VAP, not on my WATCH !!!
France Ellyson
ANM, MNH ICU
Kuwait 2014
• http://www.youtube.com/watch?v=RueE4
rMU
Introduction
Mechanical ventilator
is one of the most
important life saving
devices used in
conditions like:
• Respiratory failure
• Protection of airway
• Head injury
• Postoperative
• Shock
What is Ventilator Associated
Pneumonia?
• A nosocomial pneumonia associated with
mechanical ventilation (either Endotracheal
tube or Tracheostomy) that develops within
48 hours or more of hospital admission and
which was not present at time of admission.
• Now considered a PREVENTABLE
HEALTHCARE ERROR
National institute of health excellence (NICE) -2007
center for disease control and prevention
What is VAP?
• Pneumonia that occurs at least 2 days after a
patient is intubated (CDC GUIDELINES)
• The presence of the ET-tubes leads to VAP
(not the ventilator)
• VAP rate increases with the # of days on
mechanical ventilation
• Mortality varies according to the type of
organisms
• Multi-resistant organisms have a higher
mortality
Epidemiology
• Hospital acquired pneumonia (HAP) is the
second most common hospital infection.
• VAP is the most common Intensive Care
Unit (ICU) infection.
• 90% of all nosocomial infections occuring in
ventilated patients are pneumonias.
• Causes more death than any of the other
healthcare associated infection
Incidence
• VAP occurs in 10-20% of all ventilated patients
Crit Care Clin (2002)
• Incidence increases with duration of MV:
3%/day for first 5 days, 2%/day for 6-10 days
and 1%/day after 10 days.
• The incidence of VAP is highest in the following
groups: Trauma, burns, neurosurgical post-op
pts
• Mortality rate is 37% and 43% with antibiotic
resistant organism
Critical Care Societies Collaborative (CCSCs)
Incidence Cont….
• Increases ventilatory support
requirements and ICU stay by 4.3 days
• Increases hospital LOS (length of stay) by
4 to 9 days
• Increases medical cost ($5,000 to
$40,000 per VAP)
Critical Care Medicine
2005;33:2184-93
Causative Organisms:
Early onset
• Hemophilus influenza
• Streptococcus
pneumoniae
• Staphylococcus aureus
(methicillin sensitive)
• Eschrichia coli
• Klebsiella
Late onset
• Pseudomonas
aeruginosa
• Acinetobacter
• Staphylococcus
aureus (methicillin
resistant)
How is the pneumonia happening?
• Most plausible mechanism and source:
– Leakage around the ETT cuff (primary route)…
aspiration of bacteria
– High rate of the oropharyngeal or
tracheobronchial colonization (gram neg
bacilli)
– Bacteria from the tongue
– Bacteria from environment: caregivers’ hand,
air, water, dust
– Contaminated equipment (ventilator tubing,
aerosol, etc.)
– Suctioning equipment
Risk Factors: Host Related
•
•
•
•
•
•
Medical / surgical disease
Immunosuppression
Malnutrition (Alb<2.2g/dl)
Advanced age
Pt’s position (supine)
LOC – impaired LOC,
delirium, coma
• Medications – sedation,
steroids, previous
antibiotic use, NM
blockers
• Number of intubationsreintubations
Risk Factors: Device Related
• Mechanically ventilated
with ETT or
Tracheostomy tube
• Prolonged MV - MV >
48 hours
• Number of intubations,
reintubations
• NGT or Orogastric tube
• Use of humidifier
Risk Factors:
Health Care Personnel Related
• Improper hand
washing
• Failure to change
gloves between
contacts with pts
• Failure to wear
personal protective
equipment when
required
Pathogenesis
Bacteria enter the lower respiratory tract
via following pathways:
• Aspiration of organisms from the
oropharynx and GI tract (most common
cause)
• Direct inoculation
• Inhalation of bacteria
Aspiration
ETT/T
• Holds vocal cords
open
• Predispose pt to
micro and macro
aspiration of
colonized bacteria
from oropharynx
• Leakage of
secretions
containing bacteria
around ETT cuff
NGT/OGT
• Interrupts gastroesophageal sphincter
leading to GI reflux and
aspiration
• Increase oropharyngeal
colonization and
stagnation of
oropharyngeal and nasal
secretions
A New Streamlined Surveillance
Definition for VentilatorAssociated Pneumonia
Critical Care Med 2012 vol.40, no.1
Any one of the following:
• NO CONSENSUS
AMONG
PHYSICIANS!!!
