1. France Ellyson ANM, MNH ICU Kuwait 2014
VAP, not on my WATCH !!!
France Ellyson
ANM, MNH ICU
Kuwait 2014

3. 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
However, as like any other devices/medications mechanical ventilation is associated with complications such as Hemodynamic instability, pneumothorax and VENTILATOR ASSOCIATED PNEUMONIA

4. 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
Ventilator-associated pneumonia (VAP) is the leading cause of death among hospital-acquired infections. Hospital mortality of ventilated patients who developed VAP is 46% compared to 32% for ventilated patients who do not develop VAP. 1
In addition VAP is associated with an increase of 7.6 days of ventilation, an increase of 8.7 days in intensive care and an increase of the total stay of 11.5 days. 2,3 
According to current data, VAP plays a role in 6-30% of additional deaths in these critically ill patients. A good number of these unfortunate outcomes are the result of from system failures that could have been avoided.

5. 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
Even the definition of VAP is getting more precise… and not all the intensivist, infection control specialist and respirologist do not agree on the definition

6. 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

7. 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)

8. 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 ;33:

9. Causative Organisms: Early onset Late onset
Hemophilus influenza
Streptococcus pneumoniae
Staphylococcus aureus (methicillin sensitive)
Eschrichia coli
Klebsiella
Pseudomonas aeruginosa
Acinetobacter
Staphylococcus aureus (methicillin resistant)

10. 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

11. 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 intubations- reintubations
COPD, obesity, ARDS, gastro esophageal disease, burn, trauma

12. 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
The presence of the ET-tubes leads to VAP (not the ventilator)

13. 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

14. 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

15. Aspiration ETT/T NGT/OGT
Holds vocal cords open
Predispose pt to micro and macro aspiration of colonized bacteria from oropharynx
Leakage of secretions containing bacteria around ETT cuff
Interrupts gastro-esophageal sphincter leading to GI reflux and aspiration
Increase oropharyngeal colonization and stagnation of oropharyngeal and nasal secretions
Primary Route of Bacterial Entry into LRT

16. A New Streamlined Surveillance Definition for Ventilator-Associated Pneumonia Critical Care Med 2012 vol.40, no.1
The problem… no consensus between all physicians…
But the MUHC infection control department has an algorithm they follow to diagnose and generate statistics

17. Any one of the following:
NO CONSENSUS AMONG PHYSICIANS!!!

18. How do we Diagnose? 2-1-2 Radiologic evidence X 2 Consecutive days
New, progressive or persistent infiltrate
Consolidation, opacity or cavitation

19. 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)

20. 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)

21. 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

22. Duration of Treatment Standard duration 7-14 days
Longer duration > days risk of toxicity and resistance
Shorter < 7 days risk of recurrence
Depends on severity
Isolation of microorganism

23. 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)

24. The VAP Bundle
BUNDLE
“Group of evidence based interventions that whenever implemented together result in better outcomes”

25. Introduction of VAP BUNDLE
Elevation of HOB to between 30-45°
Daily sedative interruption and daily assessment of readiness to extubate
The utilization of endotracheal tubes with subglottic secretion drainage (Not at MNH yet)
Stress ulcer disease prophylaxis – including initiation of safe enteral nutrition within hours of ICU admission
IN TH COMPONENT of Daily oral care and decontamination with Chlorhexidine
Crit.Care 2012 vol.40, no.1
Vap Bundle originated in 2005 from the Institute of Health Care Improvement
We are presently working on 1. Collective Order
Chlorhexidine gluconate 0.12% solution (Peridex) to be used every 4 hours to perform oral care on mechanically ventilated patients in intensive care units.

26. 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
Remember to wash your hands The 5 moments of handwashing:
Before touching pt
Before clean/aseptic procedure
After body fluid exposure risk
After touching pt
After touching pt’s surroundings

27. HOB 30-45°  HOB 30-45° unless contraindicated
Especially recommended for Neuro population
To prevent aspiration during enteral feeding 
Contraindications:
Hypotension MAP < 70
Tachy?? >150
CI <2.0
Central line procedure
Cervical instability – use reverse trendelenburg

28. Daily sedative interruption and daily assessment of readiness to extubate
OVERSEDATION predisposes pts to:
Thromboemboli
Pressure ulcers
Gastric regurgitation and aspiration
VAP
Sepsis

29. 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

30. 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

31. Stress Ulcer Prophylaxis
Sucralfate, H2 receptor blocker and proton pump inhibitor – increases gastric ph and minimize bacterial colonization and reduces risk of VAP

32. Enteral Feedings
Initiation of safe enteral nutrition within hours of ICU admission
Early initiation decreases bacterial colonization
HOB 30-45°
Routinely + PRN verification tube placement

33. Additional Evidence-Based Component of Care:
Deep venous thrombosis (DVT) prophylaxis (unless contraindicated)
TED stockings
SCD machine
Heparin S/C

34. Deep venous Thrombosis Prophylaxis and early mobility practices
Pt turning Q 2hours increase pulmonary drainage and decreases risk VAP
Early mobilization

35. 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
Dental plaque due to the absence of mechanical chewing and the saliva are reservoirs for potential pathogens that cause VAP

36. Sage Oral Care Products

38. 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.

39. 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
Oral intubation AND gastric tube preferred… prevent sinusitis and consequently VAP (CDC AII).

40. Prevent micro-aspiration of secretions
ml 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

41. 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

42. 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

43. 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

44. We are not yet using at Neuro

45. 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)

46. 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

48. References
National Guideline Clearinghouse (current). Guideline Summary NGC-6634: Prevention of ventilator-associated pneumonia. Retrieved from: md.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
Safer Healthcare now (2012). Ventilator associated pneumonia. Retrived from: px
Safer Healthcare now (2012). Getting Started Kit. Retrieved from P%20Getting%20Started%20Kit.pdf

49. References
Alhazzani, W. & all. (2013) Tooth brushing for critically ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator- associated pneumonia. DOI: /ccm.0b013e d45 Center for Disease Control and prevention(2011). Improving Surveillance for Ventilator- Associated 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: /bmj 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: /CMR 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): Insitute for Healthcare Improvement (2011). IHI ventilator bundle: daily oral care with chlorhexidine. Retrieved from