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VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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  • 1. VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION Dr.T.V.Rao MD Dr.T.V.Rao MD 1
  • 2. Introduction to Patient Safety: Definition • Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events (Emanuel et al., 2008) . Dr.T.V.Rao MD 2
  • 3. Introduction to Patient Safety: Background • Adverse medical events are widespread and preventable (Emanuel et al., 2008) . • Much unnecessary harm is caused by health-care errors and system failures. – Ex. 1: Hospital acquired infections from poor hand-washing. – Ex. 2: Complications from administering the wrong medication. Dr.T.V.Rao MD 3
  • 4. Required Attitudes Being an effective team player. Commitment to preventing HAIs Dr.T.V.Rao MD 4
  • 5. ICU patients • Sickest patients (multiple diagnoses, multi-organ failure, immunocompromised, septic and trauma) • Move less • Malnourished • More obtunded (Glasgow coma scale) • Diabetics and Heart failure Dr.T.V.Rao MD 5
  • 6. ICU patients • Sickest patients (multiple diagnoses, multi-organ failure, immunocompromised, septic and trauma) • Move less • Malnourished • More obtunded (Glasgow coma scale) • Diabetics and Heart failure Dr.T.V.Rao MD 6
  • 7. Remember Some One at Risk with Ventilator Dr.T.V.Rao MD 7
  • 8. Who is Responsible for Ventilator care • The registered nurse is responsible for the assessment, planning and delivery of care to the patient. • • Care of the ventilated patient can vary from the basic nursing care of activities of daily living to caring for highly technical invasive monitoring equipment and managing and monitoring the effects of interventions. Dr.T.V.Rao MD 8
  • 9. Basic Observations • Ensure the endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions. Dr.T.V.Rao MD 9
  • 10. Always check the patient first. • Observe the patient’s facial expression, colour, respiratory effort, vital signs and ECG tracing. Dr.T.V.Rao MD 10
  • 11. What is Mechanical Ventilator • Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator. • A ventilator delivers gas to the lungs with either negative or positive pressure. Dr.T.V.Rao MD 11
  • 12. Purposes: • To maintain or improve ventilation, & tissue oxygenation. • To decrease the work of breathing & improve patient’s comfort.Dr.T.V.Rao MD 12
  • 13. Intensive Care Unit Nosocomial Pneumonia Dr.T.V.Rao MD 13
  • 14. VENTILATOR ASSOCIATED PNEUMONIA (VAP) • VAP is the leading cause of nosocomial infection in the ICU and reflects 60% of all deaths attributable to nosocomial infections. • Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway, which increases the opportunity for aspiration and colonization. Dr.T.V.Rao MD 14
  • 15. Definition- “Know thy enemy” Pneumonia that develops in someone who has been intubated -Typically in studies, patients are only included if intubated greater than 48 hours -Early onset= less than 4 days -Late onset= greater than 4 days Endotracheal intubation increases risk of developing pneumonia by 6 to 21 fold Accounts for 90% of infections in mechanically ventilated patients American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.Dr.T.V.Rao MD 15
  • 16. Who gets VAP? (Risk factors) • Study of 1014 patients receiving mechanical ventilation for 48 hours or more and free of pneumonia at admission to ICU • Increased risk associated with admitting diagnosis of : – Burns (risk ratio=5.09) – Trauma (risk ratio=5.0) – Respiratory disease (risk ratio=2.79) – CNS disease (risk ratio=3.4) Cook et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Dr.T.V.Rao MD 16
  • 17. Risk factors for bacterial pneumonia Host Factors Factors that facilitate reflux & aspiration into the lower RT • Elderly • Severe Illness • Underlying Lung Disease - Mechanical ventilation • Depressed Mental Status - Tracheostomy • Immunocompromising - Use of a Nasogastric Tube Conditions or Treatments - Supine Position • Viral Respiratory Tract Factors that impede normal Infection Pulmonary Toilet Colonisation - Abdominal or thoracic surgery • Intensive Care Setting - Immobilisation • Use of Antimicrobial Agents • Contaminated hands • Contaminated Equipment Dr.T.V.Rao MD 17
  • 18. Incidence of VAP • The exact incidence of HAP is usually between 5 and 15 cases per 1,000 hospital admissions depending on the case definition and study population; the exact incidence of VAP is 6- to 20- fold greater than in nonventilated patients (Level II) • HAP accounts for up to 25% of all ICU infections • In ICU patients, nearly 90% of episodes of HAP occur during mechanical ventilation Dr.T.V.Rao MD 18
