most of the patients hospitalized in the intensive care unit ( icu ) due to acute 
 respiratory failure require endotracheal intubation and mechanical ventilation . one of the most common and serious complications 
 among mechanically ventilated patients is the risk of ventilator- associated pneumonia 
 ( vap ) . hospital acquired pneumonia is the second common hospital infection 
 after urinary tract infection and is often observed among the patients under 
 ventilation . incidence of pneumonia in the mechanically ventilated patients has been 
 estimated 9 - 27% . one study reported that the incidence of vap in general and intensive surgical units of 
 tehran , iran were 22.5% and 18.2% respectively . vap increases the treatment costs and mortality , and causes prolonged mechanical 
 ventilated and hospitalization in the icu .   considering high prevalence and numerous physiologic and economic effects of vap , nowadays , various interventions are suggested to prevent this 
 complication , including head elevation of 30 - 45 degree , suctioning of the mouth and 
 subgluteal space and regulating the pressure of cuff in the tracheal tube in the range of 
 20 - 30 cm h2o . one of the interventions that can reduce the incidence of vap is backrest elevation . in 
 the clinical guideline of disease control and prevention and clinical guideline of american 
 icu nursing association , it is recommended to elevate the backrest up to 30 - 45 degree among 
 the patients with a tracheal tube . the 
 results of a study showed that laying the patient in the supine position during the first 
 24hr of mechanical ventilation is indirectly associated with incidence of vap and its 
 mortality.another study showed that elevation of the patients backrest up to 45 
 degree , compared to supine position , significantly reduced the incidence of vap . meanwhile , a study showed that laying 
 patients backrest in 45 degree elevation did not resulted in a reduction of vap , compared 
 to 10 degree of elevation . another interventions that can diminish the vap is lowering the risk of oral secretions 
 aspiration . the results of a study 
 showed that continuous suctioning of oral secretions plays a key role in reduction of vap 
 and shortening the length of mechanical ventilation and hospitalization in the 
 icu . another study revealed that 
 removal of oral secretions prior to a position change could reduce the incidence of 
 vap . another nursing care that can reduce the aspiration of the secretions remaining in the 
 subgluteal space , is controlling and regulation of cuff pressure in the tracheal 
 tube . if the cuff leaks or has 
 inadequate pressure , the secretions over the cuff can leak to the airway and predispose the 
 patient to vap . if cuff pressure reaches less than 20 cm h2o , the 
 incidence of vap could significantly increase . the results of a study demonstrated that the 
 risk of vap increased by four folds in the pressure less than 20 cm 
 h2o .   in the icu ward of alzahra hospital in isfahan , oral and subgluteal space suctioning in 
 the mechanically ventilated patients is administrated every two hours , regardless of the 
 time of patients position change . there is no specific protocol to control and regulate the 
 cuff pressure , and the nurses regulate the cuff pressure in the different ranges . although 
 elevation of backrest is respected , there is no specific protocol for its degree and the 
 nurses regulate that differently . therefore , in the icus of alzahra hospital in isfahan , 
 none of these methods is conducted with a unique protocol now . there is no study that investigated the effect of simultaneous application of these three 
 methods on incidence of vap . therefore , the researcher investigated the effect of 
 simultaneous application of oral and sub gluteal space suctioning , elevation of backrest up 
 to 45 degree and preservation of cuff pressure of tracheal tube in the range of 25 cm 
 h2o on incidence of vap among the patients , mechanically ventilated in the 
 icus . this was a singleblinded clinical trial on patients undergoing mechanical ventilation in 
 the icu of alzahra hospital , isfahan , iran . the sample size was calculated using the 
 results of a study conducted by vincent . based on the results of vincent , and according to the type i error probability of 0.05 and 
 a power of 0.8 , the sample size was determined to be 32 patients for each group . convenience sampling method was performed for enrolling the participants . allocating the 
 subjects to the study and control groups an informed consent was obtained 
 from the participants , and for unconscious patients , the consent was obtained from their 
