1. Preventing VAP - evidence for a care bundle

2. VAP Incidence ~ 10 - 30% ventilated patients 7-15 / 1000 ventilator days Atributable mortality of 0-50% Atributable increase LOS of ~ 3 weeks

3. Prevent VAP Care Bundle Reduce time on ventilator: Assess sedation requirements daily Assess suitability for weaning and extubation daily While on ventilator: Semi-recumbent positioning Oral chlorhexidine ? Subglottic drainage

4. 128 ventilated patients Randomised: daily sedation break and titration v. standard care Outcomes: duration of ventilation, ICU & hospital stay

5. VentilatorICUHospital p=0.004 p=0.02 p=0.19

6. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Brook AD, Ahrens TS, Schaiff R et al Crit Care Med.1999;27:2609-15 321 ventilated patients Randomised: nurse-led sedation protocol v. standard care Outcomes: duration of ventilation, ICU & hospital stay

7. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Brook AD, Ahrens TS, Schaiff R et al Crit Care Med.1999;27:2609-15 P=0.003 P=0.013 P<0.001

8. 300 ventilated patients Randomised: daily weaning trial v. standard care Outcomes: duration of ventilation, ICU & hospital stay

10. RCT of protocol-directed v. physician-directed weaning from mechanical ventilation. Kollef MH, Shapiro SD, Silver P et al. Crit Care Med. 1997; 25:567-74

11. RCT of protocol-directed v. physician-directed weaning from mechanical ventilation. Kollef MH, Shapiro SD, Silver P et al. Crit Care Med. 1997; 25:567-74

14. Avoiding Ventilation Daily sedation titration and weaning protocols will reduce ventilator days and ICU stay VAP may be less common

15. 86 ventilated patients VAP in 23% supine patients (28.4/1000 Vent d) v. 5% semi-recumbent (7.3/1000 Vent d) NNT (95%CI) = 6 (3-23)

16. Study groupSemi-recumbent n = 112 Standard n = 109 Average bed elevation Day 1 Day 7 28.1 o 22.6 o 9.8 o 16.1 o VAP11.6% 10.2/1000 Vent d 7.3% 7.8/1000 Vent d

17. Semi-recumbency 45 o head-up tilt is very difficult to achieve No benefit of semi- recumbency ~30 o over standard care ~10 o Supine position is harmful

18. Oro-pharyngeal Antiseptics

21. Crit Care Med 2007; 35:595–602

24. Subglottic drainage In patients expected to be ventilated > 3 days In patients to be intubated de novo Halves the risk of VAP NNT = 8 (95% CI 5-15) Shortens ventilation 2 days & ICU stay 3 days

25. Prevent VAP Care Bundle Assess sedation requirements daily Assess suitability for weaning and extubation daily Semi-recumbent position Oral chlorhexidine ? Subglottic drainage

26. Do VAP prevention programmes work? Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Zack JE et al Crit Care Med 2002; 30: 2407-12 An educational intervention to reduce VAP in an integrated health system: a comparison of effects. Babcock HM et al Chest 2004; 125: 2224-31 Reducing VAP rates through a staff education programme. Salahuddin N et al J Hosp Infect. 2004; 57 :223-7 Adherence to simple and effective measures reduces the incidence of VAP. Baxter AD et al Can J Anaesth. 2005; 52: 535-41

31. VAP in Critical Care, RIE

32. Conclusion There is reasonable evidence from RCTs and their metanalyses to support the elements of the proposed ‘ Prevent VAP Care Bundle’ Other groups have halved VAP rates through education programmes, reinforcing adoption of protocols to prevent VAP