  • 19. Resistant Bacteria leading Cause • Many patients with HAP, VAP, and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II) Dr.T.V.Rao MD 19
  • 20. Pathogenesis • Where do the bacteria come from? – Tracheal colonization- via oropharengeal colonization or GI colonization – Ventilator system • How do they get into the lung? – Breakdown of normal host defenses – Two main routes • Through the tube • Around the tube- micro aspiration around ETT cuff Dr.T.V.Rao MD 20
  • 21. 21 Etiology • Bacteria cause most cases of HAP, VAP, and HCAP and many infections are polymicrobial; rates are especially high in patients with ARDS (Level I) • HAP, VAP, and HCAP are commonly caused by aerobic gram-negative bacilli, such as P. aeruginosa, K. pneumoniae, and Acinetobacter species, or by gram-positive cocci, such as S. aureus, much of which is MRSA; anaerobes are an uncommon cause of VAP (Level II) Dr.T.V.Rao MD
  • 22. 22 Predisposing causes in Pneumonia – Pseudomonas aeruginosa. • the most common MDR gram-negative bacterial pathogen causing HAP/VAP, has intrinsic resistance to many antimicrobial agents – Klebsiella, Enterobacter, and Serratia species. • Klebsiella species – intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum –lactamases (ESBLs) – ESBL-producing strains remain susceptible to carbapenems • Enterobacter species • Citrobacter and Serratia species Dr.T.V.Rao MD
  • 23. 23 Predisposing causes in Pneumonia –Acinetobacter species • More than 85% of isolates are susceptible to carbapenems, but resistance is increasing • An alternative for therapy is sulbactam • Stenotrophomnonas maltophila, and Burkholderia cepacia: – resistant to carbapenems – susceptible to trimethoprim–Sulphmethoxazole, Ticarcillin–clavulanate, or a fluoroquinolone Dr.T.V.Rao MD
  • 24. 24 Predisposing causes in Pneumonia – Methicillin-resistant Staphylococcus aureus • Vancomycin-intermediate S. aureus – sensitive to linezolid – linezolid resistance has emerged in S. aureus, but is currently rare – Streptococcus pneumoniae and Haemophilus influenza. • sensitive to Vancomycin or linezolid, and most remain sensitive to broad-spectrum quinolones Dr.T.V.Rao MD
  • 25. Initiation of Mechanical Ventilation Dr.T.V.Rao MD 25
  • 26. Guidelines in the Initiation of Mechanical Ventilation • Primary goals of mechanical ventilation are adequate oxygenation/ventilation, reduced work of breathing, synchrony of vent and patient, and avoidance of high peak pressures • Set initial FIO2 on the high side, you can always titrate down • Initial tidal volumes should be 8-10ml/kg, depending on patient’s body habitus. If patient is in ARDS consider tidal volumes between 5-8ml/kg with increase in PEEP Dr.T.V.Rao MD 26
  • 27. Guidelines in the Initiation of Mechanical Ventilation • Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2 • Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP • When facing poor oxygenation, inadequate ventilation, or high peak pressures due to intolerance of ventilator settings consider sedation, analgesia or neuromuscular blockage Dr.T.V.Rao MD 27
  • 28. Ventilators • After every patient, clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturer’s instructions. Dr.T.V.Rao MD 28
  • 29. Suctioning mechanically ventilated patients • Hand washing before and after the procedure. • Wear clean gloves to prevent cross- contamination • Use a sterile single-use catheter ; if it is not possible then rinse catheter with sterile water and store it in a dry, clean container between uses and change the catheter every 8 - 12 hours. Dr.T.V.Rao MD 29
  • 30. Suction Bottle Use single-use disposable, if possible Non-disposable bottles should be washed with detergent and allowed to dry. Heat disinfect in washing machine or send to Sterile Service Department. Dr.T.V.Rao MD 30
  • 31. Nebulizers • Use sterile medications and fluids for nebulization • Fill with sterile water only. • Change and reprocess device between patients by using sterilization or a high level disinfection or use single-use disposable item. • Small hand held nebulizers – minimise unnecessary use – between uses for the same patient disinfect, rinse with sterile water, or air dry and store in a clean, dry place • Reprocess nebulizers daily Dr.T.V.Rao MD 31
