A stitch in time saves nine


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  • Since mechanically ventilated patients cannot be fed orally, their salivary secretions decrease, and self-cleansing of the oral cavity is markedly reduced. As a result, oral cavity hygiene worsens, and the number of bacteria increases excessively, leading to bacterial colonization of the oropharynx.
  • Methods : Patients more than 18 years old receiving mechanical ventilation for more than 48 hours in a medical intensive care unit at a university-affiliated medical center were studied in 2 consecutive 24-month periods. Patients in the group studied before the intervention (n = 779) had no oral assessments, no suctioning of the subglottic space, no tooth brushing, and suctioning of secretions in the oral cavity as needed. The group studied during the intervention (n = 759) included patients treated under a protocol whereby the oral cavity was assessed, deep suctioning was done every 6 hours, oral tissue cleansing was done every 4 hours or as needed, and tooth brushing was done twice daily. Results: Compliance with protocol components exceeded 80%. The rate of ventilator-associated pneumonia was 12.0 per 1000 ventilator days before the intervention and decreased to 8.0 per 1000 ventilator days during the intervention ( P = .06). Duration of mechanical ventilation and length of stay in the intensive care unit differed significantly between groups, as did mortality.
  • Prospective, randomized, single-blind, controlled study conducted in 54 centers in North America. A total of 9417 adult patients (18 years) were screened between 2002 and 2006. A total of 2003 patients expected to require mechanical ventilation for 24 hours or longer were randomized. Patients were assigned to undergo intubation with 1 of 2 high volume, low-pressure endotracheal tubes, similar except for a silver coating on the experimental tube.
  • A stitch in time saves nine

    2. 2. Sources of Cross Contamination <ul><li>(II) Artificial Ventilation Devices </li></ul>(I) Respiratory Care Devices
    3. 3. Respiratory care devices <ul><li>Under normal circumstances, low-flow oxygen systems do not present clinically important risk of infection and do not require routine replacement on the same patient (AARC RECOMMENDATION) </li></ul><ul><li>All devices may carry the risk of infection transmission </li></ul><ul><li>All equipments should be cleaned, disinfected, and/or sterilized. </li></ul><ul><li>It is recommended to use disposable items as ambobags, suction sets, circuits, and prefilled humidifiers…etc </li></ul>
    4. 5. Definition & Impact <ul><li>Nosocomial pneumonia is acquired 48 hours after intubation in patients receiving mechanical ventilation. </li></ul><ul><li>Its incidence is estimated to be 9-27%. </li></ul><ul><li>Am J Respir Crit Care Med 171:388-416 (2005) </li></ul><ul><li>It’s occurrence increases patient mortality to an estimated 20 to 55%. Intensive Care Med 35:9–29 (2009) </li></ul><ul><li>It increases duration of hospital stay as an average of one week. </li></ul><ul><li>Cost has been estimated to be above 40,000$ per patient. </li></ul><ul><li>British Association of Critical Care Nurses, 2007 Vol 12 No 6 </li></ul>
    5. 6. How to Handle VAP? Prevention
    6. 7. Risk Factors <ul><li>Device related factors </li></ul><ul><li>Personnel related factors </li></ul><ul><li>Presence of artificial airway is the primary/major risk factor </li></ul>
    7. 8. VAP Preventative Measures <ul><li>Non-Pharmacological </li></ul>Pharmacological
    8. 9. Strategies aimed at prevention of VAP Kollef (1999)
    9. 10. Non-Pharmacological Bundle to Prevent VAP <ul><li>Hand washing </li></ul><ul><li>Body position (HOB elevation) </li></ul><ul><li>Oropharyngeal cleaning and decontamination </li></ul><ul><li>Route of endotracheal tube (Nasal Vs. Oral) </li></ul><ul><li>Closed Vs. open suction </li></ul><ul><li>Change of ventilator circuit </li></ul><ul><li>Type of airway humidification (Active Vs. Passive) </li></ul><ul><li>Endotracheal tubes </li></ul><ul><li>No More Tubes!!! </li></ul>
