1. Ventilator-Associated Pneumonia (VAP) An Overview for RC Students Special thanks to: Donald Dumford Donald Dumford Beth Israel Deaconess Medical Center CDC

2. General Overview of Medical Protocols Morbidity, mortality and cost associated with VAP Morbidity, mortality and cost associated with VAP Who gets VAP? Risk factors that increase likelihood of developing VAP Who gets VAP? Risk factors that increase likelihood of developing VAP Etiology: The bugs Etiology: The bugs Treatment: The drugs Treatment: The drugs How VAP develops (Pathogenesis) How VAP develops (Pathogenesis) Measures to prevent VAP Measures to prevent VAP

3. General Care & Nursing Objectives Review policy and procedural practice changes for VAP prevention Review policy and procedural practice changes for VAP prevention Discuss BIDMC practice changes related to: Discuss BIDMC practice changes related to: Hand Hygiene Hand Hygiene Oral Care Oral Care HOB elevation HOB elevation Suctioning Suctioning Vent Circuits Vent Circuits

4. Who is at Greatest Risk? Reintubation Reintubation Supine position Supine position Impaired cough/depressed LOC Impaired cough/depressed LOC Oropharyngeal colonization Oropharyngeal colonization Presence of NG/OG tubes and enteral feeding Presence of NG/OG tubes and enteral feeding Cross contamination by staff Cross contamination by staff

5. Definition- “Know thy enemy” Pneumonia that develops in someone who has been intubated -Typically in studies, patients are only included if intubated greater than 48 hours -Early onset= less than 4 days -Late onset= greater than 4 days Endotracheal intubation increases risk of developing pneumonia by 6 to 21 fold Accounts for 90% of infections in mechanically ventilated patients American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.

6. Why Do We Care? Hospital acquired pneumonia (HAP) is the second most common hospital infection Hospital acquired pneumonia (HAP) is the second most common hospital infection VAP is the most common intensive care unit (ICU) infection VAP is the most common intensive care unit (ICU) infection VAP occurs in 10 - 65% of all ventilated patients Crit Care Clin (2002) VAP occurs in 10 - 65% of all ventilated patients Crit Care Clin (2002) VAP is one of critical care’s quality initiatives which can improve patient outcomes VAP is one of critical care’s quality initiatives which can improve patient outcomes

7. $$$$ VAP increases: VAP increases: Medical costs Medical costs Ventilator days Ventilator days ICU and hospital LOS ICU and hospital LOS Estimated direct cost of excess hospital stay due to VAP is $40,000 per patient Estimated direct cost of excess hospital stay due to VAP is $40,000 per patient Chest (2002) Chest (2002)

8. Length of stay and cost Remember that Medicare is no longer reimbursing for nosocomial infections Remember that Medicare is no longer reimbursing for nosocomial infections VAP increased length of stay in the ICU by 5-7 days (mean of 6.1 days) 1,2 VAP increased length of stay in the ICU by 5-7 days (mean of 6.1 days) 1,2 Increase in cost Increase in cost Increase of $10,000-$40,000 per patient 1,2 Increase of $10,000-$40,000 per patient 1,2 1 Safdar N et al. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review 2 Rello et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database

9. How Do We Diagnose? 2-1-2 Radiographic evidence x 2 consecutive days Radiographic evidence x 2 consecutive days New, progressive or persistent infiltrate New, progressive or persistent infiltrate Consolidation, opacity, or cavitation Consolidation, opacity, or cavitation At least 1 of the following: At least 1 of the following: Fever (> 38 degrees C) with no other recognized cause Fever (> 38 degrees C) with no other recognized cause Leukopenia ( 12,000 WBC/mm3) Leukopenia ( 12,000 WBC/mm3) At least 2 of the following: At least 2 of the following: New onset of purulent sputum or change in character of secretions New onset of purulent sputum or change in character of secretions New onset or worsening cough, dyspnea, or tachypnea New onset or worsening cough, dyspnea, or tachypnea Rales or bronchial breath sounds Rales or bronchial breath sounds Worsening gas exchange ( ↓ sats, P:F ratio < 240, ↑ O 2 req.) Worsening gas exchange ( ↓ sats, P:F ratio < 240, ↑ O 2 req.)