  • 32. Humidifiers • Clean and sterilize device between patients. • Fill with sterile water which must be changed every 24 hours or sooner, if necessary. • Single-use disposable humidifiers are available but they are expensive. Dr.T.V.Rao MD 32
  • 33. Ventilator cleaning and Decontamination • After every patient, clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturer’s instructions. Dr.T.V.Rao MD 33
  • 34. If put on Oxygen mask • Change oxygen mask and tubing between patients and more frequently if soiled Dr.T.V.Rao MD 34
  • 35. Prevalence of VAP • Occurs in 10-20% of those receiving mechanical ventilation for greater than 48 hours • Rate= 14.8 cases per 1000 ventilator days Cook et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Dr.T.V.Rao MD 35
  • 36. When does VAP occur? • Cook et al showed . . . –40.1% developed before day 5 –41.2% developed between days 6 and 10 –11.3% developed between days 11-15 –2.8% developed between days 16 and 20 –4.5% developed after day 21 Cook et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Dr.T.V.Rao MD 36
  • 37. Time frame of intubation and risk • Risk of pneumonia at intubation days –3.3% per day at day 5 –2.3% per day at day 10 –1.3% per day at day 15 Cook et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Dr.T.V.Rao MD 37
  • 38. Dr.T.V.Rao MD 38 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
  • 39. Dr.T.V.Rao MD 39 HOB Elevation HOB at 30-45º CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005
  • 40. Dr.T.V.Rao MD 40 HOB Elevation References 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
  • 41. HOB UP 30 DEGREES OR HIGHER • Recommended elevation is 30-45 degrees • If semi-recumbent or supine 34% incidence VAP • If semi-recumbent position 8% incidence VAP* • ↑HOB → ↓risk of aspiration of gastrointestinal contents ↓risk of aspiration of oropharengeal secretions ↓risk of aspiration of nasopharyngeal secretions Dr.T.V.Rao MD 41
  • 42. HOB UP 30 DEGREES OR HIGHER • HOB improves patients’ ventilation • Supine patients have lower spontaneous tidal volumes on PS • than those seated in upright position • ↑HOB may aid ventilatory efforts and minimize atelectasis Dr.T.V.Rao MD 42
  • 43. Ventilator Associated Pneumonia (VAP) Practice Alert 43 HOB Elevation Leads to Significant Deduction in VAP Dravulovic et al. Lancet 1999;354:1851-1858 0 5 10 15 20 25 %VAP Supine HOB Elevation
  • 44. Dr.T.V.Rao MD 44 CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 Frequency of Equipment Changes Ventilator Tubing Ambu Bags Inner Cannulas of Trachs No Routine Changes Between Patients Not Enough Data
  • 45. Dr.T.V.Rao MD 45 Hand washing What role does hand washing play in nosocomial pneumonias? Albert, NEJM 1981; Preston, AJM 1981; CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
  • 46. Ventilator Associated Pneumonia (VAP) Practice Alert 46 VAP Prevention and Hand Washing Wash hands or use an alcohol- based waterless antiseptic agent before and after suctioning, touching ventilator equipment, and/or coming into contact with respiratory secretions. CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 AACN Practice Alert for VAP, 2007
  • 47. Suctioning mechanically ventilated patients • Hand washing before and after the procedure. • Wear clean gloves to prevent cross- contamination • Use a sterile single-use catheter ; if it is not possible then rinse catheter with sterile water and store it in a dry, clean container between uses and change the catheter every 8 - 12 hours. Dr.T.V.Rao MD 47
  • 48. VAP Reduction with ET Suction Above the Cuff 0 5 10 15 20 Percent(%) No Suction Suction Ventilator Associated Pneumonia (VAP) Practice Alert 48 Smulders et al. Chest;121:858-862
  • 49. Suction Bottle Use single-use disposable, if possible Non-disposable bottles should be washed with detergent and allowed to dry. Heat disinfect in washing machine or send to Sterile Service Department. Dr.T.V.Rao MD 49
  • 50. Nebulizers • Use sterile medications and fluids for nebulization • Fill with sterile water only. • Change and reprocess device between patients by using sterilization or a high level disinfection or use single-use disposable item. • Small hand held nebulizers – minimise unnecessary use – between uses for the same patient disinfect, rinse with sterile water, or air dry and store in a clean, dry place • Reprocess nebulizers daily Dr.T.V.Rao MD 50
  • 51. Humidifiers • Clean and sterilize device between patients. • Fill with sterile water which must be changed every 24 hours or sooner, if necessary. • Single-use disposable humidifiers are available but they are expensive. Dr.T.V.Rao MD 51