How do we Diagnose? 2-1-2
Radiologic evidence
X 2 Consecutive
days
• New, progressive
or persistent
infiltrate
• Consolidation,
opacity or
cavitation
How do we diagnose? 2-1-2
Clinical Signs:
At least 1of the
following:
• Fever > 38 °C with
no other recognized
cause
• Leukopenia (<4,000
WBC/mm3) or
leukocytosis
(>12,000
WBC/mm3)
How do we Diagnose? 2-1-2
At least 2 of the following:
• New onset of purulent
sputum or change in
character of secretions
• New onset or worsening
cough, dyspnea or
tachypnea
• Rales or bronchial sounds
• Worsening gas exchange
(decreased sats, increased
oxygen requirements)
Treatment Protocol
• Start when VAP is suspected
• Do not delay
• Individualized to institution – Hospital
epidemiologic data, drug cost and
availability
• Individualized to pt - Early onset vs Late
onset of VAP, prior antibiotic use,
underlying disease, renal, liver, etc
• Surveillance cultures
Duration of Treatment
• Standard duration 7-14 days
• Longer duration > 14-21 days risk of toxicity
and resistance
• Shorter < 7 days risk of recurrence
• Depends on severity
• Isolation of microorganism
Prevention
• Specific practices have been shown to
decrease VAP
• Strong evidence that a collaborative,
multidisciplinary approach incorporating
many interventions is paramount
• Intensive education directed at nurse and
respiratory care practitioners resulted in a
57% decrease in VAO
Crit Care Med (2002)
The VAP Bundle
BUNDLE
• “Group of evidence
based interventions
that whenever
implemented
together result in
better outcomes”
Introduction of VAP BUNDLE
1. Elevation of HOB to between 30-45°
2. Daily sedative interruption and daily
assessment of readiness to extubate
3. The utilization of endotracheal tubes with
subglottic secretion drainage (Not at MNH
yet)
4. Stress ulcer disease prophylaxis – including
initiation of safe enteral nutrition within 2448 hours of ICU admission
5. IN 2010 5TH COMPONENT of Daily oral care
and decontamination with Chlorhexidine
Crit.Care 2012 vol.40, no.1
Additional Evidence-Based
Component of Care:
HANDWASHING
• Single most important
and ( easiest!!)
method for reducing
the transmission of
pathogens
• Use of waterless
antiseptic
preparations is
acceptable and may
increase compliance
HOB 30-45°
• HOB 30-45° unless
contraindicated

• Especially
recommended for
Neuro population
• To prevent aspiration
during enteral feeding
Daily sedative interruption and daily
assessment of readiness to extubate
OVERSEDATION predisposes pts to:
•
•
•
•
•
Thromboemboli
Pressure ulcers
Gastric regurgitation and aspiration
VAP
Sepsis
Daily sedative interruption and daily
assessment of readiness to extubate
OVERSEDATION predisposes pts to:
•
•
•
•
Difficulty in monitoring neuro status
Increased use of diagnostic procedures
Increased ventilator days
Prolonged ICU and Hospital stay
Daily Wake-up
• Every pt must be awakened
daily unless contraindicated
• Daily weaning assessments
reduce the duration of MV
• If pt becomes symptomatic
– rebolus and restart
infusion at lower dose than
original dose
• Goal is to decrease
sedation
Stress Ulcer Prophylaxis
• Sucralfate, H2
receptor blocker and
proton pump
inhibitor – increases
gastric ph and
minimize bacterial
colonization and
reduces risk of VAP
Enteral Feedings
• Initiation of safe
enteral nutrition
within 24-48 hours
of ICU admission
• Early initiation
decreases bacterial
colonization
• HOB 30-45°
• Routinely + PRN
verification tube
placement
Additional Evidence-Based
Component of Care:
• Deep venous
thrombosis (DVT)
prophylaxis (unless
contraindicated)
– TED stockings
– SCD machine
– Heparin S/C
Deep venous Thrombosis Prophylaxis
and early mobility practices
• Pt turning Q 2hours
increase pulmonary
drainage and
decreases risk VAP
• Early mobilization
Daily Oral care
• Oral assessment Q shift
• Brushing teeth, tongue and
gums with a soft toothbrush
(minimally twice daily)
• Moisturizing agent for mouth
• Antiseptic rinse
• Swabs are not effective at
removing plaques
• Chlorhexidine
decontamination of mouth
• Routine suctioning of mouth to
manage oral secretions and
minimize risk of aspiration
Sage Oral Care Products
• http://www.youtube.com/watch?v=MYO_Md
dtYNs
Mouthcare
• Using chlorhexidine
gluconate 0.12%
(Peridex) solution
every 6-12 hours to
perform oral care,
according to your
protocol
• solution is used to
rinse the patients’
mouth.
