3 IntroductionMechanical ventilator is one of the most important life saving devices used in conditions like:Respiratory failureProtection of airwayHead injuryPostoperativeShockHowever, 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 ERRORNational institute of health excellence (NICE) -2007center for disease control and preventionVentilator-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. 1In 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 ventilationMortality varies according to the type of organismsMulti-resistant organisms have a higher mortalityEven 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 EpidemiologyHospital 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 IncidenceVAP 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 ptsMortality rate is 37% and 43% with antibiotic resistant organismCritical Care Societies Collaborative (CCSCs)
8 Incidence Cont….Increases ventilatory support requirements and ICU stay by 4.3 daysIncreases hospital LOS (length of stay) by 4 to 9 daysIncreases medical cost ($5,000 to $40,000 per VAP) Critical Care Medicine ;33:
9 Causative Organisms: Early onset Late onset Hemophilus influenzaStreptococcus pneumoniaeStaphylococcus aureus (methicillin sensitive)Eschrichia coliKlebsiellaPseudomonas aeruginosaAcinetobacterStaphylococcus aureus (methicillin resistant)
10 How is the pneumonia happening? Most plausible mechanism and source:Leakage around the ETT cuff (primary route)… aspiration of bacteriaHigh rate of the oropharyngeal or tracheobronchial colonization (gram neg bacilli)Bacteria from the tongueBacteria from environment: caregivers’ hand, air, water, dustContaminated equipment (ventilator tubing, aerosol, etc.)Suctioning equipment
11 Risk Factors: Host Related Medical / surgical diseaseImmunosuppressionMalnutrition (Alb<2.2g/dl)Advanced agePt’s position (supine)LOC – impaired LOC, delirium, comaMedications – sedation, steroids, previous antibiotic use, NM blockersNumber of intubations- reintubationsCOPD, obesity, ARDS, gastro esophageal disease, burn, trauma
12 Risk Factors: Device Related Mechanically ventilated with ETT or Tracheostomy tubeProlonged MV - MV > 48 hoursNumber of intubations, reintubationsNGT or Orogastric tubeUse of humidifierThe presence of the ET-tubes leads to VAP (not the ventilator)
13 Risk Factors: Health Care Personnel Related Improper hand washingFailure to change gloves between contacts with ptsFailure to wear personal protective equipment when required
14 PathogenesisBacteria enter the lower respiratory tract via following pathways:Aspiration of organisms from the oropharynx and GI tract (most common cause)Direct inoculationInhalation of bacteria
15 Aspiration ETT/T NGT/OGT Holds vocal cords openPredispose pt to micro and macro aspiration of colonized bacteria from oropharynxLeakage of secretions containing bacteria around ETT cuffInterrupts gastro-esophageal sphincter leading to GI reflux and aspirationIncrease oropharyngeal colonization and stagnation of oropharyngeal and nasal secretionsPrimary Route of Bacterial Entry into LRT
16 A New Streamlined Surveillance Definition for Ventilator-Associated Pneumonia Critical Care Med 2012 vol.40, no.1The 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 infiltrateConsolidation, 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 causeLeukopenia (<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 secretionsNew onset or worsening cough, dyspnea or tachypneaRales or bronchial soundsWorsening 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 availabilityIndividualized to pt - Early onset vs Late onset of VAP, prior antibiotic use, underlying disease, renal, liver, etcSurveillance cultures
22 Duration of Treatment Standard duration 7-14 days Longer duration > days risk of toxicity and resistanceShorter < 7 days risk of recurrenceDepends on severityIsolation of microorganism
23 Prevention Specific practices have been shown to decrease VAP Strong evidence that a collaborative, multidisciplinary approach incorporating many interventions is paramountIntensive education directed at nurse and respiratory care practitioners resulted in a 57% decrease in VAOCrit Care Med (2002)
24 The VAP BundleBUNDLE“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 extubateThe 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 admissionIN TH COMPONENT of Daily oral care and decontamination with ChlorhexidineCrit.Care 2012 vol.40, no.1Vap Bundle originated in 2005 from the Institute of Health Care ImprovementWe are presently working on 1. Collective OrderChlorhexidine 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: HANDWASHINGSingle most important and ( easiest!!) method for reducing the transmission of pathogensUse of waterless antiseptic preparations is acceptable and may increase complianceRemember to wash your hands The 5 moments of handwashing:Before touching ptBefore clean/aseptic procedureAfter body fluid exposure riskAfter touching ptAfter touching pt’s surroundings
