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VAP: A Preventable Disease

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1 VAP: A Preventable Disease

2 Ruben D Restrepo MD RRT FAARC
Professor of Respiratory Care The University of Texas Health Science Center at San Antonio

3 Disclosure: Ruben D. Restrepo, MD, RRT, FAARC
Teleflex Medical Speaker Member, Medical Advisory Board Oridion Capnography (Covidien) Consultant and investigator Salter Labs Consultant Fisher & Paykel Investigator

4 Objectives Upon completion of this module, participants should understand and be able to communicate: Impact of VAP Diagnostic criteria for VAP and VAE Recommended strategies to minimize contamination of equipment used during mechanical ventilation Evidence Based Clinical Practice Guidelines directed to reduce incidence of VAP Role of the VAP Bundle  Risks associated with breathing circuit condensation and the advantages and disadvantages of current options available for condensation management Review objectives

5 Hospital-Acquired Infections - VAP
ICU environment: Patients are sicker and maybe immunocompromised Mechanically ventilation: use of life-saving, but invasive devices (catheters and ETTs) Superhighways for bacterial invasion Magnitude of HAI: Pneumonia 15% of HAI 27% of ICU acquired infections 24% of infections in coronary care units Pneumonia is the second most common healthcare associated infection in the United States and is associated with substantial morbidity and mortality. Patients with mechanically assisted ventilation have a high risk of developing pneumonia. Prevention and control of healthcare-associated pneumonia is discussed in the CDC/HICPAC document, Guideline for the Prevention of Nosocomial Pneumonia. The guideline strongly recommends that surveillance be conducted for bacterial pneumonia in ICU patients who are mechanically ventilated to facilitate identification of trends and for interhospital comparisons 8 2 Fridkin SK, Welbel SF, Weinstein RA. Magnitude and prevention of nosocomial infections in the intensive care unit. Infect Dis Clin of North Am 1997;11: Klevens RM, Edward JR, et al. Estimating health care-associated infections and deaths in U.S. hospitals, Public Health Reports 2007;122:

6 Hospital-Acquired Infections - VAP
Magnitude of VAP: 2nd most common HAI in the US1 Most common HAI in the ICU CDC : per 1,000 ventilator days2 Increased length of stay (LOS) by: 25 hospital days 22 ICU days Associated cost: $40,000?3 $60,000?4 1st cause of death from HAI5 Attributable mortality as high as 27%5 Klevens RM, Edward JR, et al. Estimating health care-associated infections and deaths in U.S. hospitals, Public Health Reports 2007;122: Centers for Disease Control and Prevention. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR 2004;53(No. RR-3). Rello J, Ollendorf DA, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122: Warren D, Shukla S, Olson M, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Critical Care Medicine. 2003;31: Fagon JY, Chastre J, et al. Nosocomial Pneumonia in Ventilated Patients: A Cohort Study Evaluating Attributable Mortality and Hospital Stay. The American Journal of Medicine. 1993;94: Klevens et al. Public Health Reports 2007;122: Centers for Disease Control and Prevention. MMWR 2004;53(No. RR-3). 3. Rello J et al. Chest. 2002;122: 4.Warren D et al. CCM. 2003;31: Fagon JY et al. Am J of Med. 1993;94:

7 How expensive are HAIs? With an incidence of approximately 4.5 HAIs for every 100 hospital admissions, the annual direct costs on the healthcare system were estimated to be $4.5 billion in 1992 dollars.[1] Adjusting for the rate of inflation using the CPI for all urban consumers, this estimate is approximately $6.65 billion in 2007 dollars. Applying two different Consumer Price Index (CPI) adjustments to account for the rate of inflation in hospital resource prices, the overall annual direct medical costs of HAI to U.S. hospitals ranges from $28.4 to $33.8 billion (after adjusting to 2007 dollars using the CPI for all urban consumers) and $35.7 billion to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services). After adjusting for the range of effectiveness of possible infection control interventions, the benefits of prevention range from a low of $5.7 to $6.8 billion (20 percent of infections preventable, CPI for all urban consumers) to a high of $25.0 to $31.5 billion (70 percent of infections preventable, CPI for inpatient hospital services). Scott II RD. The Direct Medical Costs of Healthcare-Associated Infection in US Hospitals and the Benefits of Prevention. CDC 2009;