10. The Bugs Figure 1 from Park Figure 1 from Park Park DR. The microbiology of ventilator-associated pneumonia.

11. Etiology- select risk factors for pathogens Streptococcus pneumoniae Smoking, COPD, absence of antibiotic therapy Haemophilus influenzae Smoking, COPD, absence of antibiotic therapy MSSA Younger age, Traumatic coma, Neurosurgery MRSA COPD, steroid therapy, longer duration of MV, prior antibiotics Pseudomonas aeruginosa COPD, steroid therapy, longer duration of MV, prior antibiotics Acinetobacter species ARDS, head trauma, neurosurgery, gross aspiration, prior cephalosporin therapy Park DR. The microbiology of ventilator-associated pneumonia.

12. What Are Our Practice Goals? Hand Hygiene Hand Hygiene Mouth care Q 2-4 hours Mouth care Q 2-4 hours HOB > 30 degrees unless contraindicated HOB > 30 degrees unless contraindicated Closed inline suction – saline only when needed Closed inline suction – saline only when needed Change vent circuits only when needed Change vent circuits only when needed

13. Hand Hygiene Hand hygiene is the single most important (and easiest!!!) method for reducing the transmission of pathogens. Hand hygiene is the single most important (and easiest!!!) method for reducing the transmission of pathogens. Waterless antiseptic preparations are more effective than soap and water and may increase compliance. Waterless antiseptic preparations are more effective than soap and water and may increase compliance.

14. Oral Care Daily inspection and assessment of oral cavity Daily inspection and assessment of oral cavity Brush teeth q 12 hours Brush teeth q 12 hours Swab mouth with antiseptic agent q 2-4 hours between brushing Swab mouth with antiseptic agent q 2-4 hours between brushing Moisturize mouth prn Moisturize mouth prn

15. HOB > 30 Degrees HOB > 30 degrees at all times including transport unless contraindicated. HOB > 30 degrees at all times including transport unless contraindicated. Aspiration of oral secretions is a presumed step in the development of VAP Aspiration of oral secretions is a presumed step in the development of VAP Pulmonary aspiration is increased by supine positioning Pulmonary aspiration is increased by supine positioning Positioning the HOB to 30 degrees or higher significantly reduces gastric reflux and VAP Positioning the HOB to 30 degrees or higher significantly reduces gastric reflux and VAP

16. Stryker beds display Fowler angle at foot of bed Keep patient at 30-45 degrees while intubated

17. HOB Elevation > 30 Degrees on all Intubated Ventilated Patients Contraindications Hypotension MAP <70 Hypotension MAP <70 Tachycardia >150 Tachycardia >150 CI <2.0 CI <2.0 Central line procedure Central line procedure Posterior circulation strokes Posterior circulation strokes Cervical spine instability use reverse trendelenburg Cervical spine instability use reverse trendelenburg Some femoral lines ie: IABP no higher than 30 degrees 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 Increased ICP, No higher than 30 degrees avoid hip flexion Proning ProningContraindications Hypotension MAP <70 Hypotension MAP <70 Tachycardia >150 Tachycardia >150 CI <2.0 CI <2.0 Central line procedure Central line procedure Posterior circulation strokes Posterior circulation strokes Cervical spine instability use reverse trendelenburg Cervical spine instability use reverse trendelenburg Some femoral lines ie: IABP no higher than 30 degrees 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 Increased ICP, No higher than 30 degrees avoid hip flexion Proning Proning

18. Reverse Trendelenburg In full reverse Trendelenburg the foot of bed will read -12 degrees. In full reverse Trendelenburg the foot of bed will read -12 degrees. Angle of head elevation is approximately 20 degrees not 30 degrees when at -12. Angle of head elevation is approximately 20 degrees not 30 degrees when at -12. Evaluate the individual clinical situation to assess if the patient can tolerate the addition of a small amount of Fowlers angle which may flex the hip. Evaluate the individual clinical situation to assess if the patient can tolerate the addition of a small amount of Fowlers angle which may flex the hip.

