Ventilator Associated Pneumonia (VAP)

An intubated patient
An Intubated Patient on the Ventilator.

Ventilator Associated Pneumonia (VAP), also known as Ventilator Acquired Pneumonia, is pneumonia that develops 48 hours or longer after a patient is intubated.  Pneumonia that develops in the first 48 hours of a patient’s time on the ventilator, or was present when the patient was placed on the ventilator, is not considered ventilator-associated because the pneumonia was present prior to the ventilator being used.

Preventing Ventilator Associated Pneumonia

A patient can help prevent the ventilator acquired pneumonia by being in the best possible health prior to surgery.  This means not smoking before surgery, taking care of any dental issues that may be present and practicing excellent oral hygiene.  In general, making an effort to be in the best possible health by eating well, exercising and following instructions for the use of medications can improve health and prevent complications after surgery.

For example, a surgery patient with diabetes who checks their blood sugar regularly and takes their medication appropriately will be in better health than a diabetic who ignores their blood sugar.  Optimizing your health prior to surgery will only help improve your surgical outcome, whether pneumonia develops or not. 


Hospitals have developed protocols to aggressively prevent ventilator-dependent patients from developing pneumonia.

  You may hear caregivers talk about “VAP protocol” or a “VAP bundle” which means incorporating prevention in the plan of care. 

Protocols typically include:

  • Frequent mouth care:  Every two to four hours the mouth should be thoroughly cleaned to prevent bacteria from multiplying in the mouth and throat.
  • Positioning the bed with the head elevated to 30 to 45 degrees: Some patients, may not tolerate this position due to their injury or illness, but those who can tolerate having their head elevated will be less likely to develop pneumonia while on the ventilator.
  • Extubate as soon as possible: The best way to prevent ventilator associated pneumonia is to not be on the ventilator.  Removing the breathing tube and allowing the patient to breathe on their own as soon as possible is key to prevention.
  • Use disposable equipment or dedicate equipment to the individual patient to prevent cross contamination between patients.
  • Bathe the patient regularly: Keeping the patient clean, along with daily baths using skin appropriate cleansers known to decrease bacteria on the skin can decrease the transfer of bacteria from the skin to the mouth and lungs.
  • Aggressive hand cleansing should be performed prior to touching the ventilator tubing, providing oral care or suctioning.

Who Is at Risk For Ventilator-Associated Pneumonia

Individuals with chronic lung diseases, such as COPD and asthma are most likely to develop ventilator acquired pneumonia. The presence of a neurological issue, such as head trauma or recovering from neurosurgery, is also a known risk factor for pneumonia.

 Smokers and patients who have multiple chronic conditions are also at higher risk than the typical patient. 

Common Risk Factors 

Longer intubation: The longer the patient remains on a ventilator the higher the risk of VAP, 1 day on a ventilator is better than 4. Patients are at the highest risk during the first five days on a ventilator.

Reintubation: The patient is extubated to breathe on their own and then reintubated and placed back on the ventilator when they are unable to successfully meet their oxygen needs.

Tracheostomy: A surgically created opening in the neck, a tracheostomy is performed to prevent damage to the delicate tissues of the throat during a prolonged time on the ventilator.

  This opening is a known risk factor for infection as it provides another way for bacteria to enter.

Frequent circuit changes: This is when the tubing connecting the patient to the ventilator is changed.

Endotracheal cuff pressure is too low: The tube that goes into the patient’s throat is typically gently inflated to prevent air from leaking.  A tube that is under-inflated will allow air to leak, but will also allow oral secretions to leak into the lungs, a major risk factor for pneumonia.

Poor subglottic suctioning: If a patient is unable to have the area of the mouth and throat in front of the endotracheal tube cuff properly suctioned to remove secretions, there is a higher chance of the secretions entering the lungs.

Patient transport out of ICU: This typically means being taken, in a bed, for testing or a procedure, such as a CT scan.

NG tube in place: A nasogastric tube is a tube that is inserted into the nose and down into the esophagus to remove fluid with suction or to allow the administration of medications, fluids or tube feeding into the stomach. Occasionally a longer tube may be inserted in the same fashion but is fed deeper into the GI tract.  This type of tube typically referred to as an NJ tube (naso-jejeunal tube) also comes with an increased risk of pneumonia.​


When possible, a sputum culture and sensitivity is obtained to identify the bacteria causing the pneumonia infection.  Broad-spectrum antibiotics, which treat a wide range of types of bacteria, is typically given when pneumonia is diagnosed.  If the results of the sensitivity show that another antibiotic may be more effective, the antibiotic may later be changed for improved results.


Risk Factors For ICU Acquired Pneumonia.  JAMA.

Ventilator Associated Pneumonia in the ICU.  Critical Care.