1. Ventilator Care Bundle
Assignment – Critical care Nursing
OUM
Dr. S.N. Silva
(MBBS)

2. VENTILATOR ASSOCIATED PNEUMONIA

3. AIMS AND OBJECTIVES
To present a clinical case illustrating the problem of ventilator-associated pneumonia (VAP)
To discuss the diagnosis and management of VAP, along with a review of the evidence
To highlight controversies in dealing with VAP

4. CASE PRESENTATION
BB 73 M
Presented to SMH with 10/7 history of “laryngitis”
Cough/SOB/Fever

5. CASE PRESENTATION PMHx DHx Prostate Ca Bilateral TKRs for OA
Hypertension
DHx
Antihypertensives
Zoladex
NKDA

7. CASE PRESENTATION Initially managed on medical ward
However, deteriorated 1/7 into admission:
Tachycardia/hypotension/tachypnoea
Transferred to ICU, deteriorated further
Intubated
Ventilated. Needing high FiO2/PEEP
Inotropic support
Broad spectrum antibiotics
Over 2/52, gradual improvement. Antibiotics stopped

9. CASE PRESENTATION Improving- FiO2 now 40%, PEEP 8
Tracheostomy for weaning
Then deterioration:
FiO2 60% to maintain PO2 8
Tachypnoea
Pyrexia

11. ???

12. WHAT IS VAP? Er, noone really knows Suggested diagnostic criteria:
New CXR changes and one of:
Fever
Leukocytosis
Increasingly purulent secretions
48 hours or longer after institution of mechanical ventilation
Confirmation by microbiological sampling (BAL/tracheal brushings)

13. WHAT IS VAP? Wide range of organisms: Gram positive: Gram negative:
Staph Aureus (both MSSA and MRSA)
Streptococcus
Gram negative:
Pseudomonas
Acinetobacter
Klebsiella
Others:
Candida/Aspergillus
Viruses (rare)

14. WHO GETS VAP?
Host
Environment
Age
Sex (M>F)
Underlying disease state (chronic disease, conscious level, sepsis etc)
Intubation
Length of ventilation
Tube cuff pressure
Reintubation
Sedation
Body postion*
Use of gastric protection*
NG feeding
Unit hygiene*
People being mechanically ventilated (Both ETT and tracheostomy)
Risk factors:

15. WHY IS IT IMPORTANT? We see it all the time (27% of ICU patients)
Mortality 27-76% (!)*

16. WHY IS IT IMPORTANT?

17. WHAT SHOULD WE DO? Identify the at risk patient Reduce the risks
Rapidly diagnose VAP when it occurs
Treat appropriately

18. REDUCING THE RISKS “Care bundles”
Series of intervention grouped together as a single one
Worked well with central venous catheters (“Matching Michigan”)*

19. REDUCING THE RISKS Elevation of bed 30-45 degrees* DVT prophylaxis
Humidification
Oral hygiene/chlorhexidine mouthwash*
Gastric ulcer prophylaxis*
Appropriate ventilator tubing management
Suctioning of oropharyngeal secretions
Sedation holding/review

20. REDUCING THE RISKS (Extra stuff from Europe)
Microbiological surveillance
Low nurse:patient ratio
Reduce antimicrobial prescriptions
Orotracheal tubes/orogastric tubes
Maintaining ETT cuff pressure >20cmH20
Subglottic aspiration*
Antiseptic coated ETTs*

21. ORAL DECONTAMINATION WITH CHLORHEXIDINE
Simple
Cheap
Quite safe
Makes sense

22. SELECTIVE DIGESTIVE DECONTAMINATION
Similar principle, but involves using oral decontamination + NG tube antibiotics + IV antibiotics in a variety of recipes
Same principle as above

23. GASTRIC ULCER PROPHYLAXIS
Reduces risk of ventilator associated stress ulcers…
But INCREASES risk of VAP
What to do?

24. GASTRIC ULCER PROPHYLAXIS
“No single strategy of stress ulcer prophylaxis is preferred when mortality is used as the outcome. In the absence of a clinical trial demonstrating survival benefit the individual clinician's assumptions regarding the effect of prophylaxis on gastrointestinal bleeding and pneumonia and the attributable mortality of pneumonia vs. gastrointestinal bleeding will have a significant effect on the decision”.

25. RAPID DIAGNOSIS Sensitivity 77%, specificity 42% 
Other biomarkers being searched for- none yet
(Procalcitonin/CRP useful treatment monitors, but not so useful for diagnosis)

26. RAPID,SPECIFIC TREATMENT
Start treatment early when suspected
Broad-spectrum antibiotic (with antipseudomonal activity) +/- aminoglycoside recommended

27. Assignment Define terms VCB – ? VAP – OUM has done
Critically ill patient - ?
Critically ill patient with VAP

28. Then….. Discuss using VCB Significance of using VCB
Critically Discuss VCB

29. Ventilator Associated Pneumonia
Multiple factors should be considered when addressing the issues of HAP and VAP. These factors include the following:
Whether or not to intubate the patient
The route of intubation or placement of tubes
Feeding the patient
Body positioning
Prevention of stress-related bleeding
Prevention of deep venous thrombosis
Use of antibiotics and control of colonization

30. Ventilator Associated Pneumonia
Who / When/ What?
While critically ill patients experience a life-threatening illness, they commonly contract ventilator-associated pneumonia. This nosocomial infection increases morbidity and likely mortality as well as the cost of health care. This article reviews the literature with regard to diagnosis, treatment, and prevention. It provides conclusions that can be implemented in practice as well as an algorithm for the bedside clinician and also focuses on the controversies with regard to diagnostic tools and approaches, treatment plans, and prevention strategies.

31. Significance
“The application of the VAP bundle in chronic ventilated patients resulted in a significant reduction in the incidence of VAP. ”

32. Significance
“Initiation of the VAP bundle is associated with a significantly reduced incidence of VAP in patients in the SICU and with cost savings.”

33. Critically?
“The ventilator bundle should be modified and expanded to include specific processes of care that have been definitively demonstrated to be effective in VAP reduction or a specific VAP bundle created to focus on VAP prevention. ”

34. Critically ? “Individual elements did not appear
effective; strict compliance with infection elements was needed. Efforts to prevent VAP may be successful in settings of high
levels of compliance with all infection-specific elements and in settings with full-time HEs.”