAP. Low pressures will allow secretions and microorganisms to enter the lower respiratory tract from the oropharynx, and excessively high pressures will damage the tracheal mucosa, producing ischemia. All the authors involved in this review agree that the cuff should have a minimum pressure of 20 cm H2O. Regarding the maximum pressure, there has been more controversy. Authors, such as Copprado et al. [32], Lau et al. [35], Alvarez Lerma et al. [36], Moreno et al. [37], Sousa et al. [39], Villamón Nevot et al. [40] and Carrera et al. [43], agree that the maximum pressure should be 30 cm H2O. Others, such as Li Bassi et al. [38] and Natesia et al. [45], consider that it should be a maximum of 35 cm H2O.
Regarding the suction of secretions, most agree that it should be used when necessary and not routinely. Always using the most aseptic and sterile technique possible, avoiding system disconnections as much as possible. Authors, such as Copprado et al. [32], Burja et al. [33] and Elier et al. [43], recommend the use of closed suction systems since they would cause greater comfort when performing the technique and thus avoid disconnections and openings of the system, although they are associated with greater colonization. Metha et al. [34] and Villamón et al. [40] do not show differences in terms of suction systems, considering that there is no clear evidence regarding the use of one or the other. According to the authors, the open system would cause greater desaturation and instability in the patient, and the closed system would entail a higher cost. Aspiration of bronchial secretions should be limited to situations in which there is clinical evidence of the presence of secretions: characteristic noises on auscultation, impaired ventilatory function, altered flow-volume-pressure curve parameters, etc.
The position of the patient constitutes a basic preventive measure. All authors agree that the supine position at 0° should be avoided and that the head of the bed should be kept between 30–45° in order to avoid gastroesophageal reflux and the probable consequent aspiration of gastric content, as well as to prevent any secretion from passing into the airway.
ETT with drainage of subglottic secretions is a preventive measure on the rise. The authors involved in this study recommend its use and are in favor of it since they have determined that it reduces the amount of contaminated secretions that are housed above the ETT cuff and that could pass into the lower respiratory system.
Regarding selective oral decontamination and selective digestive decontamination, the authors who cite it in their studies, such as Metha et al. [34], Lau et al. [35] and Alvarez et al. [36], are in favor of its use due to its proven efficacy in reducing incidence and mortality. This thus constitutes a useful prophylactic strategy composed of antimicrobial agents, such as colistin, tobramycin and amphoterifin B, to eradicate colonization of the oropharynx, stomach and intestine by potentially pathogenic microorganisms while preserving the endogenous flora itself.
Lau et al. [35] and Moreno et al. [37] report that the orogastric tube should be performed better than the nasogastric tube since the latter has been associated with sinusitis and increased secretions. Among the basic care of the SNG is the measurement of the gastric residue to check that the intakes are being tolerated and reduce the risk of reflux. Authors, such as Villamon et al. [40] and Elier et al. [43], agree that the debit should be checked every 4 h. Stephanie et al. [42] report that it should be checked every 8 h.
The authors who mention the change of circuits, tubing and systems agree that routine changes should not be made to them and that they should only be replaced when they are visibly dirty or damaged or, at most, once a week.
The level and state of patient sedation should be reduced to the minimum possible and authors, such as Metha et al. [34], Lau et al. [35], Kim-Peng et al. [44] and Thomas et al. [46], recommend carrying out daily sedation windows. The use of scales to assess the level of sedation has been estimated, such as the Ramsey scale used by Villamón et al. [40] and the RASS scale used by Natesia et al. [45].
These measures of proven efficacy manage to reduce the incidence and mortality associated with VAP. Authors such as Metha et al. [34] and Lau et al. [35] even state that up to half of VAP cases can be reduced and avoided. That is why common prevention guidelines and protocols should be drawn up in order to implement them in daily clinical practice.
Regarding the microbiology of the VAP-causing agents, all authors agree that Gram-negative germs are involved in most cases. Cilloniz et al. [47] estimate that Gram-negative organisms cause 50% to 80% of infections, while Luyt et al. [50] in line with the above comment that 70% of cases are caused by Gram-negative germs. Huang et al. [52] estimate the percentage at 80%. Among the most commonly isolated Gram-negative germs, Pseudomonas aeruginosa would be the most common. However, in the studies carried out by Al Zahra et al. [49] and Maricela et al. [51], the Klebsiella species was the most common among the Gram-negatives with a proportion of 45% and 24.5%, respectively.
On the other hand, among the Gram-positive microorganisms, all authors agree that Staphyloccoccus aureus was the most common, with an incidence of up to 30% according to the study by Cilloniz et al. [47].
The great heterogeneity of microbiology highlights the need for a local epidemiological and microbiological evaluation.
Regarding the adherence and knowledge of the nursing staff regarding preventive measures, different data can be obtained. The studies carried out by Vahid et al. [53], Hassan et al. [54] and Rafiei et al. [56] show an inadequate degree of knowledge and regular adherence to preventive measures. However, studies by Joao Ricardo et al. [57] and Okgun et al. [58] show knowledge of more than 80% of the preventive measures against VAP and a significant reduction in incidence achieved through good adherence. Pujante-Palazon et al. [55] observed in their studies that there was a trend between the years worked in the unit and the degree of knowledge about the pathology and its prevention, although this trend was not entirely significant. On the other hand, Miranda da Cruz et al. [57] determined that there was no relationship between the time worked in the ICU and the level of knowledge.
The average health costs per case of additional VAPs on medical care present different values depending on the various studies. Ladbrook et al. [60] estimated the average cost per case of VAP to be around USD 25,000. On the other hand, Veliz et al. [61] show a lower average cost of about USD 4475 per VAP case. The studies carried out by Luckraz et al. [62] and Sosa-Hernandez et al. [63] present similar results in terms of costs of USD 11,637 and USD 10,796, respectively, per case of VAP. The highest cost data was obtained in a study carried out in Japan by Nanao et al. [64], where the average cost was estimated at USD 34,884. Although with different figures and values, they all agree on the great additional cost that this pathology implies on health care.