  • 52. Indications for an actively humidified circuit (Westmead ICU) • 􀀪 minute volume greater than 10 litres • 􀀪 chest trauma with pulmonary contusion • 􀀪 airway burns • 􀀪 severe asthma • 􀀪 hypothermia (<340 C) • 􀀪 pulmonary haemorrhage • 􀀪 severe sputum plugging/pulmonary oedema leading to HME occlusion • 􀀪 consultant order Dr.T.V.Rao MD 52
  • 53. Pooling of Secretions • Pooled secretions above the ETT/trachi cuff are associated with ventilator associated pneumonia (VAP). This is a result of aspiration of bacteria colonizing the oropharynx or GIT and subsequently leaking below the cuff into the trachea. Therefore thorough oropharyngeal suctioning should be performed before letting down the cuff to reposition the ETT or to check cuff pressure. Dr.T.V.Rao MD 53
  • 54. Suction of an Artificial Airway • To maintain a patent airway • • To promote improved gas exchange • • To obtain tracheal aspirate specimens • • To prevent effects of retained secretions eg. infection, consolidation , atelectasis, increased airway pressures or a blocked tube. • • It is important to oxygenate before and after suctioning Dr.T.V.Rao MD 54
  • 55. Sterilisation and decontamination After use, the patient circuit should be detached from the ventilator and disassembled to expose all surfaces prior to cleaning. Thoroughly clean to remove all blood, secretions, thick mucus and other residue. You may use multi enzyme cleaner. Medical detergent solution can also be used to thoroughly to flush the tubing's. Dr.T.V.Rao MD 55
  • 56. Contd… 2% Glutaraldehyde is used for routine sterilisation of tubing's and other accessories. Please follow manufacturer’s directions and recommendations. Ethylene Oxide – gas sterilisation is also used. Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components. Dr.T.V.Rao MD 56
  • 57. Contd… Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous. After sterilisation, the tubing's must be properly aerated to dissipate residual gas absorbed by the materials. Dr.T.V.Rao MD 57
  • 58. VAP Prevention Wash hands or use an alcohol-based waterless antiseptic agent before and after suctioning, touching ventilator equipment, and/or coming into contact with respiratory secretions. Dr.T.V.Rao MD 58 2004
  • 59. Dr.T.V.Rao MD 59 VAP Protection • Use a continuous subglottic suction ET tube for intubations expected to be > 24 hours • Keep the HOB elevated to at least 30 degrees unless medically contraindicated CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 AACN Practice Alert for VAP, 2007
  • 60. Hand Hygiene • leading cause of infection in health care settings is the lack of proper hygiene practices by health care professionals. The CDC VAP protocol guidelines recommend improved hand hygiene practices by health care workers including alcohol based antiseptic solutions. Changing disposable gloves and washing the hands before putting on another pair can also lower the risk of VAP. Dr.T.V.Rao MD 60
  • 61. How to use waterless hand rub • Apply a palmful of product in cupped hand • Rub hands palm to palm • Right palm over left hand with interlaced fingers • Palm to palm with fingers interlaced • Backs of fingers to opposing palms with fingers interlocked • Rub between thumb and forefinger • Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa • Once dry your hands are safe. Dr.T.V.Rao MD 61
  • 62. HAND HYGIENE • The best method to prevent healthcare acquired infections including VAP is to practice good Hand Hygiene including use of : • Antimicrobial soap and water • Alcohol Based Hand Rub (Isagel) when there is no visible soiling on hands Dr.T.V.Rao MD 62
  • 63. Compliance with Isolation Precautions • Stringent adherence to the use of Personal Protective Equipment (PPE) such as Gowns, Masks, Gloves will decrease the transmission of pathogenic microorganisms to ventilated patients when patients are identified as requiring Contact and Droplet Precautions Dr.T.V.Rao MD 63
  • 64. Dr.T.V.Rao MD 64
  • 65. Why should hospitals care so much about the oral cavity ? Most bacterial nosocomial pneumonia are caused by aspiration of bacteria colonizing the oropharynx or upper GI tract of the patient. Centres for Disease Control (1997) Nosocomial pneumonia accounts for 10-15% of all hospital acquired infections. 20-50% of all infected patients will die as a result of the infection J.Can.Dent.Assoc.(2002)
  • 66. How Does Aspiration Pneumonia (including VAP) Occur? ASPIRATION + GRAM - BACTERIA + OVERWHELM IMMUNE SYSTEM MUST HAVE ALL 3 Dr.T.V.Rao MD 66
