Spotlight on Non-Ventilator-Associated Hospital-Acquired Pneumonia

Pneumonia prevention interventions such as proper oral care, head-of-bed elevation, and incentive spirometry, are not being provided to most patients outside the ICU, leading to greater than two-thirds of hospital-acquired pneumonia.

Nosocomial infections affect an estimated 1.7 million hospitalized patients each year in the United States, resulting in 98,000 deaths.1 Although ventilator-associated hospital-acquired pneumonia (VHAP) accounts for a significant portion of these cases, studies suggest that non-ventilator-associated HAP (NVHAP) accounts for roughly two-thirds of cases.2

Compared with VHAP, NVHAP has been linked to a similar or greater mortality risk, significant morbidity, and higher cost.3-5 However, NVHAP is not subject to the same tracking, reporting, and prevention standards that apply to VHAP. In a growing number of studies and other scholarly articles, experts are increasingly calling for greater vigilance and prevention efforts for NVHAP.4

Potential Causes of NVHAP

Multiple variables may lead to the development of NVHAP, according to Sharon E. Bryant, DNP, RN, ACNP-BC, assistant professor of nursing at Vanderbilt University School of Nursing in Nashville, Tennessee. “For the most part, patients who are not ventilated do not reside in the ICU and therefore have a lower acuity level, resulting in less interaction with nursing staff,” she said in an interview.

In a 2018 study, Baker and Quinn examined data pertaining to 1300 NVHAP patients from 21 hospitals in the US and found that 70.8% of these infections were acquired outside the ICU.5 The results also showed that pneumonia prevention interventions including proper oral care, head-of-bed elevation, and incentive spirometry were not provided to most of these patients, with some variation between hospitals.

“Nurse-led patient interventions such as incentive spirometry and Turning, Coughing, and Deep Breathing (TCDB) maneuvers may not be followed up due to an assumption that they are being done by the coherent patient — and there is a difference between encouraging these interventions and ensuring they are performed,” Dr Bryant said. Patients and family members may hide dysphagia in hopes of earlier discharge and patients may not achieve adequate mobilization on their own.

Surveillance Methods

“Identification of NVHAP requires routine surveillance in the way of vital signs and nursing assessments, with timely reporting of HAP symptoms,” Dr Bryant stated.

Noting the resource intensiveness of conducting manual surveillance of NVHAP, researchers at the University Hospital Zurich developed and tested a semi-automated NVHAP surveillance system using an algorithm to distinguish “at-risk” patients from “not-at-risk” patients. Those identified as “at-risk” underwent subsequent manual screening.6

In a study, the algorithm reduced manual screening by 93.8% and demonstrated a sensitivity, negative predictive value, and accuracy of 97.5%, 99.2%, and 99.4%, respectively.6

Identification of comorbid conditions that may predispose patients to the development of HAP is also important, Dr Bryant added. A 2019 study found that male sex and older age were associated with an increased risk of non-device-associated pneumonia, chronic bronchitis, and emphysema (hazard ratio [HR], 2.07; 95% CI, 1.40–3.06); congestive heart failure (HR, 1.48; 95% CI, 1.07–2.05); and paralysis (HR, 1.72; 95% CI, 1.09–2.73). Also at increased risk were those who were immunosuppressed (HR, 1.54; 95% CI, 1.18–2.00); and those admitted to the ICU (HR, 1.49; 95% CI, 1.06–2.09).7

Preventive Measures

Oral care, early mobility, and pulmonary hygiene are among the key recommendations to prevent NVHAP. “Aggressive pulmonary toileting with incentive spirometer and TCDB prevents secretion pooling and allows for thoracic expansion, allowing alveoli to remain open for maximum V/Q [ventilation/perfusion] match,” Dr Bryant explained. In addition, minimizing the use of “opioids and other sedative medications will help prevent aspiration or central hypoventilation syndromes.”

In a 2020 study, Lacerna et al demonstrated the effectiveness of such measures in preventing NVHAP in high-risk patients across 21 hospitals. After the interventions were implemented, there were significant reductions in HAP rates (from 5.92 to 1.79 per 1,000 admissions; P =.0031), mortality (from 4.37 to 1.24 per 100,000 members), and broad-spectrum antibiotic use between 2012 and 2018.8

Remaining Needs

In June 2021, experts from various US public health agencies and professional associations, along with industry partners and members of academia (together comprising the National Organization to Prevent Hospital-Acquired Pneumonia), issued a call to action to increase awareness and action regarding NVHAP.4 Their aims are to launch a national conversation about the topic, improve education about NVHAP prevention for patients and health care professionals, gain support from insurers and health care systems to support such efforts, and encourage new research on NVHAP surveillance and prevention strategies.

The authors point to a need to elucidate the pathophysiology of NVHAP, clarify associated economic costs, develop more effective surveillance methods, and identify and test various prevention strategies.4

“Documentation of HAP rates in patients with specific comorbidities would be helpful in identifying which patients are at highest risk of developing HAP,” Dr Bryant said. Because “we know that oral care, early mobility, effective GERD management, and aggressive pulmonary toilet play a large role in HAP development, knowing the degree to which these factors and comorbidities increase HAP risk could be used to develop population-specific tool,” she concluded.


1. Haque M, Sartelli M, McKimm J, Abu Bakar M. Health care-associated infections – an overviewInfect Drug Resist. 2018;11:2321-2333. doi:10.2147/IDR.S177247

2. Wolfensberger A, Clack L, von Felten S, et al. Implementation and evaluation of a care bundle for prevention of non-ventilator-associated hospital-acquired pneumonia (nvHAP) – a mixed-methods study protocol for a hybrid type 2 effectiveness-implementation trial. BMC Infect Dis. 2020;20(1):603. doi:10.1186/s12879-020-05271-5

3. Mitchell BG, Russo PL, Cheng AC, et al. Strategies to reduce non-ventilator-associated hospital-acquired pneumonia: A systematic review. Infect Dis Health. 2019;24(4):229-239. doi:10.1016/j.idh.2019.06.002

4. Munro SC, Baker D, Giuliano KK, et al. Nonventilator hospital-acquired pneumonia: A call to action. Infect Control Hosp Epidemiol. 2021:1-6. doi:10.1017/ice.2021.239

5. Baker D, Quinn B. Hospital acquired pneumonia prevention initiative-2: incidence of nonventilator hospital-acquired pneumonia in the United States. Am J Infect Control. 2018;46(1):2-7. doi:10.1016/j.ajic.2017.08.036

6. Wolfensberger A, Jakob W, Faes Hesse M, et al. Development and validation of a semi-automated surveillance system-lowering the fruit for non-ventilator-associated hospital-acquired pneumonia (nvHAP) prevention. Clin Microbiol Infect. 2019;25(11):1428.e7-1428.e13. doi:10.1016/j.cmi.2019.03.019

7. Strassle PD, Sickbert-Bennett EE, Klompas M, et al. Incidence and risk factors of non-device-associated pneumonia in an acute-care hospital. Infect Control Hosp Epidemiol. 2020;41(1):73-79. doi:10.1017/ice.2019.300

8. Lacerna CC, Patey D, Block L, et al. A successful program preventing nonventilator hospital-acquired pneumonia in a large hospital system. Infect Control Hosp Epidemiol. 2020;41(5):547-552. doi:10.1017/ice.2019.368

This article originally appeared on Clinical Advisor