VENTILATOR ASSOCIATED

PNEUMONIA

DR. C S ARAVIND (IST YEAR PG RESIDENT)

UNIT CHIEF – DR. ANBARASU M.D

SYNOPSIS

INTRODUCTION- WAT IS VAP?

FACTS AND FIGURES

WHAT ARE THE TYPES OF VAP ?

WHO ARE AT RISK ?

HOW DO THE ORGANISMS CAUSE VAP ?

IS IT BACTERIA / VIRUS / FUNGUS- IF SO , WHAT ARE THE POSSIBLE

ORGANISM ?

HOW TO DIAGNOSE VAP ?

HOW TO TREAT ?

IS THERE ANY PREVENTIVE STRATEGY ?

CONCLUSION

INTRODUCTION- WHAT IS VAP

PNEUMONIA THAT

OCCURS 48-72 HRS

AFTER

ENDOTRACHEAL

INTUBATION

FACTS AND FIGURES

½ OF HAP

2ND MC CAUSE OF NOSOCOMIAL

INFECTION IN ICU

MC CAUSE OF NOSOCOMIAL INFECTION

IN VENTILATOR BOUND PATIENTS

MORALITY RATE IS HIGHER IN PATIENT

OF TRAUMA, BURNS, POST OP

60- 70 % MORTALITY IN PATIENTS OF

PSEUDOMONAS AND ACINOBACTOR

WHEN IS THE VAP MOST NOTORIOUS

FIRST 5 DAYS (RISK-3%)

MEAN DURATION - 3.3 day from the day

of ET intubation

5TH TO 10TH DAY (RISK 2%)

THEREAFTER 1%

WHEN IS THE VAP MOST NOTORIOUS

FIRST 5 DAYS (RISK-3%)

MEAN DURATION - 3.3 day from the day

of ET intubation

5TH TO 10TH DAY (RISK 2%)

THEREAFTER 1%

WHAT PERCENT OF PATIENTS WITH VAP DIE

CRUDE MORTALITY IS AROUND 60-70%

ATTRIBUTABLE MORTALITY – 33-50%

Latest lancet 2013 trial on 6284 pts from 24 studies - attributable mortality to 9-13 %

EARLY ONSET VS LATE ONSET

EARLY ONSET VAP

<4 D

LESS VIRULENT

BUGS

COMMUNITY AQUIRED

AB SENSITIVE

LATE ONSET VAP

>4 D

MORE VIRULENT

HOSPITAL ACQUIRED

MDR

WHO ARE AT RISK

INDEPENDENT RISK FACTORS

VAP

MALE SEX

UNDERLYING DISEASE

TRAUMA

RISK FACTORS

HOST RELATED Medical /surgical disease, Immunosuprssion, Malnutrition (Alb<2.2g/dl ), Advanced age, Supine position, Level of conciousness, Medication-NMB, sedation, steroids, Previous antibiotic use

DEVICE RELATED

MV with ETT or TRACHEOSTOMY TUBE , MV>48 hrs, Reintubations, NGT or Oro- gastric tube, Use of Humidifier

HEALTHCARE PERSONNEL RELATED

Improper hand washing, Failure to change gloves and use mask gown when ever required .

RISK FACTORS (CONT.)

HOST RELATED:

-UNDERLYING MEDICAL CONDITIONS-COPD, OBESITY, ARDS, GERD, BURN,

TRAUMA, MODS ETC--

-IMMUNOSUPPRESSION, MALNUTRITION(S.ALBUMIN<2.2G/DL)

-ADVANCED AGE

-PATIENTS’ BODY POSITION

-LEVEL OF CONSCIOUSNESS- IMPAIRED LOC, DELIRIUM, COMA.

-NUMBER OF INTUBATIONS-REINTUBATIONS

-MEDICATIONS (ANTIBIOTICS, SEDATION, NM BLOCKERS)

RISK FACTORS (CONT.)

Device related:

- MV with Endotracheal tube, trcheostomy

-Prolonged MV

-Number of intubations- reintubation

-Use of humidifier

-Nasogastric or orogastric tubes

Personnel related:

-Improper hand washing

-Failure to change gloves between contacts with pts

-Not wearing personal protective equipment when antibiotic resistant bacteria have been identified.

BJMP jun2009: vol.2,nub.2, 16-19. & Am.jour of Criti care nurse 2007; 27:32-39

HOW DO THE ORGANISM GET IN?

HOW DO THE ORGANISM GET IN (CONT)

MICROASPIRATION

BIOFILM

TRICKLING AROUND THE CUFF

IMPAIRED MUCOCILIARY CLEARANCE

POSITIVE PRESSURE FROM VENTILATOR

WHAT ARE THE BUGS CAUSING VAP ?