  • 67. When does Colonization occur? Within 48 hours of admission to hospital the oropharengeal flora of critically ill patients changes from  the usual gram + streptococci and dental pathogens to  gram – organisms including Pathogens that cause VAP and Aspiration Pneumonia American Journal of Critical Care (2004) Dr.T.V.Rao MD 67
  • 68. Oral Care Research Treatment with oral hygiene alone, reduced occurrence of pneumonia in older adults in nursing homes by 30% Yoneyama et.al. (2002) Dr.T.V.Rao MD 68
  • 69. Oral decontamination • Chan et al. investigated antibiotics and antiseptics – Antibiotics were not found to be beneficial – Antiseptics were found to be beneficial in 6 out of 7 studies • Chlorhexidine studied in 6, five of which showed benefit – Note that mortality, ICU stay and duration of mechanical ventilation were not statistically significant Dr.T.V.Rao MD 69
  • 70. Oral Cleansing • Bacteria in the mouth can cause intubated patients to get infections or pneumonia. Establishing regular oral cleansing and disinfection of patients receiving respiratory ventilation reduces the risk of infection. Dr.T.V.Rao MD 70
  • 71. Current Oral Care Practices Continued… Foam swabs are commonly used to provide mouth care to patients who cannot provide their own care. SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF. Journal of Advanced Nursing (1996) Nursing Times (1996) Dr.T.V.Rao MD 71
  • 72. Why should hospitals care so much about the oral cavity ? Most bacterial nosocomial pneumonia are caused by aspiration of bacteria colonizing the oropharynx or upper GI tract of the patient. Centres for Disease Control (1997) Nosocomial pneumonia accounts for 10-15% of all hospital acquired infections. 20-50% of all infected patients will die as a result of the infection J.Can.Dent.Assoc.(2002) Dr.T.V.Rao MD 72
  • 73. Oral Care • Common medical knowledge that poor oral care and suctioning leads to (HAP) and (VAP). Research has shown that (HAP) and (VAP) can be reduced with suctioning of subglottic secretions and improved oral hygiene in both non-ventilated and ventilated patients. Unfortunately some patients tend to bite down and resist oral hygiene and tracheal suctioning. Dr.T.V.Rao MD 73
  • 74. Oral Care • Also tracheal suction catheters commonly inserted nasally, tend to coil upon insertion, causing multiple unsuccessful attempts, nasal trauma and bleeding. These problems make oral hygiene and tracheal suctioning difficult or even impossible, increasing a patients risk to develop (HAP) and (VAP). Dr.T.V.Rao MD 74
  • 75. Oral Care: AACN • AACN 5th Edition, 2005 Scott JM, Vollman KM • Endotracheal Tube and Oral Care, Procedure # 4 • Unit One Pulmonary System • Perform ET suctioning only when clinically indicated • Oral hygiene should be performed every 2-4 hours and should include: • Toothbrushing at least two times a day; • Oral swabs with 1.5% hydrogen peroxide solution every 2-4 hours; • Mouth moisturizer to oral mucosa and lips • Subglottic suctioning continuously or intermittently Dr.T.V.Rao MD 75
  • 76. Oral Care: plaque Grap MJ, Munro CL 2004: • Tooth brushing is the most effective means of mechanical removal of plaque. Munro CL, Grap MJ, Elswick RK, el al: 2006;Am J Crit Care;15 • Higher plaque scores confer greater risk for VAP Dr.T.V.Rao MD 76
  • 77. Procedure - Brushing • Wash hands and put on gloves • Obtain PLAC VAC BRUSH • Attach suction to toothbrush, moisten toothbrush and apply baking soda • Brush patient’s teeth, gums, tongue, palate and inside cheeks • Apply suction to cleansed areas • Rinse brush in water, repeat step 4-5 • Soak dentures in denture solution Dr.T.V.Rao MD 77
  • 78. Alternate Procedure Chlorhexidine 0.12% 1. Place 15ml of chlorhexidine in medication cup 2. Soak toothette in chlorhexidine 3. Rub teeth, tongue, gums, and sides of mouth in circular motion 4. Suction oral cavity and do not rinse 5. Apply oral moisturizer to lips Dr.T.V.Rao MD 78
  • 79. Oral Care: use of antiseptics Fourrier 2005 Crit Care Med 33 • CHG – reduced colonization but not VAP Munro & Grap 2006 Crit Care Med 34 • CHG – effective in reducing VAP Seguin 2006 Crit Care Med 34 • Povidone-Iodine - decreased prevalence of VAP in head trauma Dr.T.V.Rao MD 79
  • 80. Dr.T.V.Rao MD 80 Oral Care • Role of oral care, colonization of the oropharynx, and VAP unclear – dental plaque may be involved as a reservoir • Limited research on impact of rigorous oral care to alter VAP rates • Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 Grap M. Amer J of Critical Care 2003;12:113-119.