8 Direct Medical Cost of HAI . ‘07 US
4.5 HAIs/100 hospital admissions Overall annual direct medical costs of HAI $ $33.8 billion - urban consumers $ $45 billion - inpatient hospital services Benefits of prevention $5.7 - $6.8 billion (20% preventable - urban consumers) $ $31.5 billion (70% preventable - inpatient hospital services). With an incidence of approximately 4.5 HAIs for every 100 hospital admissions, the annual direct costs on the healthcare system were estimated to be $4.5 billion in 1992 dollars.[1] Adjusting for the rate of inflation using the CPI for all urban consumers, this estimate is approximately $6.65 billion in 2007 dollars. Applying two different Consumer Price Index (CPI) adjustments to account for the rate of inflation in hospital resource prices, the overall annual direct medical costs of HAI to U.S. hospitals ranges from $28.4 to $33.8 billion (after adjusting to 2007 dollars using the CPI for all urban consumers) and $35.7 billion to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services). After adjusting for the range of effectiveness of possible infection control interventions, the benefits of prevention range from a low of $5.7 to $6.8 billion (20 percent of infections preventable, CPI for all urban consumers) to a high of $25.0 to $31.5 billion (70 percent of infections preventable, CPI for inpatient hospital services). Treatment of suspected and confirmed VAP is estimated to account for approximately 50% of antibiotic dispensing in ICUs [10–12]. Scott II RD. The Direct Medical Costs of Healthcare-Associated Infection in US Hospitals and the Benefits of Prevention. CDC 2009;

9 Attributable Cost Estimates
According to Stone et al2005 $36,441 BSI $25,546 SSI $9,969 VAP $1,006 CAUTI Stone PW, et al. Systematic review of economic analyses of health care-associated infections. Am J Infect Control 2005;33: According to Anderson et al2007 $23,242 BSI $10,443 SSI $25,072 VAP $758 CAUTI surgical site infections (SSIs), central line associated bloodstream infections (CLABSIs), ventilator-associated pneumonias (VAPs), catheter-associated urinary-tract infections (CAUTIs), and Clostridium difficile-associated disease (CDI). Anderson DJ, et al. Under resourced hospital infection control and prevention programs: penny wise, pound foolish? Infect Control Hosp Epidemiol 2007;28:

10 NASCENT Study (n= 30 VAP vs. n=90 no VAP)
Median total hospital charges for patient case $198,200 vs. $96,540 (P< .001) Median loss to hospital for patient case $ 32,140 vs. $19,360 (P= .151) Services with the highest median charges: hospital ($23,190 vs. $11,110) p <0.05 respiratory ($4,838 vs. $2,787) p<0.05 Abstract OBJECTIVES: To characterize the current economic burden of ventilator-associated pneumonia (VAP) and to determine which services increase the cost of VAP in North American hospitals. DESIGN AND SETTING: We performed a retrospective, matched cohort analysis of mechanically ventilated patients enrolled in the North American Silver-Coated Endotracheal Tube (NASCENT) study, a prospective, randomized study conducted from 2002 to 2006 in 54 medical centers, including 45 teaching institutions (83.3%). METHODS: Case patients with microbiologically confirmed VAP (n = 30)were identified from 542 study participants with claims data and were matched by use of a primary diagnostic code, and subsequently by the Acute Physiology and Chronic Health Evaluation II score, to control patients without VAP (n = 90). Costs were estimated by applying hospital-specific cost-to-charge ratios based on all-payer inpatient costs associated with VAP diagnosis-related groups. RESULTS: Median total charges per patient were $198,200 for case patients and $96,540 for matched control patients (P < .001); corresponding median hospital costs were $76,730 for case patients and $41,250 for control patients (P = .001). After adjusting for diagnosis-related group payments, median losses to hospitals were $32,140 for case patients and $19,360 for control patients (P = .151). The median duration of intubation was longer for case patients than for control patients (10.1 days vs 4.7 days; P < .001), as were the median duration of intensive care unit stay (18.5 days vs 8.0 days; P < .001) and the median duration of hospitalization (26.5 days vs 14.0 days; P < .001). Examples of services likely to be directly related to VAP and having higher median costs for case patients were hospital care (P < .05) and respiratory therapy (P < .05). CONCLUSIONS: VAP was associated with increased hospital costs, longer duration of hospital stay, and a higher number of hospital services being affected, which underscores the need for bundled measures to prevent VAP.