 relatives . inclusion criteria were age over 18 years , being under ventilation for more than 
 24 hours , having no pneumonia or respiratory infection ( at the time of entrance to hospital , 
 before intubation and the first 48 hours of intubation ) and the prohibition of backrest 
 elevation , ordered by the physician . exclusion criteria were parents refusal to continue 
 with the study , patients expiration before the end of study , being extubated before the end 
 of study , transfer to other wards or hospitals during study , and undergoing a surgery during 
 study .   in this study , the instrument for data collection consisted of two parts . the first part 
 included demographic and clinical information and the second part included modified 
 pulmonary infection clinical scale ( mpics ) . this is a standard scale including five criteria 
 of body temperature , pulmonary secretion , wbc , po2- fio2 ratio based on mmhg and a chest 
 x - ray . each sub- scale is scored 0 - 2 in this tool and the maximum score is 10 . the persian version 
 of modified pulmonary infection clinical scale was used in the present study . sabery et al . , 
 assessed the reliability of this scale through cronbach alpha with internal consistency of 
 0.91 . this scale was completed 
 before and on the third , fourth and fifth days of study at 8:00 o'clock by an 
 anesthesiologist . the anesthesiologist did not aware of that the subjects belonged to each 
 groups . firstly , the researcher explained the objectives and methodology of the study to hospital 
 administrators , anesthesiologists , nurses and authorities of intensive care units of 
 al - zahra hospital , isfahan , iran and obtained their consent . then the researcher attended in 
 these units every day ( from 7:00 to 19:00 o'clock ) and randomly allocated the patients who 
 met the inclusion criteria and had signed the consent form to study and control groups . in 
 the night shifts ( from 19:00 to 7:00 oclock ) , a trained nurse colleague followed the study 
 protocols . after random allocation of the subjects to experimental or control groups , the researcher 
 extracted all the demographic and clinical information of the patients and entered them in 
 the first section of instrument . before intervention , then , the 
 researcher administrated a scheduled upper respiratory care in the study group . this 
 intervention included oral sub gluteal space suctioning before each position change , 
 measuring and regulating cuff pressure of tracheal tube in the range of 25 cm h2o 
 ( twice a day at 8:00 and 20:00 oclock ) , and checking the backrest elevation at 45 degree by 
 use of a bevel ( twice a day at 8:00 and 20:00 oclock ) . the intervention started when the 
 consent was signed by each subject and carried out until fifth day . the subjects in the 
 control group underwent upper respiratory routine care of alzahra hospital . in the icu ward 
 of this hospital , oral and sub gluteal space suctioning in the mechanically ventilated 
 patients is administrated every two hours , regardless of the time of patients position 
 change . participation in this study was completely 
 voluntary and all patients signed the informed consent form . independent ttest was used to check subjects age homogeneity and chi - square test was used 
 for subjects homogeneity concerning sex , hospitalization cause , and medical history , 
 smoking history and immune system defects . chi - square test was adopted to compare frequency 
 of vap between intervention and control groups . in the present study , 72 subjects in the two groups of intervention ( n=35 ) and control 
 ( n=37 ) were studied . during the study , eight patients ( three patient in the intervention and 
 five patient in the control group ) finally , 
 64 subjects in two groups of intervention ( n=32 ) and control ( n=32 ) were studied . the mean ( sd ) of participants age and duration of intubation in the intervention and 
 control groups were 50.96 ( 18.7 ) vs. 49.50 ( 17.9 ) years and 3.12 ( 0.8 ) vs. 3.12 ( 0.9 ) days , 
 respectively . of the participants , the participants causes 
 of hospitalization were internal ( 29% ) , surgical ( 31% ) and internal  surgical ( 40% ) problems . majority of the subjects had history of non- pulmonary diseases ( 45% ) and were non- smoker 
 ( 70% ) . the results of independent ttest and chi - square test showed no significant differences in 
 age , gender , duration of intubation , cause of admission , disease history , history of smoking 
 and immune system defect between the two groups ( table 
 1 ) ( p > 0.05 ) . table two shows the frequency of vap in the third , fourth and fifth days of study in the 
