Risk is greatest in patients with trauma or surgery of the head, neck, thorax, or abdomen.
Mechanically ventilated (ETT or trache) for > 48 hours
Ventilator associated pneumonia
VentilatorAssociated Pneumonia (VAP) DR. PHILIP
Case- 50yrs old man transferred from KKH on 26/12/1433Mr. MIAH HASAN,as case of RTA-head injury with Cx spine # C4-C6(operated),Infected stage 4 sacral Bed Sorewith respiratory failure (neural mediated RF).DAY-148 in ICU/hospitalDAY 1468 on ventilator(tracheostomy) SIMV mode Vt-500ml, RR-12/min, Fio2 45%,PEEP-3mbar, PS-16mbar Since five days Fio2- 65-75% ,PEEP -8, to maintainSpo2 above 95% and Pco2 -78mmHg , ABG-RES. ACIDOSIS WITH HYPOXIEMIA O/E- Temp38.9 degree celcius HR-102b/min ,BP-98/58mmHg ,RR-28breaths/min, pallor, emaciated, on noradrenaline & dopamine BED SORES partially clean with health granulation tissue Diarrhea since 10 days S/E -RS- mucopurulent resp secretion B/L crackles Rt>Lt , P/A and CVS-unremarkable CNS- conscious, vague response to vc, Quadriplegic LAB. R - Wbc-22,Hb-9.5g/dl , plt- 93 alb-2.46mg/dl TP-5.9mg/dl wbc-41(4/5) Sputum analysis- Candida, GPC-++ Pus cells-+++, Stool analysis –NBFSputum-c/s(4/5/33)-pseu.auerginosa, klebsiella pneumonia. Sensitive to Ceftazidime, Tienam. CXR– will reviewTREATMENT- Antibiotics,zantac, iron folic acid, clexan and supportive treatment NGTFEEDING partially supported by parenteral . Antibiotic- tienam and cipro
INTRODUCTIONMechanical ventilator is one of the important lifesaving devices used in conditions likeRespiratory failure (main indication)Protection of airwaysHead injuryPost operativeShockHowever, as like any other devices/ medicationsMV also associated with complications likeHemodynamic instability, Pneumothorax, VALI andVENTILATOR ASSOCIATED PNEUMONIA
What is VAP? A Nosocomial pneumonia associated with mechanical ventilation (either by Endotracheal tube or Tracheostomy) that develops within 48 hours or more of hospital admission and which was not present at the time of admission. National institute of health excellence (NICE)-2007 center for disease control and prevention
TYPES--EARLY ONSET: -within 3-4days of MV less virulent, community acquiredorganism- Str.pneumonia, H. influenzaeLATE ONSET: -After 3-4 days of MV More virulent, hospital acquired organism-Pseudomonas, Acinetobacter, MRSA, Enterobacteriaceae
EPIDEMIOLOGY•Hospital acquired pneumonia (HAP) is thesecond most common hospital infection.• VAP is the most common intensive care unit(ICU) infection.• 90% of all nosocomial infections occurringin ventilated patients are pneumonias.