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12 VAP: An Expensive Proposition

13 Most common HAI in critical care patients.
VAP New or progressive infiltrates on CXR Fever Abnormal WBC count Purulent sputum New or progressive infiltrates on portable chest radiographs, fever, abnormal white blood cell count and purulent sputum. Quantitative culture of bronchoalveolar lavage fluid is only approximately 50–75% sensitive and 50–90% specific [31–35]. Protected specimen brush cultures likewise only have a sensitivity of 30–60% and a specificity of 50–90% [31–36]. MV > 48 h 10%-20% Most common HAI in critical care patients.

14 Clinical Diagnostic Strategy
Clinical suspicion Patient on Mechanical Ventilation + infiltrate CXR + 2/3 findings Symptoms  infection: (1) Fever, (2) purulent tracheal secretions Laboratory  infection: (3) Leukocytosis or leukopenia [Hypoxemia] Differential diagnosis Chemical aspiration without infection Atelectasis Pulmonary embolism ARDS Pulmonary hemorrhage Lung contusion Drug reaction Other

15 VAP Definition(s) Halpern NA et al. CCM 2012
CDC's National Healthcare Safety Network Pneumonia that occurs in a patient who was intubated and ventilated at the time of, or within 48 hrs, “before” the onset of the pneumonia ATS and the IDSA (clinically oriented) Pneumonia that arises >48–72 hrs “after” intubation VAP diagnostic criteria require the presence of a new or progressive and persistent radiographic opacity, a change in pulmonary secretions or symptoms, or evidence of impaired gas exchange and systemic signs of infection Microbiological evidence of lower respiratory tract infection is optional

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18 NHSN Surveillance for Ventilator-Associated Events in Adults

19 NHSN Surveillance for Ventilator-Associated Events in Adults

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21 How Will I Find Cases of VAP?

22 http://www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf JUNE 2011
This is the formula that is used to calculate the VAP rate for a given unit. In the NICU, this is calculated separately for each birthweight category. JUNE 2011

23 VAP Definition Early Onset VAP2 Late Onset VAP2
Occurs in the period of 2-5 days post intubation Pathogens responsible are susceptible to antibiotic therapy Staphylococcus Aureus (Meth sensitive) Streptococcus pneumoniae Hemophilus influenzae Proteus species Serratia species Klebsiella pneumoniae Escherichia coli Late Onset VAP2 >5 days post intubation Usually caused by antibiotic-resistant organisms Pseudomonas aeruginosa, Methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter species Enterobacter species Vancomycin-resistant enterococcus (VRE) Anesth Analg Nov;109(5): Epub 2009 Aug 27. Late-onset ventilator-associated pneumonia in nontrauma intensive care unit patients. Gacouin A, Barbarot N, Camus C, Salomon S, Isslame S, Marque S, Lavoué S, Donnio PY, Thomas R, Le Tulzo Y. Service des Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Rennes Cedex 9, France. Abstract BACKGROUND: Most studies designed to determine the factors associated with the acquisition of late-onset ventilator-associated pneumonia (VAP) were performed in critically ill trauma patients. The impact of enteral nutrition (EN) on the risk of acquiring VAP has been discussed. In this study, we assessed factors associated with late-onset VAP in nontrauma patients and determined whether nutrition provided early was associated with development of late-onset VAP in this population. METHODS: We performed a prospective observational cohort study in a 21-bed polyvalent intensive care unit in a university hospital. RESULTS: Three hundred sixty-one intubated adult patients with a duration of mechanical ventilation (MV) of 6 days or more were admitted over a 28-mo period. Late-onset VAP was confirmed in 76 patients (21%) by the presence of at least one microorganism at a concentration >or=10(4) colony-forming units/mL on the bronchoalveolar lavage. Gram-negative bacilli represented 75% and Staphylococcus aureus 21% of recovered organisms. Factors independently associated with late-onset VAP by multivariate analysis included a high simplified acute physiology score II score (odds ratio: 1.021; 95% confidence interval [CI]: ; P = 0.01), development of acute respiratory distress syndrome during the first 5 days of MV (odds ratio: 1.98; 95% CI: ; P = 0.04), and size of the endotracheal tube >or=7.5 (odds ratio: 2.06; 95% CI: ; P = 0.03). EN started within 48 h of MV onset was not associated with a higher risk for late-onset VAP. CONCLUSION: In our nontrauma patient population, early EN was not associated with development of late-onset VAP. In this population, severity of the disease during the first 5 days of MV seemed to be associated with late-onset VAP. In addition, our results suggest that the risk of late-onset VAP is higher in patients with a tube size >or=7.5 than in patients with a tube size <7.5. 1 Mayhall G. C. Special Issue: Ventilator-Associated Pneumonia or Not? Contemporary Diagnosis. Emerging Infectious Diseases Vol. 7, No. 2, March-April 2001 p. 201. 2 Davies, J. Pathogens Associated with the Intensive Care Unit Environment : Considerations for the Respiratory Therapist. Clinical Foundations: A Patient-focused Education Program for Respiratory Care Professionals. December 2009.