 both intervention and control groups . according to this table , by increasing the duration of 
 intubation , the frequency of vap increased in the both groups . the results of the chi - square test for between - groups comparison showed that on the third 
 day of study , there was no significant difference between the study groups in terms of the 
 vap ( p > 0.05 ) . meanwhile , on the fourth and fifth day of study the frequency of vap was 
 significantly lower in the intervention group , compared to control group ( table 2 ) ( p < 0.05 ) . the results of this study indicated that administration of upper respiratory care 
 including regulating the cuff pressure in the range of 25 cm h2o , preservation of backrest 
 elevation up to 45 degree and oral and subgluteal suctioning before patients position 
 change reduced the incidence of vap . previous studies have not investigated the simultaneous 
 and cumulative effect of these variables on vap , but some studies investigated the effect of 
 these interventions on vap separately .   consistent with our study , drakulovic et al . , showed that the elevation of patients 
 backrest up to 45 degree significantly decreased the incidence of vap , compared to supine 
 position . chow et al . , also showed 
 that continuous oral suctioning has led to reduction of vap . furthermore , rello et al . showed that regulation of cuff 
 pressure over 20 cmh2o has led to reduction of vap . our results also showed that the incidence of vap was similar until the third day of study 
 in the both intervention and control groups . however , on the fourth and fifth days of study , 
 the incidence of vap was significantly lower in the intervention group , compared to control 
 group . these findings reveal that in the long term period , conducting a designed upper 
 respiratory cares can reduce the incidence of vap . salimi et al . , concluded that standardization of nursing cares in the long term ( 4 months ) 
 has reduced the incidence of vap from 17.18 to 3.48% . grap et al . , also concluded that in the long term period ( seven days ) , 
 the risk of vap is higher among the patients with backrest elevation of lesser than 30 
 degree . in addition , chao et al . , 
 showed that oral suctioning before position change , in the long term , could reduce the 
 incidence of vap by 32% .   a reduction in the incidence of vap , have reported from airway care protocols such as 
 regulating the cuff pressure about 25 cm h2o , preservation of backrest elevation up to 45 
 degree and oral and subgluteal suctioning before each position change seems to be associated 
 with patients secretions aspiration . therefore , nurses can reduce the incidence of vap through performing of such an 
 interventions in addition to other interventions . regulating the tracheal tube cuff pressure about 25 cmh2o , preservation of 
 backrest elevation up to 45 degree and oral and sub gluteal space suctioning before each 
 position change can reduce the incidence of vap . therefore , nurses are recommended to use 
 this method for prevention of mechanically ventilated pneumonia . appreciation goes to the research deputy of isfahan university of medical sciences and the 
 hardworking staff of the icus of isfahan alzahra hospital who helped us in conducting this 
 study .
introduction : ventilator - associated pneumonia is a common 
 complication of mechanical ventilation . 
 this study aimed to evaluate the effect of 
 designed respiratory care program on incidence of ventilator - associated pneumonia ( vap ) in 
 the mechanically ventilated patient . 
 methods : in this clinical trial , 64 patients were selected 
 among those who had undergone mechanical ventilation in the icu of alzahra hospital , 
 isfahan , iran , using convenience sampling method . 
 the subjects were randomly allocated to 
 intervention and control groups . in the intervention group an upper respiratory care 
 program and in the control group , routine cares were done . modified clinical pulmonary 
 infection questionnaire was completed before and on the third , fourth and fifth day of 
 study . 
 data were analyzed by chi - square and independent t - test through spss ver.13 . 
 results : the results of this study showed that until the 
 third day of study , the incidence of vap was similar in the both groups . 
 however , on the 
 fifth day of study , the incidence of vap in the intervention group was significantly lower 
 than control group . 
 conclusion : the results of this study showed that an upper 
 respiratory care program reduced the incidence of vap . 
 therefore , nurses are recommended 
 to perform this program for prevention of vap .