INCIDENCE VAP occurs in 10 - 65% of all ventilated patients Crit Care Clin (2002) Incidence increases with duration of MV 3% /day for first 5days, 2%/day for 6-10days and 1%/day after 10 days. The incidence of VAP is highest in the following groups: Trauma, Burns, Neurosurgical pts. Postop. Mortality rate is 27% &43%with antibiotic resistant organism. critical care societies collaborative(CCSCs) Mortality rate in VAP caused by Pseudomonas or Acinetobacter is as high as 76% Crit Care Med (2004)
Cont…VAP Increases ventilatory support requirements and ICU stay by 4.3 days Increases hospital LOS by 4 to 9 days Increases medical cost Chest 2002;122:2115 Critical Care Medicine 2005;33:2184-93
Causative Organisms Early onset: Hemophilus influenza Streptococcus pneumoniae Staphylococcus aureus (methicillin sensitive) Escherichia coli Klebsiella Late onset: Pseudomonas aeruginosa Acinetobacter Staphylococcus aureus (methicillin resistant) Most strains responsible for early onset VAP are antibiotic sensitive. Those responsible for late onset VAP are usually multiple antibiotic resistant Am J Resp Crit Care (1995)
RISK FACTORS FOR VAP Host related: -Underlying medical conditions- COPD, obesity, ARDS, gastro esophageal disease, burn, trauma, MODS etc-- -Immunosuppression, Malnutrition(S.Albumin<2.2g/dl) -Advanced age -Patients’ body position -Level of consciousness- impaired LOC, delirium, coma. -Number of intubations- Reintubations -Medications (Antibiotics, sedation, NM blockers)
Cont..• Device related: - MV with Endotracheal tube, trcheostomy -Prolonged MV -Number of intubations- reintubation -Use of humidifier -Nasogastric or orogastric tubes• Personnel related: -Improper hand washing -Failure to change gloves between contacts with pts -Not wearing personal protective equipment when
PATHOGENESIS Bacteria enter the lower respiratory tract via following pathways: Aspiration of organisms from the oropharynx and GI tract (most common cause) Direct inoculation Inhalation of bacteria Haematogeneous spread
ASPIRATION- Primary Route ofBacterial Entry into LRT ENDOTACHEAL TUBE Holds the vocal cordsopen-predispose to micro & macro aspirationof colonized bacteria from oropharynx to LRT.Leakage of secretion containing bacteriaaround the ETT cuff. NGT OR OROGASTRIC TUBE Interrupt gastro-esophageal sphincterleading GI reflux and aspiration.Increase oropharyngeal colonization, stagnationof oropharyngeal and nasal secretion.
HOW DO WE DIAGNOSE? 2-1-2 Radiographic evidence x 2 consecutive days New, progressive or persistent infiltrate Consolidation, opacity, or cavitation Clinical sings At least 1 of the following: Fever (> 38 degrees C) with no other recognized cause Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000 WBC/mm3) At least 2 of the following: New onset of purulent sputum or change in character of secretions New onset or worsening cough, dyspnea, or tachypnea Rales or bronchial breath sounds Worsening of gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)
CONT…Microbiological criteria (optional)At least one of the following:• Positive growth in blood culture not related to anothersource of infection.• Positive growth culture pleural fluid.• Bronchoaleveolar lavage > 105colony forming units/ml. sensivity &specificity 42-93% &45-100% Protectedspecimen brushing >103cfu/ml (33-100% & 50-100%) chest.Apr2000;117(4suppl2):198-2002)•Histopathological evidence of pneumonia
Cont--•RADIOLOGICAL FINDING AND 2 CLINICALCRITERIA SENCIVITY OF DIAGNOSING VAPIS 69% AND THE SPECIFICITY IS 75%• SAMPLING OF RESPIRATORY SECREATION can be obtained from distal or proximal airway howeverthe sensivity and specificity is more with distal airwaysample(Bronchoalveolar lavage(BAL) , Protected specimenbrush sampling(PAB).•ABSENCE OF RADIOLOGICAL FINDINGHELPFUL FOR EXCLUDING THE DIAGNOSISOF VAP