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25 Measures to Prevent VAP In addition to handwashing and use of protective gowns and gloves, we had a standard care protocol to prevent VAP in which a semirecumbent body position was maintained if possible, the oropharynx cavity was cleaned 4 times daily with chlorhexidine, and intracuff pressures were periodically verified. Subglottic drainage was not applied to any patients, and we did not use closed suctioning systems. In addition, no systemic antibiotic regimen for nosocomial pneumonia prophylaxis or selective decontamination of the digestive tract was prescribed during the period of the study. Maintenance of ventilator circuits did not change over the study period. Except for patients with chronic obstructive pulmonary disease (COPD) and those with acute respiratory distress syndrome (ARDS), heat and moisture exchangers (Humid-Vent Filter Compact S, Teleflex Medical, High Wycombe, UK) were used during the first 5 days of MV and changed at 72-h intervals if not grossly soiled. From the start of MV for patients with COPD and ARDS and from Day 6 for the other patients, heated humidifiers with wire-heated circuits (MR 730 device, Fisher & Paykel Healthcare, Auckland, New Zealand) were used. Gacouin A, et al. Late-Onset Ventilator-Associated Pneumonia in Nontrauma Intensive Care Unit Patients Anesth Analg 2009;109:

26 VAP Pathogenesis Bacterial invasion of the pulmonary parenchyma in a patient receiving mechanical ventilation Inoculation of the formerly sterile lower respiratory tract typically arises from: Aspiration of secretions Colonization of the aero digestive tract Use of contaminated equipment or medications TALKING POINTS Mechanically Assisted Ventilation and Endotracheal Intubation Increased risk for pneumonia in intubated, mechanically ventilated patients is partly dueto the carriage of oropharyngeal microorganisms via passage of the endotracheal tube into the trachea during intubation, as well as to depressed host defenses secondary to the patient's severe underlying illness (13;16;25;239). In addition, bacteria can aggregate on the surface of the endotracheal tube over time and form a glycocalyx (i.e., biofilm) that protects the bacteria from antimicrobial agents or host defenses (240). Some investigators believe that these bacterial aggregates may become dislodged by ventilation flow, tube manipulation, or suctioning and subsequently embolize into the lower respiratory tract and cause focal pneumonia (241;242). Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

27 Biofilm on ETT Endotracheal Tube Subglottic Secretions
VAP Pathogenesis Endotracheal Tube Subglottic Secretions Endotracheal Tube Cuff Biofilm on ETT Pooled Secretions in Airway Dispersal of Biofilm With Ventilation

28 Curr Opin Infect Dis. 2013 Jan 2. [Epub ahead of print]

29 Risk factors for VAP include:
Modifiable: Duration of ventilation Position in bed (supine) Enteral feeding Witnessed aspiration Paralytic agents Prior antibiotic use Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

30 Risk factors for VAP include:
Nonmodifiable: Extreme ages Comorbidities Pulmonary disease HIV/AIDS Head trauma MOF Immunosupression Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

31 Every Choice Matters Prevention of VAP
Quality improvement initiatives suggest that many cases of VAP might be prevented by careful attention to the process of care Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

32 Existing Guidelines and Recommendations AARC – CDC – IHI - IDSA
Reducing risk of VAP Active surveillance Hand-hygiene guidelines NIV whenever possible Minimize the duration of MV Daily assessments of readiness to wean and use weaning protocols Educate healthcare personnel who care for patients undergoing ventilation about VAP review Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

33 SHEA/IDSA Guidelines “Compendium of Strategies to Prevent Healthcare-Associated Infections” SHEA-Society for Healthcare Epidemiology of America/ IDSA-Infectious Diseases Society of America Prioritizing VAP as highly preventable Review bullet points Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

