1. Journal Club

2. Background to the paper Pneumonia is THE MOST COMMON nosocomial infection in ICU patients 12 to 18 cases per 1000 ventilator days Oropharyngeal colonisation Aspiration of oropharyngeal bugs!

3. Outcomes Primary outcome Frequency of suspected pneumonia in a semirecumbent & supine posture. Secondary outcome Compare frequency of microbiol confirmed pneumonia in the 2 groups.

4. Methods Recruited for 1 year 1000 bed tertiary hospital Stress ulcer prophylaxis Continous enteral feeding Gastric aspiration every 4 hours

5. Methods II Exclusions Recent abdo surgery in last 7 days Neurosurgery in last 7 days Refractory shock Previous endotracheal intubation in last 30 days

6. Methods III Random allocation to 0 deg or 45 deg head up Computer generated randomization list Clin suspicion defined: new infiltrates on CXR Fever > 38.3 WCC 12. Purulent tracheal secretions Pathogenic organism in BAL PSB

7. VAP: Why is it Important? VAP occurs in 10-25% of patients undergoing mechanical ventilation (4-16 cases/1000 ventilator days Patients stay in ICU on average 4-9 more days Attributable mortality 20-50% High morbidity and mortality Preventable with simple technology

8. Trial profile

9. Baseline data

10. Micro data

11. Pneumonia results

12. Major Results

13. Ventilator Associated Pneumonia (VAP) Practice Alert 13 HOB Elevation Leads to Significant Deduction in VAP Dravulovic et al. Lancet 1999;354:1851-1858

14. Results 86 mechanically ventilated patients randomized to either supine (flat) vs semi-recumbent (45 degrees) to assess relationship to nosocomial pneumonia Trial stopped early Clinically suspected pneumonia decreased from 34% to 8% (p=0.003) in semi-recumbent group Microbiologically confirmed pneumonia was reduced from 23% to 5% in the semi-recumbent group (p=0.018) The semi-recumbent body position reduces frequency and risk of pneumonia. The risk of pneumonia increased with longer duration of mechanical ventilation and with decreased consciousness.

16. Ventilator Associated Pneumonia (VAP) Practice Alert 16 Continuous Removal of Subglottic Secretions Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation. CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005

17. Ventilator Associated Pneumonia (VAP) Practice Alert 17 HOB Elevation HOB at 30-45º Torres et al, Annals of Int Med 1992;116:540-543 Ibanez et al. JPEN 1992;16:419-422 Orozco-Levi et al. Am J Respir Crit Care Med 1995;152:1387-1390 Drakulovic et al. Lancet 1999;354:1851-1858 Davis et al. Crit Care 2001;5:81-87 Grap et al. Am J of Crit Care 2005 14:325-332

18. Ventilator Associated Pneumonia (VAP) Practice Alert 18 Is HOB Elevation Done? Despite effectiveness of HOB elevation, compliance is poor. Grap et al. Am J Crit Care 1999;8:475-480 Grap et al. Am J Crit Care 2005;14:325-332 Degrees of HOB Elevation