19. Suctioning In line suction: In line suction: Maintain closed system Maintain closed system Use separate suction tubing for inline & yankauer Use separate suction tubing for inline & yankauer Normal saline: Normal saline: Should not be routinely used to suction pts Should not be routinely used to suction pts Causes desaturation Causes desaturation Does not increase removal of secretions Does not increase removal of secretions Can potentially dislodge bacteria Can potentially dislodge bacteria Should be used to rinse the suction catheter after suctioning Should be used to rinse the suction catheter after suctioning

20. Subglottal Suctioning Should be done using a 14 Fr sterile suction catheter: Should be done using a 14 Fr sterile suction catheter: Prior to ETT rotation Prior to ETT rotation Prior to lying patient supine Prior to lying patient supine Prior to extubation Prior to extubation

21. Suctioning Yankauer: Yankauer:  Use separate suction tubing  Change q 24 hours – unless visibly soiled date and time when changed  Clean after each use with NS or sterile H2O  Wipe with clean 4 X 4 gauze, place in package  Store in original package, taped to vent

22. Suctioning SET UP SET UP YANKAUER STORAGE YANKAUER STORAGE

23. Pathogenesis- Through the tube 1) Condensate in tubing 2) Development of ETT biofilm

24. Condensate Condensate in ventilator tubing becomes rapidly contaminated with bacteria from patient’s oropharynx Condensate in ventilator tubing becomes rapidly contaminated with bacteria from patient’s oropharynx Craven et al showed that 33% of inspiratory circuits were colonized within 2 hours and 80% within 24 hours Craven et al showed that 33% of inspiratory circuits were colonized within 2 hours and 80% within 24 hours

25. ET tube biofilm (RT’s should know this…) Exopolysaccharide outer layer with quiescent bacteria within Exopolysaccharide outer layer with quiescent bacteria within Difficult for bacteria to penetrate outer layer and bacteria within resistant to bactericidal effects of bacteria Difficult for bacteria to penetrate outer layer and bacteria within resistant to bactericidal effects of bacteria Adair et al study Adair et al study “Microorganisms of high pathogenic potential were isolated from all ETs collected from patients with VAP compared with 30% of ETs from the control group.” “Microorganisms of high pathogenic potential were isolated from all ETs collected from patients with VAP compared with 30% of ETs from the control group.”

26. Around the tube 1) Oral decontamination and selective decontamination of the digestive tract 2) Aspiraton of subglottic secretions including continuous aspiration of subglottic secretions 3) Semi-recumbent positioning 4) Sucralfate for stress ulcer prophylaxis

27. Condensate management Heat-moisture exchanger Heat-moisture exchanger Theoretical advantage=prevents bacterial colonization of tubing Theoretical advantage=prevents bacterial colonization of tubing Studies= Mixed results Studies= Mixed results Disadvantage=increases dead space and resistance to breathing Disadvantage=increases dead space and resistance to breathing Heated wire to elevate temp of inspired air Heated wire to elevate temp of inspired air Advantage=Decreases condensate formation Advantage=Decreases condensate formation Disadvantage=Blockage of ET tube by dried secretions Disadvantage=Blockage of ET tube by dried secretions CDC.gov. Guidelines for preventing health-care-associated pneumonia, 2003.

28. Ventilator Circuits Vent circuits (including inline suction systems) will be in place for the duration of ventilation unless: Vent circuits (including inline suction systems) will be in place for the duration of ventilation unless: Defective Defective Damaged Damaged Visibly soiled Visibly soiled The humidification system requires changing The humidification system requires changing

29. What Is Next? What Is Next? Standardization of oral care Standardization of oral care Products being trialed Products being trialed Sedation Sedation Improve practice regarding weaning sedation and daily wake up Improve practice regarding weaning sedation and daily wake up Vent weaning Vent weaning Improve practice around weaning and extubation Improve practice around weaning and extubation

30. Stay Tuned… More to come! More to come!