34 SHEA Guidelines: Core Recommendations
Designed to interrupt the three most common mechanisms by which VAP develops: Aspiration of Secretions Colonization of the aero digestive tract Use of contaminated equipment Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

35 Strategies to Reduce Aspiration of Secretions
Maintain patients in a semi recumbent position (30-45° head of the bed elevation) unless contraindicated 67% reduction in early onset VAP Avoid gastric over distention Avoid unplanned extubation and reintubation Use a cuffed endotracheal tube with in-line or subglottic suctioning effective in preventing early-onset VAP Maintain an endotracheal cuff pressure of at least 20cm H20 TALKING POINTS Drainage of subglottic secretions In the intubated patient, leakage around the cuff of the endotracheal tube allows bacterialaden secretions (which pool below the glottis and above the endotracheal-tube cuff) direct access to the lower respiratory tract (243;244). The effect of using an endotracheal tube that has a separate dorsal lumen which allows drainage (i.e., removal by suctioning) of the subglottic secretions has been compared to that of a conventional endotracheal tube ( ). In the first study in ICU patients, intermittent (i.e., hourly) subglottic secretion drainage was associated with a lower incidence (13% vs 29%) as well as a delayed onset ( days vs days) of VAP (246). Subsequent studies corroborated these findings: lower VAP incidence:14/76 (18.4%) vs 25/77 (32.5%) (248), and 3/49 (4%) vs 12/56 (16%) (247); and delayed onset of VAP: days vs days (248), and days vs days (247); albeit the decrease in VAP incidence was not statistically significant: 8/160 (5%) vs 15/183 (8.2%) in one study of patients who had undergone cardiac surgery (245) Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

36 Strategies to Reduce Colonization of the Aero digestive Tract
Orotracheal intubation is preferable to nasotracheal intubation Nasotracheal intubation increases the risk of sinusitis, which may increase the risk for VAP Avoid H2–blocking agents and proton pump inhibitors Unless at high risk for developing a stress ulcer or stress gastritis. Perform regular oral care with an antiseptic solution Talking Points Oral care Munro and Grap (2004) contended that reducing the number of micro-organisms in the mouth through oral care decreased the risk of translocation and colonization in the lungs and therefore had the ability to reduce the risk of VAP. In addition, Sole et al. (2002) identified that most suctioning equipment (including Yankauer devices and tubing) colonized with potential VAP pathogens within 24 h of use. According to the Centre for Disease Control and Prevention (CDC) (Tablan et al., 2003), oral hygiene in ICU should include the following: • tooth brushing • mouth rinsing • oral suctioning • storage, rinsing and replacement of suction devices. Four years after the CDC directive was issued, Cason et al. (2007) published the results of a survey of 1200 ICU nurses to evaluate the extent to which they implemented best practice in line with the CDC guidelines on oral care. They discovered that only 56% of hospitals had an oral care protocol and nurses in those hospitals were more likely to provided better oral care for their patients. They concluded that significant reductions in rates of VAP might be achieved by a broader implementation of oral care protocols. The authors have found no evidence of a successful implementation of an oral care protocol in anyUK ICU. Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

37 Strategies to Reduce Use of Contaminated Equipment
Thoroughly clean all respiratory equipment to be sterilized or disinfected (IA) After disinfection, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items (IA) DO NOT routinely change the ventilator breathing circuit. ONLY when visibly soiled or mechanically malfunctioning. (IA) Periodically drain and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward the patient. (IB) Wear gloves to perform the above procedure or handle the fluid (IB) Talk about the SHEA appendix, what it is for. Review points Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

38 General Measures Decontaminate hands with soap and water (if hands are visibly soiled) or with an alcohol based hand rub, after performing the procedure or handling the fluid (IA) Use sterile (not distilled non sterile) water to fill bubble humidifiers (II) Change any HME that is in use by a patient when it malfunctions mechanically or becomes visibly soiled (II) Do not routinely change more frequently than every 48 hours a HME that is in use by a patient (II) review Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

39 Summary of General Recommendations
You can make a difference! Quality improvement initiatives show VAP (and the associated mortality) might be prevented by careful attention to the process of care Focus on preventing three most common mechanisms by which VAP develops: Aspiration of Secretions Colonization of the aero digestive tract Use of contaminated equipment