ET Tube Care
• Cuff pressure (between 20-30cm H2O)
• Oral intubation preferred
• Continuous or intermittent sub-glottic
aspiration
• Avoid unnecessary disconnection of MV
circuit
• Open vs close suctioning… benefits is not
demonstrated yet
Prevent micro-aspiration of secretions
• 100-150ml of oral
secretion can
accumulate in patient
mouth in 24hrs
• Mouth can colonize as
quickly as 24hr after
admission
• Intermittent and
continuous subglottic
suctioning
• Suctioning of the mouth
before position change
Suctionning of Oral Secretions
• Suction oropharyngeal secretions Q
2hours, before repositionning, before
suctionning ETT, before mobilizing
patient and PRN
• Gently follow tongue to suction back of
throat
• Use yankauer suction
Suctioning
Oral suction devices
(Yankauer)
• Follow policy for
use and storage
• ?Harbor potentially
pathogenic
bacteria within 24
hours
• Date and change Q
day
• Rinse with sterile
water after each
use
• Allow to air dry
Subglottal Suctioning
Should be done using a
14 French sterile
suction catheter
• Prior to ETT
suctionning
• Prior to pt change of
position
• Prior to extubation
* Continuous subglottic
ETT with dedicated
lumen above cuff may
reduce risk of VAP
Prevent contamination of equipment
• Ventilator tubing
• Heat and moisture exchangers (green
filters) are preferred over humidifiers (CDC
B-II)
• Sterile suctioning
• Be careful with the tubing of the ventilator
when you suction patient…
• Remove contaminated condensate from
ventilator circuit (CDC, A-II)
Summary
• Nosocomial pneumonia and especially VAP are
the most frequent infectious complications in
the ICU, and they significantly contribute to
morbidity and mortality
• VAP is an important determinant of ICU and
Hospital lengths of stay and healthcare costs
• No standard to diagnose
• Several simple preventative measures (VAP
bundle) and timely initiation of appropriate
antibiotics ensure better outcomes in pts with
VAP
• http://www.youtube.com/watch?v=Ehi2Vt
dRc
References
National Guideline Clearinghouse (current). Guideline Summary NGC-6634:
Prevention of ventilator-associated pneumonia. Retrieved from:
http://files.imd.com/medinfo/material/f97/4eb0b88d44aece1112f7bf97/4eb0b8a944
aece1112f7bf9a.pdf
Niel-Weise, B. & all. (2011). An evidence-based recommendation on bed head
elevation for mechanically ventilated patients. Critical Care 2011, 15:R111.
Postma, D.F., Sankatsing, S.U.C., Thijsen, S.F.T. & Enderman, H. (2012). Effetcs
of chlorhexidine oral decomtamination on respiratory colonization during
mechanical ventilation in intensive care unit patients. Infection Control
and Hospital Epidemiology, vol 33 no.5, pp.527-530.
Safer Healthcare now (2012). Ventilator associated pneumonia. Retrived from:
http://www.saferhealthcarenow.ca/en/interventions/vap/pages/default.as
px
Safer Healthcare now (2012). Getting Started Kit. Retrieved from
http://www.saferhealthcarenow.ca/EN/Interventions/VAP/Documents/VA
P%20Getting%20Started%20Kit.pdf
References
Alhazzani, W. & all. (2013) Tooth brushing for critically ill mechanically ventilated patients: a
systematic review and meta-analysis of randomized trials evaluating ventilatorassociated pneumonia. DOI: 10.1097/ccm.0b013e3182742d45
Center for Disease Control and prevention(2011). Improving Surveillance for VentilatorAssociated Events in Adults. Obtain from MUHC Infection Control Departement.
Chan, E.Y., Ruest, A., Omeade, M. & Cook, D.J (2007). Oral decontamination for prevention of
pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ,
doi: 10.1136/bmj.39136.528160.BE
Fagon, J-Y. (2011). Biological markers and diagnosis of ventilator-assocaited pneumonia.
Critical Care 20111, 15:130.
Koenig, S.M. & Truwit, J.D. (2006) Ventilator-assocaited pneumonia: diagnosis, treatment, and
prevention. Clinical Microbiology Reviews, doi: 10.1123/CMR.00051-05
Hillier B. Wilson C. Chamberlain D. King L. (2013). Preventing ventilator-associated
pneumonia through oral care, product selection, and application method: a literature
review. AACN Advanced Critical Care. 24(1):38-58.
Insitute for Healthcare Improvement (2011). IHI ventilator bundle: daily oral care with
chlorhexidine. Retrieved from
http://www.ihi.org/knowledge/pages/changes/dailyoralcarewithchlorhexidine.aspx