Ventilator associated pneumonia

1. Ventilator
Associated Pneumonia
(VAP)
Abdelrahman Al-daqqa
2/1/2016 1

2. What is VAP?
 A Nosocomial pneumonia associated with
mechanical ventilation (either by
Endotracheal tube or Tracheostomy) that
develops within 48 hours or more of
hospital admission and which was not
present at the time of admission.
National institute of health excellence (NICE)-2007
center for disease control and prevention
2/1/2016 2

3. 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 occurring in
ventilated patients are pneumonias.
•Added costs of $40,000 - $50,000 per stay
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4.  Early–Onset Pneumonia (< 96 hours of
intubation or ICU admission)
 Community-acquired
 Pathogens:
 Streptococcus pneumoniae
 Haemophilus influenzae
 Staphylococcus aureus
 Antibiotic-sensitive
TYPES--
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5.  Late-Onset Pneumonia (> 96 hours of
intubation or ICU admission)
 Hospital-acquired
 Pathogens:
 Pseudomonas aeruginosa
 Methicillin resistant Staphylococcus aureus (MRSA)
 Acinetobacter
 Enterobacter
 Antibiotic-resistant
TYPES--
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6. INCIDENCE
 VAP occurs in 10 - 65% of all ventilated
patients Crit Care Clin (2002)
 Incidence increases with duration of MV
3% /day for first 5days, 2%/day for 6-10days
and 1%/day after 10 days.
 Mortality rate is 27% &43%with antibiotic
resistant organism.
critical care societies collaborative(CCSCs)
 Mortality rate in VAP caused by Pseudomonas
or Acinetobacter is as high as 76%
Crit Care Med (2004)
2/1/2016 6

7. Cont…
VAP
 Increases ventilatory support requirements
and ICU stay by 4.3 days
 Increases hospital LOS by 4 to 9 days
 Increases medical cost
Chest 2002;122:2115
Critical Care Medicine 2005;33:2184-93
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8. RISK FACTORS
HOST RELATE D
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 .
2/1/2016 8

9. 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
 Haematogeneous spread
2/1/2016 9

10. HOW DO WE DIAGNOSE? 2-1-2
 Radiographic evidence x 2 consecutive days
 New, progressive or persistent infiltrate
 Consolidation, opacity, or cavitation
 Clinical sings
At least 1 of the following:
 Fever (> 38 degrees C) with no other recognized cause
 Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000
WBC/mm3)
 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 breath sounds
 Worsening of gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)2/1/2016 10

11. CONT…
Microbiological criteria (optional)
At least one of the following:
• Positive growth in blood culture not related to another
source of infection.
• Positive growth culture pleural fluid.
• Bronchoaleveolar lavage
> 105colony forming units/ml.
sensivity &specificity 42-93% &45-100%
Protected specimen brushing >103cfu/ml
(33-100% & 50-100%) chest.Apr2000;117(4suppl2):198-2002)
•Histopathological evidence of pneumonia
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12. Cont--
• RADIOLOGICAL FINDING AND 2 CLINICAL
CRITERIA SENCIVITY OF DIAGNOSING VAP
IS 69% AND THE SPECIFICITY IS 75%
• SAMPLING OF RESPIRATORY SECREATION
can be obtained from distal or proximal airway however
the sensivity and specificity is more with distal airway
sample(Bronchoalveolar lavage(BAL) , Protected specimen
brush sampling(PAB).
• ABSENCE OF RADIOLOGICAL FINDING
HELPFUL FOR EXCLUDING THE DIAGNOSIS
OF VAP
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13. A new streamlined surveillance defintion for
ventilator-associated pneumonia
Any one of the following
1. Opacity, infiltrate, or consolidation that appears, evolves, or persists over 72 hrs
2. Cavitation
Any one of the following
1. Temperature 100.4°F within past 24 hrs
2. White blood cell 4,000 or 12,000 white blood cells/mm3 within past 24 hrs
Both of the following
1. Two days of stable or decreasing daily minimum FIO2 followed by increase in
daily minimum FIO2 15 points sustained for 2 calendar days OR 2 days of stable or
decreasing daily minimum positive end-expiratory pressure followed by increase in
daily minimum positive end-expiratory pressure by 2.5 cm H2O sustained for 2
calendar days
2. Gram-negative stain of respiratory secretions with moderate (2+) or more
neutrophils per low power field within 72 hrs.
Critical care med 2012 vol.40,no.12/1/2016 13