40 AARC Evidence-Based Clinical Practice Guidelines
Principal author: Dean R Hess PhD RRT FAARC. Writing committee:Thomas J Kallstrom RRT FAARC, Carl D Mottram RRT FAARC, Timothy R Myers RRT-NPS, Helen M Sorenson MA RRT FAARC, and David L Vines MHS RRT Hess DR, et al. AARC Evidence-Based Clinical Practice Guidelines. Respir Care 2003:48(9):

41 How do you take these best practices and effectively implement them?
VAP Bundle How do you take these best practices and effectively implement them? VAP Bundle Group of best practices that an institution employs to decrease their incidence of VAP Typically evidence based with a monitoring / compliance component

42 VAP Bundle: Evidence of Benefit
If we accept the reduction of the VAP rate (based on the unreliable current VAP definition) as the only outcome to be improved (independent of the absence of mortality and morbidity benefits), then there is an argument to potentially incorporate a few preventive measures (e.g., elevation of the head of the bed, continuous aspiration of subglottic secretions, oral topical antibiotics) into a VAP bundle. However, if we interpret the Joint Commission definition of proven outcome benefits as a reduction in VAP-associated mortality and morbidity, then there are no individual VAP preventive measures that have undergone adequate scientific replication that could be entered into any VAP bundle.

43 VAP Bundle: Evidence of Benefit
If we accept the reduction of the VAP rate (based on the unreliable current VAP definition) as the only outcome to be improved (independent of the absence of mortality and morbidity benefits), then there is an argument to potentially incorporate a few preventive measures (e.g., elevation of the head of the bed, continuous aspiration of subglottic secretions, oral topical antibiotics) into a VAP bundle. However, if we interpret the Joint Commission definition of proven outcome benefits as a reduction in VAP-associated mortality and morbidity, then there are no individual VAP preventive measures that have undergone adequate scientific replication that could be entered into any VAP bundle.

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45 Klompas M MD, Prevention of ventilator-associated pneumonia. Expert Rev. Anti Infect. Ther. 2010;8(7):

46 Klompas M MD, Prevention of ventilator-associated pneumonia. Expert Rev. Anti Infect. Ther. 2010;8(7):

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48 VAP Bundle: Evidence of Benefit
Benefits VAP-Industrial Complex Reporting of Quality Metrics The Quest for Zero VAP The VAP Bureaucracy The Joint Commission’s patient safety advisory group recently concluded that VAP will not be adopted as a National Patient Safety Goal in the near future because VAP cannot be consistently defined, identified or measured (42). The CDC has also recognized the subjectivity and complexity of their VAP surveillance definition and is currently working on a modified diagnostic algorithm (S.S. Magill, personal communication, 2011). Nevertheless, ICUs are still mandated to comply with hospital and state-based VAP bundle and surveillance programs even as VAP lingers in diagnostic and bureaucratic flux.

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51 Product Solutions and VAP
Advanced Heat and Moisture Exchangers Viral/Bacterial Filters Water Traps Closed System Water Traps Heated-wire circuits Advanced heated-wire circuits Maintenance Free Water Removal Accessory Advanced NIV products

52 ETT: Beyond Silver-coated Imanaka CCM 212
At extubation, only one ETT in 12 patients with ETTs was colonized in the Mucus Shaver group, whereas 10 ETTs out of 12 patients with ETTs were colonized in the control group. Scanning electron microscopy showed little secretions on the ETT from the study group, whereas thick bacterial deposits were on all the ETTs from the control group. No adverse events were observed and nursing staff seemed to be satisfied by its feasibility.

53 ETT: Beyond Silver-coated Imanaka CCM 212
At extubation, only one ETT in 12 patients with ETTs was colonized in the Mucus Shaver group, whereas 10 ETTs out of 12 patients with ETTs were colonized in the control group (8% vs. 83%; p <0.001). Scanning electron microscopy showed little secretions on the ETT from the study group, whereas thick bacterial deposits were on all the ETTs from the control group. No adverse events were observed and nursing staff seemed to be satisfied by its feasibility.