5. Conclusions

With regard to determining and demonstrating the effectiveness of the preventive measures used to reduce the incidence of VAP, we have shown the existence of measures that reduce both incidence and mortality from VAP, such as hand washing, oral hygiene and oropharyngeal suction with chlorhexidine, correct positioning of the patient in bed, adequate cuff pressure of the pneumotamponade, the use of ETT with a subglottic secretion drainage device, the use of DDS and DOS, the correct aspiration of secretions and the evaluation of the optimal sedation status of the patient, among others. After studying the incidence and prevalence of the pathogenic microorganisms that cause VAP, we can determine that the microbiology of the causative agents varies, taking into account various factors such as the epidemiology of the study area, previous exposure to antibiotics, the length of hospital stay, the personal factors of each individual and the prevalent microorganisms in each hospital or health area (which may even vary between units of the same hospital). However, it has been possible to objectify that mostly Gram-negative germs cause most of the cases. After evaluating the adherence and knowledge of the nursing staff regarding the application of preventive measures against VAP, it has been possible to show that more than half of the nursing staff generally have inadequate and/or insufficient knowledge about the subject of study at issue, highlighting the need for training education in health matters on Ventilator-associated pneumonia. All professionals must be trained in accordance with the best available scientific evidence in order to provide quality care. Finally, to determine the health and economic costs derived from VAP, it is shown that cases of this type of pneumonia entail a large additional average cost over the care provided, requiring a great effort on the part of the health institutions in terms of budgets that could be partially avoided.

Author Contributions

Conceptualization, F.J.P.J. and M.L.-S.; methodology, Á.A.-P.; software, F.J.P.J. and M.d.C.Z.-B.; validation, Á.A.-P., J.J.-P. and Á.A.-P. formal analysis, Á.A.-P. investigation, M.L.-S. and Á.A.-P.; resources, J.J.-P.; data curation, F.J.P.J.; writing—original draft preparation, Á.A.-P.; writing—review and editing, Á.A.-P.; visualization, F.J.P.J.; supervision, Á.A.-P.; project administration, Á.A.-P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

Abbreviations

NNNosocominal pneumonia
VAPNosocominal pneumonia associated with mechanical ventilation
MVMechanical ventilation
IMVInvasive mechanical ventilation
ICUIntensive care unit
ETTEndotracheal tube
COPDChronic obstructive pulmonary disease
MDROMultidrug resistance organism
DDSSelective digestive descontamination
DOSSelective oral descontamination