    10. 11. <ul><li>1. Hand washing </li></ul><ul><li>Hands of healthcare workers are one of the main causes of VAP </li></ul><ul><li>(Safdar et al-2005) </li></ul><ul><li>The CDC in USA (Tablan et al.,2003) recommended that : </li></ul><ul><li> Hands should be decontaminated before & after contact </li></ul><ul><li>with patients in conjunction with wearing gloves. </li></ul><ul><li> Washing with soap and water if they are visibly dirty or </li></ul><ul><li>soiled with bodily fluids </li></ul><ul><li> Use of alcohol-based antiseptic agent (hand rub) if hands </li></ul><ul><li>are not soiled </li></ul>
    11. 12. <ul><li>2. HEAD OF BED ELEVATION </li></ul><ul><li>Studies using radiolabeled enteral feeding solutions have reported that aspiration of gastric contents occurs to a greater degree when patients are in the supine position, compared with the semi-recumbent position. </li></ul><ul><li>The semirecumbent body position is a low-cost and easy-to-apply measure to reduce the risk of nosocomial pneumonia. </li></ul><ul><li>The guidelines suggest keeping patients in the semirecumbent (30°-45°) to prevent aspiration. </li></ul><ul><li>The available evidence suggests that semi-recumbent position should be used routinely. </li></ul><ul><li>Respiratory Care. July 2005 VoL 50 No 7 </li></ul><ul><li>Recommended by CDC and ATS/IDSA guidelines </li></ul>
    12. 14. <ul><li>3. Oropharyngeal cleaning and decontamination </li></ul><ul><li>Studies have revealed that oral care can: </li></ul><ul><li>1. Reduce the incidence of VAP in </li></ul><ul><li>ICU patients </li></ul><ul><li>2. Lower the risk of VAP development </li></ul><ul><li>3. Delay the onset of VAP </li></ul><ul><li>Chlorhexidine gluconate is been used to decontaminate the oral cavity. </li></ul><ul><li>Chlorhexidine likely delays rather than prevents VAP </li></ul><ul><li>Significant reductions in rates of VAP may be achieved by broader implementation of oral care protocols . </li></ul><ul><li>(American Journal of Critical Care. 2007;16:28-38) </li></ul>
    13. 16. <ul><li>4. Route of endotracheal tube (Nasal Vs. Oral) </li></ul><ul><li>Oral intubation is encouraged since nasal intubation increases the risk of sinusitis and bacterial colonization of the upper airways </li></ul>
    14. 17. <ul><li>5. Closed Vs. open suction </li></ul><ul><li>There was no significant advantage for the use of either suctioning system. </li></ul><ul><li>Meta-analysis of RCTs; Intensive Care Med (2006) 32:1329-1335 </li></ul><ul><li>The choice of suctioning system should be based on: </li></ul><ul><li> Handling </li></ul><ul><li> Cost </li></ul><ul><li> Individual patient’s disease </li></ul>
    15. 19. <ul><li>6. Change of ventilator circuit </li></ul><ul><li>Frequency of ventilator circuit changes didn’t appear to influence VAP rates. </li></ul><ul><li>The maximum duration of time that </li></ul><ul><li>circuits can be used safely is unknown. </li></ul><ul><li>Disposable circuits are recommended. </li></ul><ul><li>Circuit should be changed only in two conditions : </li></ul><ul><li>1. Visibly soiled circuit </li></ul><ul><li>2. Any malfunction or defect in the circuit </li></ul>
    16. 21. <ul><li>7. Type of airway humidification (Active Vs. Passive) </li></ul><ul><li>Evidence is lacking related to (VAP) and issues of heated versus unheated circuits, type of heated humidifier, method for filling the humidifier, and technique for clearing condensate from the ventilator circuit. </li></ul><ul><li>Respir Care 2003;48(9):869–879/ Evidence-Based Guidelines </li></ul><ul><li>A significant reduction in the incidence of VAP in patients </li></ul><ul><li>humidified with HMEs was found, particularly in patients ventilated for 7 days or longer. Intensive Care Med (2005) 31:5–11 </li></ul><ul><li>Issues related to the use of passive humidifiers (resistance, dead space volume, airway occlusion risk) preclude a recommendation for it’s general use. </li></ul>