  • 81. Eye & Mouth care • For unconscious patients eyes are kept closed by taping. • Goggles can also be used. • Regular & proper mouth care should be given. Dr.T.V.Rao MD 81
  • 82. Eye Care • The unconscious, sedated or paralyzed patient is at risk of developing eye problems ranging from mild conjunctivitis to serious corneal injury and ulceration. Permanent eye damage may result from ulceration, perforation, vascularization and scarring of the cornea • 2nd hourly eye care using saline soaked gauze to clean the eye and the application of lactrilube regularly in the ventilated patient is recommended to help reduce the risk of complications Dr.T.V.Rao MD 82
  • 83. SDD- selective decontamination of the digestive tract • Multiple studies showing effectiveness • Big concern is antibiotic resistance • Most recently- NEJM January 2009 –Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 3.5% in patients receiving SDD –Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 2.9%Dr.T.V.Rao MD 83
  • 84. Monitoring for infection • Color, consistency, and amount of the sputum / secretions with each suctioning should be observed. • Fever and other parameters have to closely observed for any other infection. (central line, etc) Dr.T.V.Rao MD 84
  • 85. 85 Bacteriologic Strategy • Quantitative cultures can be performed on endotracheal aspirates or samples collected either bronchoscopically or nonbronchoscopically, and each technique has its own diagnostic threshold and methodologic limitations. The choice of method depends on local expertise, experience, availability, and cost (Level II) Dr.T.V.Rao MD
  • 86. 86 Comparing Diagnostic Strategy • A patients with suspected VAP should have a lower respiratory tract sample sent for culture, and extra pulmonary infection should be excluded, as part of the evaluation before administration of antibiotic therapy (Level II) • If there is a high pretest probability of pneumonia, or in the 10% of patients with evidence of sepsis, prompt therapy is required, regardless of whether bacteria are found on microscopic examination of lower respiratory tract samples (Level II) Dr.T.V.Rao MD
  • 87. Imperfect diagnostic tests • Blood cultures, limited role, sensitivity is only 8% to 20% • Sputum neither sensitive, nor specific • Tracheo-bronchial aspirates- high sensitivity, weakness- does not differentiate between pathogen and colonizer • Hospital-acquired pneumonia: Risk factors, microbiology, and treatment. Chest. 119: 2001; 373S-384S. BAL, PSB’s do not differ from less invasive tests in terms of sensitivity, specificity or, more importantly, morbidity and mortality luck of consensus on the role of invasive diagnostic testing for HAP, subject of ongoing debate - Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: Evaluation of outcome. Am J Respir Crit Care Med. 162: 2000; 119-125. - Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: A randomized trial. Ann Intern Med. 132: 2000; 621-630.
  • 88. HCAP, HAP, VAP Treatment • Delay in empiric antibiotics use, worse outcome International conference for the development of consensus on the diagnosis and treatment of ventilator-associated pneumonia. Chest. 120: 2001; 955-970. • Mortality with prompt antibiotic use 30% vs. 91 % when delayed Nosocomial pneumonia: A multivariate analysis of risk and prognosis. Chest. 93: 1988; 318-324 • Regimens in patients with no known risk factors for MDR pathogens, and who have early-onset pneumonia (within 5 days of hospitalization) should include coverage for Enterobacter spp., E. coli, Klebsiella spp., Proteus spp., and Serratia marcescens), Haemophilus influenza and Streptococcus pneumoniae, MSS. aureus
  • 89. HCAP, HAP, VAP Treatment • Ceftriaxone or a quinolone (e.g., ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem • Fluoroquinolone in the empirical regimen of patients with penicillin allergies • Penicillin skin testing – a mean to decrease fluoroquinolones use • A pilot study of penicillin skin testing in patients with a history of penicillin allergy admitted to a medical ICU. Chest. 118: 2000; 1106-1108.