27 HOB 30-45° HOB 30-45° unless contraindicated Especially recommended for Neuro populationTo prevent aspiration during enteral feedingContraindications:Hypotension MAP < 70Tachy?? >150CI <2.0Central line procedureCervical instability – use reverse trendelenburg
28 Daily sedative interruption and daily assessment of readiness to extubate OVERSEDATION predisposes pts to:ThromboemboliPressure ulcersGastric regurgitation and aspirationVAPSepsis
29 Daily sedative interruption and daily assessment of readiness to extubate OVERSEDATION predisposes pts to:Difficulty in monitoring neuro statusIncreased use of diagnostic proceduresIncreased ventilator daysProlonged ICU and Hospital stay
30 Daily Wake-up Every pt must be awakened daily unless contraindicated Daily weaning assessments reduce the duration of MVIf pt becomes symptomatic – rebolus and restart infusion at lower dose than original doseGoal 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 FeedingsInitiation of safe enteral nutrition within hours of ICU admissionEarly initiation decreases bacterial colonizationHOB 30-45°Routinely + PRN verification tube placement
33 Additional Evidence-Based Component of Care: Deep venous thrombosis (DVT) prophylaxis (unless contraindicated)TED stockingsSCD machineHeparin S/C
34 Deep venous Thrombosis Prophylaxis and early mobility practices Pt turning Q 2hours increase pulmonary drainage and decreases risk VAPEarly mobilization
35 Daily Oral care Oral assessment Q shift Brushing teeth, tongue and gums with a soft toothbrush (minimally twice daily)Moisturizing agent for mouthAntiseptic rinseSwabs are not effective at removing plaquesChlorhexidine decontamination of mouthRoutine suctioning of mouth to manage oral secretions and minimize risk of aspirationDental plaque due to the absence of mechanical chewing and the saliva are reservoirs for potential pathogens that cause VAP
38 MouthcareUsing chlorhexidine gluconate 0.12% (Peridex) solution every 6-12 hours to perform oral care, according to your protocolsolution is used to rinse the patients’ mouth.
39 ET Tube Care Cuff pressure (between 20-30cm H2O) Oral intubation preferredContinuous or intermittent sub-glottic aspirationAvoid unnecessary disconnection of MV circuitOpen vs close suctioning… benefits is not demonstrated yetOral 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 24hrsMouth can colonize as quickly as 24hr after admissionIntermittent and continuous subglottic suctioningSuctioning 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 PRNGently follow tongue to suction back of throatUse yankauer suction
42 Suctioning Oral suction devices (Yankauer) Follow policy for use and storage?Harbor potentially pathogenic bacteria within 24 hoursDate and change Q dayRinse with sterile water after each useAllow to air dry
43 Subglottal Suctioning Should be done using a 14 French sterile suction catheterPrior to ETT suctionningPrior to pt change of positionPrior to extubation* Continuous subglottic ETT with dedicated lumen above cuff may reduce risk of VAP
45 Prevent contamination of equipment Ventilator tubingHeat and moisture exchangers (green filters) are preferred over humidifiers (CDC B-II)Sterile suctioningBe careful with the tubing of the ventilator when you suction patient…Remove contaminated condensate from ventilator circuit (CDC, A-II)
46 SummaryNosocomial pneumonia and especially VAP are the most frequent infectious complications in the ICU, and they significantly contribute to morbidity and mortalityVAP is an important determinant of ICU and Hospital lengths of stay and healthcare costsNo standard to diagnoseSeveral simple preventative measures (VAP bundle) and timely initiation of appropriate antibiotics ensure better outcomes in pts with VAP
48 ReferencesNational Guideline Clearinghouse (current). Guideline Summary NGC-6634: Prevention of ventilator-associated pneumonia. Retrieved from: md.com/medinfo/material/f97/4eb0b88d44aece1112f7bf97/4eb0b8a944 aece1112f7bf9a.pdfNiel-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, ppSafer Healthcare now (2012). Ventilator associated pneumonia. Retrived from: pxSafer Healthcare now (2012). Getting Started Kit. Retrieved from P%20Getting%20Started%20Kit.pdf
49 ReferencesAlhazzani, 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
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