14. TREATMENT
• GENERAL APPROACH FOR INFECTION CONTROL
• ANTIBIOTICS-
Selection of antibiotics:
Early onset of VAP and no risk for MDR -
Cefrioxone, fluroquinolones, ampicillin-sublactum
Late onset of VAP and risk for MDR-
Antipseudomonal cephalosporin(cfepime,ceftazidime)
Carbapenems(imipenem,meronem),
Beta lactam/betalactamase inhibitors- piperacillin-tazobactam
Amonoglycocides with vancomycine,linezoid
ANTIBIOTCS TO BE ADJUSTED FURTHER ON THE
BASIS OF CULTURE REPORT2/1/2016 14

15. Risk Factors for drug resistance
 ABX in last 14 days
 Prior culture with MRO
 Immunocompromised
 Chronic primary lung pathology
 Acute or long term care hospitalization within
14 days
 Tracheostomy for > 5 day
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16. DURATION OF TREATMENT
- Depends on severity,
- Time to clinical response and micro organism response
- Isolation of microorganism
- Longer duration >14-21days risk of toxicity and resistance
- Shorter duration<7days- risk of recurrence
-standard duration of treatment 7-14 days
- Longer durtion 14-21 days may be indicated in
Multilobular involvement, cavitation, gram-ve
necrotising pneumonia, isolation of Pseudomonas,
Acnetobacter
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17. Further inpatient care
About 30% of pts. Fail to respond-
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18. EFFECT OF VAP BUNDLE CARE
VAP RATE UPTO 65%
VAP BUNDLE:
HOB elevation between 30-45degree,
DVT prophylaxis,
Stress ulcer prophylaxis,
Daily interruption of sedation,
Daily oral care with Chlorohexidine
VAP rate reduced
by 44.5%
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PREVENTION

19. Care Bundle
 A care bundle is …...
“A systematic method of measuring and
improving clinical care processes based on
groups of care elements for particular
diagnoses and procedures”
NHS Modernization Agency
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20. Ventilator Associated Pneumonia Care
Bundle -Evidence Based Practices
 Head Of Bed elevated to 30˚-45˚
 Daily sedation vacation &daily assessment
of readiness to wean
 DVT Prophylaxis
 Stress Ulcer Prophylaxis
 Subglottic secretion drainage
 Daily mouth care with chlorhexidine
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21. 1.HOB UP 30 DEGREES OR HIGHER
 Recommended elevation is 30-45 degrees
 If semi-recumbent or supine 34% incidence VAP
 ↑HOB → ↓risk of aspiration of gastrointestinal contents
↓risk of aspiration of oropharyngeal secretions
↓risk of aspiration of nasopharyngeal secretions
 ↑HOB improves patients’ ventilation
Supine patients have lower spontaneous tidal volumes on PS
than those seated in upright position
↑HOB may aid ventilatory efforts and minimize atelectasis
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22. HOB Elevation > 30 Degrees on all
Intubated Ventilated Patients
Contraindications
 Hypotension MAP <70
 Tachycardia >150
 CI <2.0
 Central line procedure
 Posterior circulation
strokes
 Cervical spine instability
use reverse trendelenburg
 Some femoral lines ie:
IABP no higher than 30
degrees use reverse
trendelenburg
 Increased ICP, No higher
than 30 degrees avoid hip
flexion
 Proning
2/1/2016