Appendix A

Table
Table A1. Selected scientific articles table.
Table A1. Selected scientific articles table.
Authors; YearType of StudyPatientsConclusion
Cilloniz et al. (2016).Systematic review.89 items.Early-onset VAP is usually caused by “community” microorganisms, such as methicillin-sensitive Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and anaerobes. Late VAP is usually caused by pathogens such as MRSA, Gram-negative rods, Pseudomonas aeruginosa, and non-fermenting bacteria such as A. baumanii and S. maltophila. Pneumonia due to two or more pathogens is also common. Late VAP has a worse prognosis when associated with MDR organisms. Gram-negative bacteria are involved in 50% to 80%, Gram-positive pathogens account for 20% to 30%.
Rebellón Sánchez et al. (2015).Systematic review.63 items.Gram-negative organisms are the main cause of VAP in general, resistant strains may be present in half of the cases and are related to increased mortality. The most common pathogens are: Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli and Acinetobacter baumannii. Staphylococcus aureus (28%), Pseudomonas aeruginosa (21.8%), Klebsiella species (9.8%), Escherichia species (6.9%), Acinetobacter species (6.8%), Enterobacter species (6.3%), Serratia species (3.5%), Stenotrophomonas maltophila (3.1%), Streptococcus pneumoniae (2.9%), Haemophilus influenza (2.7%).
Al Zahraa et al. (2021).Observational prospective study.60 patients.The most commonly isolated microorganisms were gram-negative bacilli. No infections based on Gram-positive isolates were recorded. Klebieslla pneumoniae (45%), Acinetobacter baumannii (12%), Moraxella group (8%), Pseudomonas aeruginosa (3%), Serratia species (2%), Enterobacter species (5%), Others (25%).
Luyt et al. (2018).Observational prospective study.465 patients from 27 ICUs in 9 European cities.The isolated microorganisms were mostly Gram-negative in 70% of the cases. Of the Gram-positive bacteria, Staphylococcus aureus was the most predominant. Staphylococcus aureus (13.9%), MRSA (6.2%), SASM (7.7%), Pseudomonas Aeruginosa (9.7%), Acinetobacter species (8.6%), Enterobacteriaceae (18.4%), Polymicrobial (13.7%), Unknown origin (13.1%), Others (8.2%).
Maricela de León Vida et al. (2019).Observational, retrospective and longitudinal study.200 patients.It is observed that the main causal germs of VAP were Klepsiella (24.5%) and Streptococcus pneumoniae (21.0%), followed by Enterobacter (18%), Escherichia coli (15%), Pseudomonas (12.5%), Acinetobacter (7%), unknown origin (2%).
Huang et al. (2018).Retrospective multicenter study.194 patients.The most commonly detected pathogens were Gram-negative (in more than 80% of cases), including P.aeruginosa (19.8%), A.baumannii (33.9%), K.pneumoniae (23.6%) and E. coli (3.4%). On the other hand, Staphylococcus aureus (7%) would be the most common gram-positive bacteria.
Vahid Shojaeimotlagh et al. (2020).Systematic review and meta-analysis.8 studies.The nurses achieved 48.31% of the total score on prevention measures. The lowest and highest scores were with respect to the frequency of changing humidifiers (15.13%) and the position of the patient (81.03%), respectively. The percentage of knowledge was higher in studies conducted in Asia than in Europe. Nursing staff achieved less than half of the total score on knowledge of preventive measures, indicating insufficient knowledge. Regular training courses and review of prevention guidelines could keep nurses’ knowledge up-to-date.
Hassan, & Wahsheh. (2017).Pre and post-intervention observational study.428 nurses.More than ¾ of the nurses had a low level of knowledge about pathophysiology, risk factors and preventive measures. This showed significant improvements in mean scores after program implementation. The main reasons for low knowledge may be due to lack of time and the lack of protocols followed in the units. Continuing health education programs regarding VAP and its prevention should be implemented in order to improve knowledge and adherence.
Pujante-Palazón et al. (2015).Descriptive, prospective, cross-sectional, and multicenter study.Three ICUs with a total of 98 professionalsThe best average score of the tests on knowledge of VAP was 6.33 out of 9. This study shows us some results that indicate a medium-high degree of knowledge compared to other studies carried out. There was also a trend between the years worked in the unit and the degree of knowledge about the pathology and its prevention, although this was not entirely significant (Pearson index 0.08).
Rafiei et al. (2020).Descriptive study.53 nurses.The average score for the items of the applied test was 4.4 +/− 1.6 out of 9 points in total. The highest score is obtained with 72.9% accuracy regarding the positioning of the patient in bed, and the lowest score with 1.9% regarding the change of humidifier. The mean knowledge score of the nurses who were familiar with the prevention guidelines and who had received training in MV care workshops was significantly higher than those who were not (5.1 vs. 4.1). The nurses who participated in this study had inadequate knowledge about the prevention of VAP, which highlights the need for training courses.
Miranda da Cruz et al. (2019).Longitudinal descriptive study.20 nurses.There was no relationship between the time worked in the ICU and the level of knowledge. 85% reported that they had a perception of good knowledge about the subject of study in question. The incidence of VAP during the study period was very low: 2 cases in 634 patients on MV. The preventive measures had more than 80% compliance, which represents a great adherence to them. However, more emphasis should be placed on the measurement of pneumo pressure and on position and asepsis when suctioning secretions. Nursing must consolidate and renew its knowledge.
Okgün Alcan et al. (2016).Observational and quasi-experimental study.54 nurses.Adherence to the care and prevention package improved after education from 10.8% to 89.8%. The VAP rate before the program was 15.91/1000 MV days and decreased to 8.5/1000 MV days after the educational program. The implementation of the VAP care and prevention package with education based on scientific evidence guidelines improved nursing staff adherence and decreased incidence.
R. Jam et al. (2017).Prospective observational study.54 nurses.Nurses’ knowledge of VAP prevention measures is not necessarily transferred to daily practice. In the population studied, the lack of application of these measures is not subject to a lack of knowledge or workload, but probably to contextual factors.
Ladbrook et al. (2021).Systematic review.10 items.The average hospital costs per case related to VAP are estimated to be between GBP 6000 and 22,000 (USD 7908 to 28,998) per patient in the UK and between USD 25,000 and 28,000 per patient in the USA. The US has identified that this adds an additional annual cost to the healthcare system of USD 1.45 billion.
Veliz Elena et al. (2017).Case-control study.18 cases.The excess expenditure used for the attention and care of these cases of VAP was USD 80,542 for the Chilean health system, which is equivalent to USD 4475 per case of VAP. The evidence indicates that hospital care for patients with VAP triples or doubles the health cost compared to those who do not present it, and may even be 7 times higher.
Luckraz Heyman et al. (2018).Propensity-matched cohort study.338 patients.Patients who developed AVN required more prolonged MV, more ventilatory support and a longer hospital stay. The cost of treating patients with VAP was significantly higher than treating patients without VAP, with an additional mean cost of £8829 (USD 11,637) per patient when the pneumonia episode occurred.
Sosa-Hernández, et al. (2019).Cross-sectional, analytical, retrospective and observational study.48 cases.The average cost of VAP per patient was estimated at USD 10,796.
Nanao et al. (2021).Retrospective study of cases and controls. The NAV incurred an additional cost of approximately USD 34,884 per case. The length of the hospital stay itself was the main factor contributing to these additional medical costs, generating an increase of about USD 9800.