EARLY ONSET

STREP. PNEUMONIAE

H. INFLEUNZA

MSSA

A/B SENSITIVE GRAM NEGATIVE RODS

LATE ONSET

PSEUDOMONAS

MRSA

ESBL RODS

ACINOBACTER

HOW TO DIAGNOSE VAP ?

NO UNVERSALLY ACCEPTED GOLD

STANDARD DIAGNOSTIC CRITERIA!!!!!

DIAGNOSIS

CLINICAL

MICROBIOLOGICAL

RADIOLOGICAL

WHAT IS CPIS SCORE

CLINICAL PULMONARY INFECTION

SCORE – by johanson et al (213 pts)

Clinical, physiological, microbiological,

radiographic evidence to predict the presence

or absence of VAP

- Score of 6 or more- consistent with diagnosis

DRAWBACK- poor sensitivity n specificity

WHAT IS CPIS SCORE

WHAT IS CPIS SCORE

MICROBIOLOGICAL DIAGNOSIS

ATS/IDSA

QUALITATIVE

CLINICAL CRITERIA

QUANTITATIVE

ENDOTRACHEAL ASPIRATE

-BAL

-MINI BAL

- PROTEECTED SPECIMEN BRUSH

CLINICAL CRITERIA VS BACTERIOLOGICAL

CRITERIA- WHICH IS BETTER?????

- ATS/ IDSA GUIDELINES CLAIMS THAT 14- DAY MORTALITY WAS LESS AS COMPARED TO CLINICAL CRITERIA

- BUT RECENT CANADIAN CLINICAL TRIALS ON 740 SUSPECTED VAP AND

- COCHRANE METAANALYSIS OF 1367 PTS PROVED THERE IS NO DIFFERENCE

RADIOLOGICAL MIMICS OF PNEUMONIA IN

ICU PATIENTS

CHEMICAL PNEUMONITIS

ATLECTASIS

CHF

ARDS

PLEURAL EFFUSION

INTRA-ALVEOLAR HG

RADIOLOGIC DIAGNOSIS

INFILTRATES

SOLITARY DIFFUSE NEW INFILTRATES

RADIOLOGICAL EVIDENCE OF PNEUMONIA

THINK BEFORE

LABELLING IT

AS VAP!!

RADIOLIGICAL EVIDENCE

IF X RAYS ARE NOT A GOOD PREDICTOR

OF VAP ,,,

THEN WAT IS IT USED FOR

‘’’

RADIOLIGICAL EVIDENCE

ANS. It is used to rule out vap. (what else do u

want ?)

Meta-analysis by KLOMPAS ET AL

VERY STRONG NEGATIVE

PREDICTIVE VALUE

HOW WILL U TREAT VAP?

BEFORE CHOOSING ANTIBIOTIC, keep in

mind on the following issues

RISK FACTORS OF THE PATIENT

WAS IT EARLY OR LATE ONSET

VIRULENCE OF ORGANISM

ANTIBIOTIC RESISTANCE

COST

HOW WILL U TREAT VAP?

CHOICE OF ANTIBIOTIC

RISK FACTORS for DRUG RESISTANCE

WHAT IF CPIS SCORE DOESN’T IMPROVE

CPIS SCORE <6 FOR MORE THAN 3 DAYS

CONSIDER ALTERNATE DIAGNOSIS

OR CONSIDER FUNGAL OR VIRAL

INFECTIONS

TREATMENT FAILURE

HOW CAN WE PREVENT VAP?

Specific practices have been shown to decrease VAP

Strong evidence that a collaborative, multidisciplinary approach incorporating many interventions is paramount

Intensive education directed at nurses and respiratory care practitioners resulted in a 57% decrease in VAP

Crit Care Med (2002)

Conventional Infection control Aproach

•DESIGN OF ICU-

Adequate space, lighting, proper function of ventilatory system, facilities

for hand washing, Isolation room.

•STAFFING-

Education, Adequate number, quality, importance of personal cleanliness and

attention to asceptic procedures.

•PERIODICAL BACTERIAL MONITORING POLICY.

• SPECIFIC PROPHYLAXIS- Use Gloves, Gown, Mask.

Use of NIPPV

Minimize duration of MV, checking daily for readiness to weaning/extubation

(Text book of criti care med. 5 the Edit. MitchellP.FinkSHOEMAKER)

Daily Sedative Interruption and Daily

Assessment of Readiness to Extubate OVERSEDATION

Predisposes patients to: Thromboemboli

Pressure ulcers

Gastric regurgitation and aspiration

VAP

Sepsis

Consequences include: Difficulty in monitoring neuro status

Increased use of diagnostic procedures

Increase ventilator days

Prolonged ICU and hospital stay

STRESS ULCER PROPHYLAXISIncreases gastric ph and minimize bacterial colonization that reduces

the risk of VAP and GI bleeding

SUCRALFATE- Decreases the VAP rate but increases the risk of GI

bleeding by 4%.