23. 2.Daily “Sedation Vacation” and Daily
Assessment of Readiness to Wean
 Correlated with reduction in rate of VAP
 Sedation vacation results in significant
reduction in time on mechanical ventilation
 Duration of mv decreased from 7.3 days to
4.9 days-study by Kress et al. (NEJM 2000)
 Weaning is easier when patients are able to
assist themselves at extubation with coughing
and control of secretions
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24. Conti….
 Allow the patient to wake.
 If the patient is co-operative and able to understand
commands leave the sedation off.
 Distressed or agitated patients require re-sedating.
 Administer boluses as appropriate to achieve safety.
242/1/2016

25. 3.Peptic Ulcer Disease
(PUD) Prophylaxis
 It is an appropriate intervention in all
sedentary patients
 Critically ill intubated patients lack the
ability to defend their airway
 Decreasing pH of gastric contents may
protect against greater pulmonary
inflammatory response to aspiration of
gastrointestinal contents
252/1/2016

26. More on PUD Prophylaxis
 Surviving Sepsis Campaign Guidelines
reviewed literature on PUD prophylaxis:
 “H2 receptor inhibitors are more efficacious
that sucralfate and are the preferred agents.
Proton Pump Inhibitors have not been assessed
in direct comparison with H2 receptor
antagonists and, therefore their relative
efficacy is unknown. They do demonstrate
equivalency in ability to increase gastric pH.”
262/1/2016

27. 4.Deep Vein Thrombosis (DVT)
Prophylaxis
 Higher incidence of
DVT in critical illness
 Risk of venous
thromboembolism is
reduced if prophylaxis
is consistently applied
 TARGET: patients
undergoing surgery,
trauma patients, acutely
ill medical patients, and
ICU patients
272/1/2016

28. 5.Subglottal Suctioning
Should be done using a 14 Fr
sterile suction catheter:
Prior to ETT rotation
Prior to lying patient supine
Prior to extubation
282/1/2016

29. Suctioning
 In line suction:
 Maintain closed system
 Use separate suction tubing
 Normal saline:
 Should not be routinely used to suction pts
 Causes desaturation
 Does not increase removal of secretions
 Can potentially dislodge bacteria
 Should be used to rinse the suction catheter
after suctioning
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30. Suctioning
302/1/2016

31. Best Practices to Achieve a High Level
of Compliance in ICUs
 Daily Multi-disciplinary Rounds including:
Head Nurse(Unit in-charge)
Reg.Nurse assigned to patient
Clinical Pharmacist / Pharmacy Residents
Infection Control Specialist
Respiratory Therapist
Registered Dietician
Nurse Case Manager
Speech Therapist
Nursing student / Instructor
 Use of Ventilator Bundle Audit Tool addressing the
bundle items daily
312/1/2016

32.  The best method to prevent healthcare
acquired infections including VAP is to
practice good Hand Hygiene including use of
 Antimicrobial soap and water
 Alcohol Based Hand Rub (Isagel) when there
is no visible soiling on hands
32
HAND HYGIENE
2/1/2016

33. Compliance with Isolation Precautions
 Stringent adherence to the use of Personal
Protective Equipment (PPE) such as Gowns,
Masks, Gloves will decrease the transmission
of pathogenic microorganisms to ventilated
patients when patients are identified as
requiring Contact and Droplet Precautions
332/1/2016

34. 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
 No CDC recommendations for:
 Preferential use of small bore tubes
 Continuous versus intermittent feeding
 Post pyloric placement CDC (2003)
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35. 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)
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36. No Data
to Support These Strategies
• Use of small bore versus large bore gastric
tubes
• Continuous versus bolus feeding
• Gastric versus small intestine tubes.
• Closed versus open suctioning methods.
• Kinetic beds.
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37. 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 preventive measures(VAP bundle) and
timely initiation of appropriate antibiotics ensure better
outcomes in patients with VAP.
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