Dr Nirmal Jaiswal MD(med);FCCS

ICU Director and Consultant Physician Suretech Hospital,Nagpur

• VAP is the 2nd most common nosocomial infection = 15% of all hospital acquired infections

• Incidence = 9% to 70% of patients on ventilators

• Increased ICU stay by several days• Increased avg. hospital stay 1 to 3 weeks• Mortality = 13% to 55%

Centers for Disease Control and Prevention, 2003. Rumbak, M. J. (2000). Stra te g ie s fo r p re ve ntio n a nd tre a tm e nt. Journal of

Respiratory Disease, 21 (5), p. 321;

• “There is no doubt that the diagnosis and management of VAP remains one of the most controversial and challenging topics in management of critically ill patients.”

Chan C, Chest 2005;127:425

• VAP is a Nosocomial Pneumonia = Hospital acquired

• Diagnosis is imprecise and usually based on a Combination of:– Clinical factors - fever or hypothermia;

change in secretions; cough; apnea/bradycardia; tachypnea

– Microbiological factors - positive cultures of blood/sputum/tracheal aspirate/pleural fluids

– CXR factors - new or changing infiltrates

• Pathogens that cause VAP differ depending on whether the condition occurs early (less than 96 hours after intubation or admission to ICU) or late (greater than 96 hours after intubation or admission to ICU)

Kollef M, Chest 2005;128:3854-62

• Early–Onset Pneumonia (< 96 hours of intubation or ICU admission)

– Community-acquired – Pathogens:

• Stre p to c o c c us p ne um o nia e• Ha e m o philus influe nz a e• Sta p hylo c o c c us a ure us

– Antibiotic-sensitive

• Late-Onset Pneumonia (> 96 hours of intubation or ICU admission)– Hospital-acquired – Pathogens:

• Ps e udo m o na s a e rug ino s a• Methicillin resistant Sta phylo c o c c us a ure us

(MRSA)• Acine to ba c te r• Ente ro ba c te r

• Antibiotic-resistant

• Major risk factor = mechanical intubation

• Factors that enhance colonization of the oropharynx &/or stomach:– Administration of antibiotics– Admission to ICU– Underlying chronic lung disease

• Conditions favoring aspiration into the respiratory tract or reflux from GI tract:– Supine position *GERD– NGT placement *Coma/delirium– Intubation and self-extubation– Immobilization– Surgery of head/neck/thorax/upper abdomen

• Conditions requiring prolonged use of mechanical ventilatory support with potential exposure to contaminated respiratory devices &/or contact with contaminated hands

• Host Factors:– Extremes of age– Malnutrition– Immunocompromised– Underlying condition/disease process

Four Algorithms :

Algorithm #1: Adolescents and adultsAlgorithm #2: Immunocompromised pAlgorithm #3: Children 1 to <12 yearsAlgorithm #4: Infants (<1 year)

Algorithm #2: Diagnosing VAP in Immunocompromised Patients

Algorithm #3: Diagnosing VAP in Children (Age >1 and <13 years)

Algorithm #4: Diagnosing VAP in Infants (Age <1 year old)

• A "bundle" is a group of evidence-based care components for a given disease that, when executed together, may result in better outcomes than if implemented individually.

• In a bundle, the individual elements are built around best evidence-based practices.

• The science supporting the individual treatment strategies in a bundle is sufficiently mature such that implementation of the approach should be considered either best practice or a reasonable and generally accepted practice.

VAP BUNDLE

• Ventilator-Associated Pneumonia (VAP)Bundle:– DVT prophylaxis– GI prophylaxis– Head of bed (HOB) elevated to 30-45°– Daily Sedation Vacation– Daily Spontaneous Breathing Trial connected

• Include deep venous prophylaxis as part of your ICU order admission set and ventilator order set.  Make application of prophylaxis the default value on the form.

• Include deep venous prophylaxis as an item for discussion on daily multidisciplinary rounds.

• Empower pharmacy to review orders for patients in the ICU to ensure that some form of deep venous prophylaxis is in place at all times on ICU patients.

• Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.

• Include peptic ulcer disease prophylaxis as part of your ICU order admission set and ventilator order set.  Make application of prophylaxis the default value on the form.

• Include peptic ulcer disease prophylaxis as an item for discussion on daily multidisciplinary rounds.

• Empower pharmacy to review orders for patients in the ICU to ensure that some form of peptic ulcer disease prophylaxis is in place at all times on ICU patients.

• Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.

• Elevate HOB to 30 to 45 degrees (if no contraindications):

• Aspiration can occur even with a properly inflated ET cuff.

Bacterial counts higher in aspirated secretions obtained while pts were in the supine (flat) position than in those obtained while patients were in the semirecumbent position (45 degrees).

Torres et al. Ann Int Med 1992;116:540-3.

■ Time spent with HOB in low position on day 1 of mechanical ventilation is most predictive of VAP in patients with high APACHE II scores.

Grap MJ, Munro CL, et al. 2005 Am J Crit Care 14(4)

• Use visual cues so it is easy to identify when the bed is in the proper position, such as a line on the wall that can only be seen if the bed is below a 30-degree angle.

• Include this intervention on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care.

• Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.

• Implement a protocol to lighten sedation daily at an appropriate time to assess for neurological readiness to extubate. – Include precautions to prevent self-extubation such as

increased monitoring and vigilance during the trial.

• Include a sedation vacation strategy in your overall plan to wean the patient from the ventilator– if you have a weaning protocol, add "sedation vacation" to

that strategy.

• Assess that compliance is occurring each day on multidisciplinary rounds.

• Consider implementation of a sedation scale such as Riker or Ramsay scoring scale to avoid oversedation. 

• Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.

• Appropriate antibiotic use• Attention to proper ET and TT cuff pressures• Avoided intubation(BiPAP)• Hand hygiene-chlorhexidine• Closed endotracheal suctioning syst• Condensation management in vent circuit• Conversion to TT for long term ventilation• Enteral feeding instead of TPN• Minimize duration of MV• Oral hygiene x 4 hrly• Subglotic suctioning before deflating the cuff of

ET/TT • Strict glucose control• Wearing gloves

• Analysis of 10 studies of small bowel feeding found that small bowel feedings are associated with reduction in gastroesophageal regurgitation, increase in protein and calories delivered, and shorter time to target dose of nutrition.

• Results of 7 randomized trials: small bowel feeding compared to gastric had.

• Heyland, et al. JPEN 2002;26:S51-S55.• Kollef MH Crit Care Med 2004:32(6)• Heyland, el al. Crit Care Med 2001;29:1495-1501

lower incidence of pneumonia

• AACN 5 th Ed itio n, 2 0 0 5 Sc o tt JM, Vo llm a n KM• Endo tra che a l Tube a nd O ra l Care , Pro c e dure # 4 • Unit O ne Pulm o na ry Sy s te m

• Perform ET suctioning only when clinically indicated

• Oral hygiene should be performed every 2-4 hours and should include:

• Toothbrushing at least two times a day;• Oral swabs with 1.5% hydrogen peroxide soln

every 2-4 hours;• Mouth moisturizer to oral mucosa and lips• Subglottic suctioning continuously or

intermittently

G ra p MJ, Munro CL 2 0 0 4:

• Toothbrushing is the most effective means of mechanical removal of plaque.

Munro CL, Grap MJ, Elswick RK, el al: 2006;Am J Crit Ca re ;15

• Higher plaque scores confer greater risk for VAP

Munro & Grap 2006 Crit Care Med 34

• CHG – effective in reducing VAP

Mouth Care Compliance and VAP Rate Trends for ICU

• Educational programs for RNs and RTs addressing VAP etiology and infection control procedures is associated with decreased VAP rates in the ICU setting.

• Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia.

Critical Care Medicine. 2002; 30(11): 2407-2412.

• “Staff education….is a cornerstone for efforts to reduce the incidence of VAP.”

Craven,D. Chest 2006;130

• Ventilator bundle staff educational sessions have a significant effect on clinical practice.

• Tolentino-DelosReyes, Ruppert, Shyang-Yun, et al Am J Crit Care 2007; 16

• Hand hygiene-chlorhexidine• HOB – HEAD OF BED ELEVATION – 30-45

DEGREE• Condensation management in vent circuit• Attention to proper ET and TT cuff pressures• Oral hygiene x 4 hrly• Closed endotracheal suctioning syst• Daily sedation vacation and spontaneous breathing

trial • Enteral feeding instead of TPN• GI prophylaxis• Strict glucose control• Subglotic suctioning before deflating the cuff of

ET/TT•

DEDICATE “URself” to the protocol

Ventilator Associated Pneumonia

Morbidity and Mortality