H2 receptor blockers/PP inhibitors- Increase rate of VAP by

increasing gastric Ph leading to colonization of bacteria and decreases

the risk of GI bleeding.

H2 receptor blocker, PP inhibitor preferred over

sucralfate

Am J Respir Crit Care Med. 2005;171(4):388-

416.

Airway Management

Mechanical ventilation

Avoidance of Endotracheal intubation

Mask ventilation trials , NIPPV

Minimize duration on MV

Orotracheal intubation

Nasotracheal intubation slightly increase the risk for VAP

Avoid Reintubations- increases risk of VAP 6 fold

(Am resp.criti car med.1995;152(1):137-141)

Maintain at 25-30 cm H2O

SUBGLOTTAL SUCTIONINGShould be done using a 14 Fr sterile suction

catheter: Prior to ETT rotation

Prior to lying patient supine

Prior to Extubation

Continuous subglottic suctioning

ETT WITH DEDICATED LUMEN IS USED FOR CONTINUOUS OR INTERMITTED

SUBGLOTTIC SUCTIONING

Enteral Feedings

Early enternal feeding decrease bacterial colonization and rate of VAP

Bolus feeding should be avoided to minimize the risk of aspiration

Elevate HOB 30 - 45 degrees

Routinely verify tube placement

PATIENT TURNING-

Routine turning of patient for every 2 hrs increase pulmonary

drainage and decrease the risk of VAP.

Use of beds with continues lateral rotation can decrease the

incidence of pneumonia but do not decreases mortality or duration

of MV (critical care 2002;30(9):1983-1986)

NEW DEVELOPMENT• National healthcare safety(NHSN) and CDC proposed-

VAP terminology changed to VAC (ventilated associated conditions and complications) not necessarily limited VAP.

• VAP Surveillance definination algorithm.

Chest x ray is not included ,

And diagnosis is mainly depend on worsening of gas exchange, clinical features, isolation of microorganism in resp.secreation.

• ETT-- with continuous subglottic suction, ployurethrenecuff,Sponge cuff , Silver nitrate and antibiotic coated ETTs.

• VAP industrial complex- kinetic beds, inlines suction catheters

• VAP bunddle with 7 components – 5+ Replacing NGT to Orogastric tube and Hand washing by health care personnel.

IMPLEMENTATION and ENFORCEMENT of VAP bundle

VAP TO VAC

NOVEL SURVEILLANCE CRITERIA BY CDC

- to include other complication in ventilated patients

WHAT IS VENTILATOR ASSOCIATED CONDITION

- defined by 2 days of stable or decreasing ventilators setting

- followed by consistently higher ventilator settings

VAP TO VAC

NOW IF IT IS ASSOCIATED BY SIGNS OF INFLAMMATION AND

INFECTION ----

“IVAC”

(INFECTION RELATED VENTILATOR

ASSOCIATED CONDITION)

POSSIBLE OR PROBABLE VAP

Based on presence of PURULENT SECRETION AND

PATHOGENIC CULTURE DATA

IVACPURULENT

SECRETION

PATH.

CULTUREPOSSIBLE

VAP

IVACPURULENT

SECRETIONPATH.

CULTURE PROBABLE

VAP

or

CONCLUSION

- SIGNIFICANT MORTALITY IN ICU PATIENTS

- NO GOLD STANDARD CRITERIA

- EARLY DIAGNOSIS AND USE OF ANTIBIOTICS

- PREVENTION IS THE CORNERSTONE OF DECREASING THE

INCIDENCE OF VAP

- APPLYING VAP BUNDLE PROTOCOL

- APPROPRIATE ANTIBIOTIC SELECTION

TAKE HOME MESSAGE

- DIAGNOSE VAP WHEN THERE IS SUSPICION

- CLASSIFY AND START EMPIRICAL ANTIBIOTIC AT THE EARLIEST

- DON’T FORGET TO SEND CULTURE SAMPLES

- PREVENTION IS THE KEY

- APPLY VAP BUNDLE PROTOCOL

- XRAYS ARE NOT DIAGNOSTIC ACCORDING TO NEW PROTOCOL

- WEAN THE PATIENT EARLY

- STOP ANTIBIOTIC RESISTANCE

- FINALLY PLS DO WASH UR HANDS ***- SIMPLE BUT EFFECTIVE

“THANK YOU”