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55 New generation HME allows bypassing aerosol Advantages:
Advanced HME’s New generation HME allows bypassing aerosol Advantages: Eliminates caregiver exposure to de-pressurizing circuits Reduces circuit manipulation and cross contamination potential Disadvantages: More expensive than traditional HME’s

56 Viral/Bacteria Filters
Reduce the risk of ventilator cross-contamination between patients. Advantages: Ease of use Depending on efficiency ratings, potential for risk reduction against transmission of bacteria and viruses Disadvantages: During HH, condensation leading to increased Raw = frequent change Required frequent breaking of the circuit, exposing patient and caregiver to cross-contamination

57 Water Traps Collects the water that condenses in the breathing circuit. Advantages: Relatively inexpensive and often Integrated into the breathing circuit Disadvantages: Labor intensive Potential clinician exposure to contaminants Requires circuit “breaks” = cross contamination “The condensate that accumulates in the ventilator circuit is contaminated and care should be taken to avoid its cross-contamination of other patients.” (AARC)

58 Closed System Water Traps
Vacuum-activated suctioning water traps Advantages: Keeps condensate from collecting in the ventilator circuit with the use of intermittent or continuous suction. Maintains a closed system: no circuit “breaks. Disadvantages: Not Passive in nature--requires some clinician interaction and management to suction out condensate Dew Point not lowered, some condensation may still pass to the ventilator

59 Heated-Wire Circuits (Advantages)
Breathing circuit may decrease or eliminate condensate (dependent on circuit and heated humidifier settings) Solution integrated into breathing circuit Clinician familiarity and comfort Some heated humidifiers allow for adjustment of heated wire power (i.e. temperature gradient) to control the amount of condensate in the breathing circuit

60 Heated-Wire Circuits (Disadvantages)
Ambient conditions that cool the circuit = circuit condensate air conditioning, window, cold rooms “milking” of the breathing circuit to fix is not recommended and could be a safety hazard. Manufacturer change-out protocols may not be “duration of patient stay” which requires “breaking” the ventilator circuit making it difficult to comply with VAP risk reduction protocols Some circuits feature a super heated expiratory limb, which can lead to condensate forming in the ventilator (ECRI)

61 Advanced Heated-Wire Circuits
Heated expiratory limb made from a unique material that allows water vapor to diffuse through the tubing wall and permeate to the atmosphere Advantages: Promotes a closed system for the expiratory limb Reduces expiratory limb maintenance for the clinician Extends the usable life of the expiratory limb filter May reduce the humidity level enough to prevent the gas from cooling and reaching its dew point within the ventilator flow sensor Disadvantages: Fragile, highly susceptible to damage during normal handling Requires 7-day change out protocol Design does not allow for universal use

62 Maintenance Free Water Removal Accessory
Maintenance free water removal from the expiratory limb of the breathing circuit during mechanical ventilation Advantages Reduce circuit manipulation and cross-contamination potential Eliminate the need to interrupt ventilation Reduce the amount of time handling and disposing of condensation. Minimize exposure to de-pressurizing circuits Avoid accumulation of condensation in the ventilator Disadvantages At ventilator placement may require caregiver to drain pooled condensate into the device

63 DO NOT INTUBATE: Advanced NIV Products
Advances in noninvasive positive pressure ventilation (NPPV) products and protocols continue to improve the success rates of therapy Masks: Designed exclusively for NIV, mask cushions are now focused on patient comfort and therapy compliance Ventilators: New modes of ventilation are advancing use of NPPV Heated Humidifiers Heated humidifiers are now compatible with NPPV therapy, allowing the delivery of heat and humidity, improving therapy comfort

64 DO NOT INTUBATE: High Flow Oxygen Therapy
Sound alternative to NPPV Increased evidence: Indications Patient selection Positive outcomes Mechanical devices

65 Infection Protection:
Summary Infection Protection: Every Choice Matters

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68 VAP Prevention: RTs Making a Difference Arroliga A et al
VAP Prevention: RTs Making a Difference Arroliga A et al. Respir Care 2012

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80 Accredited Respiratory Education Programs
Advances in Respiratory Therapy Peer-to-Peer program: content created, reviewed and presented by respected respiratory thought leaders Focused on topics/therapeutic areas which enhance clinical outcomes Clinical Foundations: Self-Study program available via mail or web (www.clinicalfoundations.org) Topics Include Delivering Optimal Humidification, Difficult airway management, Trends in NIV, and Infection Prevention Strategies for the RT www. FirstDoNoHarm.com Website: Online resource devoted to preventing infections, saving lives and cutting costs Includes latest unbiased, authoritative information on preventing VAP

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82 Thank you for your attention!


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