title: Ventilator-associated pneumonia: the potential critical role of emergency medicine in prevention.
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).
  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.
  
  
  CONCLUSIONS
  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 H(2)O.
authors.affiliation: School of Nursing, Virginia Commonwealth University, Richmond, Virginia 23219, USA.
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Grap
authors.forename: Cindy L
authors.initials: CL
authors.lastname: Munro
authors.forename: Takeshi
authors.initials: T
authors.lastname: Unoki
authors.forename: V Anne
authors.initials: VA
authors.lastname: Hamilton
authors.forename: Kevin R
authors.initials: KR
authors.lastname: Ward
mesh_terms: D055416:Evidence-Based Emergency Medicine; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods; D053717:Pneumonia, Ventilator-Associated / Q000209:etiology / Q000517:prevention & control*; D011187:Posture; D012307:Risk Factors; D012308:Risk Management / Q000379:methods