A new streamlined surveillance defintion for ventilator-associated pneumoniaAny one of the following1. Opacity, infiltrate, or consolidation that appears, evolves, or persists over 72 hrs2. CavitationAny one of the following1. Temperature 100.4°F within past 24 hrs2. White blood cell 4,000 or 12,000 white blood cells/mm3 within past 24 hrsBoth of the following1. Two days of stable or decreasing daily minimum FIO2 followed by increase indaily minimum FIO2 15 points sustained for 2 calendar days OR 2 days of stable ordecreasing daily minimum positive end-expiratory pressure followed by increase indaily minimum positive end-expiratory pressure by 2.5 cm H2O sustained for 2calendar days2. Gram-negative stain of respiratory secretions with moderate (2+) or moreneutrophils per low power field within 72 hrs.Critical care med 2012 vol.40,no.1
TREATMENT PROTOCAL• Initial therapy is empiric• Start when VAP is suspected, Don’t delay• Individualize to institution- -Hospital epidemiologic data -Drug cost and availability• Individualize to patient- -Early onset versus Late onset of VAP -Prior antibiotic use -Underlying disease Renal, liver disease etc -Surveillance cultures -Use gram stain results if possible
TREATMENT• GENERAL APPROACH FOR INFECTION CONTROL• ANTIBIOTICS- Selection of antibiotics:Early onset of VAP and no risk for MDR - Cefrioxone, fluroquinolones, ampicillin-sublactum Late onset of VAP and risk for MDR- Antipseudomonal cephalosporin(cfepime,ceftazidime) Carbapenems(imipenem,meronem), Beta lactam/betalactamase inhibitors-piperacillin-tazobactam Amonoglycocides with vancomycine,linezoidANTIBIOTCS TO BE ADJUSTED FURTHER ON THE
Risk Factors for drug resistance ABX in last 14 days Prior culture with MRO Immunocompromised Chronic primary lung pathology Acute or long term care hospitalization within 14 days Tracheostomy for > 5 day
DURATION OF TREATMENT- Depends on severity,- Time to clinical response and micro organism response- Isolation of microorganism- Longer duration >14-21days risk of toxicity and resistance- Shorter duration<7days- risk of recurrence-standard duration of treatment 7-14 days- Longer durtion 14-21 days may be indicated in Multilobular involvement, cavitation, gram-venecrotising pneumonia, isolation of Pseudomonas,Acnetobacter
Further inpatient careAbout 30% of pts. Fail to respond-
PREVENTION Specific practices have been shown to decrease VAP Strong evidence that a collaborative, multidisciplinary approach incorporating many interventions is paramount Intensive education directed at nurses and respiratory care practitioners resulted in a 57% decrease in VAP Crit Care Med (2002)
PREVENTIONConventional Infection control Aproach•DESIGN OF ICU- Adequate space, lighting, proper function of ventilatory system, facilities for hand washing, Isolation room.•STAFFING- Education, Adequate number, quality, importance of personal cleanliness and attention to asceptic procedures.•Hand washing and Hand rubbing with alcohol based solution.•PERIODICAL BACTERIAL MONITORING POLICY.• SPECIFIC PROPHYLAXIS- Use Gloves, Gown, Mask. Use of NIPPV Minimize duration of MV, checking daily for readiness toweaning/extubation (Text book of criti care med. 5 the Edit.
VAP BUNDLE (VAP reduction rate44.5%)VAP bundle(4) originated in 2005 from INSTITUTEOF HEALTH CARE IMPROVEMENT(IHI) & CDC1. Elevation of the head of the bed (HOB) to between 30 and45 degrees.2. Daily sedative interruptional and daily assessment ofreadiness to extubate.3. Stress ulcer disease prophylaxis.4. Deep venous thrombosis (DVT) prophylaxis (unlesscontraindicated)5.IN 2010 FIFTH COMPONENT DAILY ORAL CAREWITH CHLORHEXIDINE IS ADDED.(criti. care 2012 vol. 40,no.1)
HANDWASHING Hand washing is the single most important (and easiest!!!) method for reducing the transmission of pathogens Use of waterless antiseptic preparations is also acceptable and may increase compliance. Remember to wash your hands Before and after patient contact Beginning and end of work day Before and after using gloves After touching contaminated surface