  • 90. Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia * in Patients at Risk for Multidrug-Resistant Pathogens Antibiotic Adult Dosage † Antipseudomonal cephalosporin Cefepime1-2 g every 8-12 hr Ceftazidime 2 g every 8 hr Carbapenems Imipenem 500 mg every 6 hr or 1 g every 8 hr Meropenem 1 g every 8 hr Beta-lactam–beta-lactamase inhibitor Piperacillin-tazobactam 4.5 g every 6 hr Aminoglycosides Gentamicin 7 mg/kg/day Tobramycin 7 mg/kg/day Amikacin 20 mg/kg/day Antipseudomonal quinolones Levofloxacin 750 mg/day Ciprofloxacin 400 mg every 8 hr Vancomycin 15 mg/kg every 12 hr Linezolid 600 mg every 12 hr Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.
  • 91. Duration of treatment • No consensus, initial low suspicion, no change in clinical status- dc in 72 hrs Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med. 162: 2000; 505-511. • Guided by severity, time to clinical response, and the pathogenic organism • Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare associated-pneumonia. Am J Respir Crit Care Med. 171: 2005; 388-416. • Treat for at least 72 hours after a clinical response is achieved • International conference for the development of consensus on the diagnosis and treatment of ventilator- associated pneumonia. Chest. 120: 2001; 955-970.
  • 92. Recommendations for Assessing Response to Treatment -Modifications of empirical therapy should be based on results of microbiology testing in conjunction with clinical parameters. -Clinical improvement of HCAP usually takes 2 to 3 days and therefore therapy should not be changed during this period unless there is a rapid clinical decline. -Narrowing therapy to the most focused regimen possible on the basis of culture data (de-escalation of antimicrobials) should be considered for the responding patient. -The nonresponding patient should be evaluated for possible MDR pathogens, extrapulmonary sites of infection, complications of pneumonia and its therapy, and mimics of pneumonia. -Testing should be directed to whichever of these causes is likely after physical examination of the patient.
  • 93. Prevention Measures • Based on expert opinion rather than hard data • CDC published a set of 74 recommendations for preventing NAP , only 15 strongly supported by well- designed experimental or epidemiologic studies • 14 out of those 15 dealt with surveillance, education, hand washing, sterilization, proper use of gloves, value of vaccination, and sanitation • Prophylactic antibiotics not be used routinely , only one supported by well-designed studies • Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR Morb Mortal Wkly Rep. 46: 1997; 1-79.
  • 94. Appropriate staffing levels in the ICU • Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP. • Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control • Kollef MH Crit Care Med 2004:32(6) Dr.T.V.Rao MD 94
  • 95. Dr.T.V.Rao MD 95 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 CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
  • 96. Things to Remember • HACP, HAP, VAP = BAD for the patient • Quantitative diagnostic microbiology- controversial! • Cover likely bugs promptly • Know your local bugs • De-escalate, shorten duration of therapy • Specific regimen, combination therapy- no proven benefits
  • 97. Compliance with Isolation Precautions • Stringent adherence to the use of Personal Protective Equipment (PPE) such as Gowns, Masks, Gloves will decrease the transmission of pathogenic microorganisms to ventilated patients when patients are identified as requiring Contact and Droplet Precautions Dr.T.V.Rao MD 97
  • 98. Objective 2 Objective 1 Avoid overtreatment without VAP Immediate treatment of patients with VAP Diagnosis and treatment of ventilator-associated pneumonia
  • 99. Brave and Committed Nurses, Doctors Save Many Lives Dr.T.V.Rao MD 99
  • 100. With Thanks .. To Many • I am grateful for several references in World Wide Web particularly from Central Disease Control Atlanta USA for propagating the knowledge on a very complex topic is simple formats Dr.T.V.Rao MD 100
  • 101. Visit me for Many Topics of Interest on Infectious Diseases Dr.T.V.Rao MD 101
  • 102. • Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Professionals Working in the Intensive Care Units • Email • doctortvrao@gmail.com Dr.T.V.Rao MD 102