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Applsci 12 10633 sch001 550
Scheme 1. Flow diagram.
Scheme 1. Flow diagram.
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Applsci 12 10633 g001 550
Figure 1. Results adherence and knowledge of nursing staff according to various studies [53,54,56,57,58].
Figure 1. Results adherence and knowledge of nursing staff according to various studies [53,54,56,57,58].
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Figure 2. Results average health cost per case of VAP [60,61,62,63,64].
Figure 2. Results average health cost per case of VAP [60,61,62,63,64].
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Table
Table 1. Databases consulted.
Table 1. Databases consulted.
Item CriteriaMedline/PubmedGoogle ScholarWOSScieloScopusTotal
Identified7544181220169
Duplicates1211651246
Title1110441140
Abstract119441038
Text complete11833934
Valid11733933
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MDPI and ACS Style

Astasio-Picado, Á.; Jiménez, F.J.P.; López-Sánchez, M.; Jurado-Palomo, J.; Zabala-Baños, M.d.C. Pneumonia Associated with Mechanical Ventilation: Management and Preventive Aspects. Appl. Sci. 2022, 12, 10633. https://doi.org/10.3390/app122010633

AMA Style

Astasio-Picado Á, Jiménez FJP, López-Sánchez M, Jurado-Palomo J, Zabala-Baños MdC. Pneumonia Associated with Mechanical Ventilation: Management and Preventive Aspects. Applied Sciences. 2022; 12(20):10633. https://doi.org/10.3390/app122010633

Chicago/Turabian Style

Astasio-Picado, Álvaro, Francisco Javier Perdones Jiménez, Miriam López-Sánchez, Jesús Jurado-Palomo, and María del Carmen Zabala-Baños. 2022. "Pneumonia Associated with Mechanical Ventilation: Management and Preventive Aspects" Applied Sciences 12, no. 20: 10633. https://doi.org/10.3390/app122010633

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