HOB 30 - 45 Degrees The supine position is an independent risk factor for death in all ICU patients HOB elevation to 30-45 degree especially during feeding prevent aspiration and 34% reduction in VAP (Lancet.nov.1999;354,1851-1858) CDC recommends HOB 30-45° unless contraindicated
Contraindications- Hypotension MAP <70-Tachycardia >150-CI <2.0-Central line procedure-Posterior circulation strokes-Cervical spine instability use reverse trendelenburg-Some femoral lines i.e.: IABP no higher than 30 degrees use reverse trendelenburg-Increased ICP, No higher than 30 degrees avoid hip flexion-Proning
Reverse Trendelenburg In full reverse Trendelenburg the foot of bed will read -12 degrees Angle of head elevation is approximately 20 degrees (not 30 degrees) when at -12 Evaluate the individual clinical situation to assess if the patient can tolerate the addition of a small amount of Fowlers angle which may flex the hip
Daily Sedative Interruption and DailyAssessment of Readiness to Extubate OVERSEDATION Predisposes patients to: Thromboemboli Pressure ulcers Gastric regurgitation and aspiration VAP Sepsis Consequences include: Difficulty in monitoring neuro status Increased use of diagnostic procedures Increase ventilator days Prolonged ICU and hospital stay
Daily Wake Up Every patient must be awakened daily unless contraindicated! Daily weaning assessments reduce the duration of mechanical ventilation. Wean infusion to off in increments of 10-25% daily in order to perform a clinical assessment Rebolus and restart infusion if the patient becomes symptomatic. Your new continuous IV dose should be lower than what you began with Consider implementation of a sedation scale such as the Richmond Agitation Sedation Scale (RASS) scale to avoid over sedation. Goal is to decrease sedation
STRESS ULCER PROPHYLAXISSUCRALFATE, H2 RECEPTOR BLOCKER,PROTON PUMP INHIBITOR Increases gastric ph and minimize bacterial colonization thatreduces the risk of VAP and GI bleedingSUCRALFATE-Decreases the VAP rate but increases the risk of GI bleeding by 4%.H2 receptor blockers/PP inhibitors-Increase rate of VAP by increasing gastric Ph leading to colonization ofbacteria and decreases the risk of GI bleeding.H2 receptor blocker, PP inhibitor preferred over sucralfate . Am J Respir Crit Care Med. 2005;171(4):388-416
Deep Venous Thrombosis(DVT) ProphylaxisThere is increase risk of thomboembolism inmechanically ventilated patient.There is no any data association between DVTprophylaxis and decreasing rates of VAP.VAP rates decreased most dramatically in hospitalswhere all elements of the Ventilator Bundle wereimplemented, including this one. Chest. 2004;126(3 Suppl):338S-400S.
DAILY ORAL CAREDental plaque- due to absence of mechanical chewingand the saliva and they are reservoir for potentialpathogens that causes VAP.MECHANICAL INTERVENTIONTooth brushing , Rinsing of oral cavity to remove dental plaquePHARMACOLOGICAL INTERVENTION0.12% CHLORHEXIDINE ORAL RINSE Am J Crit Care. 2009 Sep;18(5):428-437Oral decontamination- 2%genta+2%Collistin+2%Vanco paste QIDSelective decontamination of digestive tract(SDD)-2%polymyxin+tobra+Amphotericine paste oral application QID. Solution 100mg poly+80mg tobra+500mg ampho QID throu NG. I/V Cefuroxime 1.5g TID first 4days.
DAILY ORAL CARE Best Practice?? Daily assessment to determine oral health Brush q 12 hours to prevent plaque Oral cleansing q 2-4 hours to promote healing and maintain integrity of oral tissues Use of an alcohol-free, antiseptic oral rinse to prevent or reduce bacterial load of oropharynx Routine suctioning of mouth to manage oral secretions and minimize risk of aspiration Use of a moisturizer Am J Crit Care (2005)
PREVENTION NIPPV Subglottic suction Maintaining ETT/TT cuff pressure 20- 30cmH20 Orotracheal rather than nasotracheal intubation Avoid unnecessary disconnection of MV circuit. Closed inline suctioning. Avoid saline instillation for suctioning thick secretion. Appropriate Humidification of inspired air. Early Enteral feeding Turning patient every 2 hrly.
Airway Management Mechanical ventilation Avoidance of Endotracheal intubation Mask ventilation trials , NIPPV Minimize duration on MV Orotracheal intubation Nasotracheal intubation slightly increase the risk for VAP Avoid Reintubations- increases risk of VAP 6 fold (Am resp.criti car med.1995;152(1):137-141) Cuff management HVLP ETT cuff VAP rate 20% , LVHP ETT cuff VAP rate 20% (Text book of criti. Care. 5 th Edit. Mitchell P.Fink SHOEMAKER) Maintain at 25-30 cm H2O
Airway Management Suctioning In-line suctioning using closed technique than open technique Normal saline Should not be routinely used to suction pts Causes desaturation Does not increase removal of secretions Can potentially dislodge bacteria from ETT to LRT Should be used to rinse the suction catheter after suctioning Maintaining adequate hydration, proper humidification of ventilatory circuit, nebulizer, mucolytic agent can help to decrease the viscosity and eliminate the need for saline lavage (Am. jour.crical care
Suctioning Oral suction devices (Yankauer) Policies for use and storage not written Harbor potentially pathogenic bacteria within 24 hours 71% of nurses store the device in its packaging (STAMP) Best practice??? Change q day Rinse with sterile water or NS Allow to air dry
SUBGLOTTAL SUCTIONING Should be done using a 14 Fr sterile suction catheter: Prior to ETT rotation Prior to lying patient supine Prior to Extubation Continuous subglottic suctioning ETT with dedicated lumen to continuously or intermittently suction above suction above the cuff may reduce the risk of VAP. Am J Respire cri car Med Oct.. 2010
Ventilator Circuit-Management Vent circuit should not be routinely opened once ventilation is initiated Disconnection of ventilation tubing can lead to loss of PEEP and alveolar de-recruitment If circuit must be disconnected, clamp ETT with padded Kelly forceps to avoid PEEP loss Expiratory condensation should be removed via the trap in the tubing Inspiratory condensation – if clean, may be drained back into the water reservoir Ventilator circuit can be changed weekly, unless it is soiled with blood or vomitus
Ventilator Circuits Humidification Systems Appropriate Humidification of inspired air Active Humidification or Passive Humidification Heat and Humidity Exchangers (HMEs) should not be routinely changed unless: Visibly soiled > 5 cm H2O auto-PEEP Convert to Heated Humidification (HH) if: Ventilated longer than 96 hours Thick/bloody secretions Resp. Acidosis Air leak from chest tube or around airway VT < 300 cc or > 750 cc
Enteral Feedings Early enternal feeding decrease bacterial colonization and rate of VAP Bolus feeding should be avoided to minimize the risk of aspiration Elevate HOB 30 - 45 degrees Routinely verify tube placement No CDC recommendations for: Preferential use of small bore tubes Continuous versus intermittent feeding Post pyloric placement CDC (2003)
PATIENT TURNING-Routine turning of patient for every 2 hrsincrease pulmonary drainage and decrease therisk of VAP.Use of beds with continues lateral rotation candecrease the incidence of pneumonia but do notdecreases mortality or duration of MV(critical care 2002;30(9):1983-1986)
No Data to Support These Strategies• Use of small bore versus large bore gastric tubes• Continuous versus bolus feeding• Gastric versus small intestine tubes.• Closed versus open suctioning methods.• Kinetic beds.
NEW DEVELOPMENT• National healthcare safety(NHSN) and CDC proposed- VAP terminology changed to VAC (ventilated associated conditions and complications) not necessarily limited VAP.• VAP Surveillance definination algorithm. Chest x ray is not included , And diagnosis is mainly depend on worsening of gas exchange, clinical features, isolation of microorganism in resp.secreation .• ETT-- with continuous subglottic suction, ployurethrene cuff,Sponge cuff , Silver nitrate and antibiotic coated ETTs.• VAP industrial complex- kinetic beds, inlines suction catheters• VAP bunddle with 7 components – 5+ Replacing NGT to Orogastric tube and Hand washing by health care personnel. IMPLEMENTATION and ENFORCEMENT of VAP bundle
SUMMARYNosocomial pneumonia and especially VAP are themost frequent infectious complications in the ICU, andthey significantly contribute to morbidity and mortality.VAP is an important determinant of ICU and hospitallengths of stay and healthcare costs.No standard to diagnose.Several simple preventive measures(VAP bundle) andtimely initiation of appropriate antibiotics ensure betteroutcomes in patients with VAP.