    17. 22. <ul><li>Passive humidifiers do not need to be changed daily for reasons of infection control or technical performance. </li></ul><ul><li>When applying active humidification, heated wire circuits are recommended for use. </li></ul><ul><li>The Hospital Infection Society (2007) 65, 285-291 </li></ul><ul><li>VAP occurrence was similar in all patient groups: </li></ul><ul><li>i. Single-heated wire circuit </li></ul><ul><li>ii. Double-heated wire circuit </li></ul><ul><li>iii. Heat-and-moisture exchanger. </li></ul><ul><li>Crit Care Med 2006 Vol. 34, No. 3 </li></ul>
    18. 23. <ul><li>8. Endotracheal tubes </li></ul><ul><li>-> Cuff pressure </li></ul><ul><li>-> ETT with dorsal lumen </li></ul><ul><li>-> Silver-coated ETT </li></ul><ul><li>-> Polyurethane cuff </li></ul>Future Advances
    19. 24. <ul><li>a. Endotracheal tube cuff pressure </li></ul><ul><li>Cuff pressure should be maintained between 20 to 30 cm H 2 O </li></ul><ul><li>Prevents migration of bacteria-rich </li></ul><ul><li>subglottic secretions </li></ul>
    20. 25. <ul><li>b. Subglottic secretion drainage </li></ul><ul><li>Subglottic secretion drainage appears effective in preventing early-onset VAP in patients expected to require 72 hours of mechanical ventilation. </li></ul><ul><li>The American Journal of Medicine, Vol 118, No 1, January 2005 </li></ul><ul><li>VAP incidence was lowered from 45% to 23% and the time of development was prolonged from 6 to 14 days when subglottic suction method was used (Properly). </li></ul><ul><li>Am J Med, 2005;23:472-474 </li></ul>
    21. 27. <ul><li>CASS doesn’t decrease mortality, but decreases the early incidence of VAP and decreases ICU stay (but not hospitalization) </li></ul>Evac-tube must be used for patients who are expected to need mechanical ventilation > 72 hours
    22. 29. <ul><li>c. Silver-coated Endotracheal Tubes </li></ul><ul><li>Silver-coated ETT prevents bacterial colonization and biofilm formation. </li></ul><ul><li>Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube. </li></ul><ul><li>No significant change in durations of intubation, ICU stay, and hospital stay; mortality; and frequency and severity of adverse events. </li></ul>JAMA. 2008;300(7):805-813
    23. 31. d. Polyurethane cuff <ul><li>PU cuff is made of ultrathin membrane designed to : </li></ul><ul><li>1. Expand more completely and follows internal diameter of the trachea </li></ul><ul><li>2. Prevent the formation of folds within the cuff </li></ul><ul><li>Prevents Microaspiration </li></ul><ul><li>Use of a PU cuffed ET instead of a standard PVC cuffed ET could significantly decrease the occurrence of clinically suspected pneumonia. </li></ul>The Journal of Thoracic and Cardiovascular Surgery - April 2008
    24. 33. <ul><li>Best ways to prevent VAP is to limit the duration of INVASIVE mechanical ventilation </li></ul>No More Tubes!!!
    25. 34. <ul><ul><li>Non-invasive Ventilation </li></ul></ul><ul><ul><li>Since the avoidance of intubation certainly has a dramatic impact on the risk of VAP, it appears that the indications for and standards of noninvasive ventilation should be established with high priority </li></ul></ul>
    26. 36. <ul><li>Protocol-driven weaning reduces use of invasive mechanical ventilation and VAP. (J Trauma. 2004;56:943–952) </li></ul><ul><li>Ventilator management protocol (VMP) was effective in reducing duration of mechanical ventilatory support and incidence of VAP </li></ul><ul><li>(CHEST 2000; 118:459–467) </li></ul><ul><li>The involvement of respiratory therapists and ICU nurses is important for the success of educational programs aimed at the prevention of VAP. </li></ul><ul><li>(CHEST 2004; 125:2224–2231) </li></ul><ul><li>Significant reductions in rates of VAP may be achieved by broader implementation of protocols . </li></ul><ul><li>(American Journal of Critical Care. 2007;16:28-38) </li></ul>Role of Education & Protocols Implementation
    27. 38. Take Home Message <ul><li>VAP is considered as a medical error </li></ul><ul><li>Preventative means is the hallmark way to deal with VAP </li></ul><ul><li>Applying one measure is insufficient to prevent VAP </li></ul><ul><li>VAP must be prevented through application of bundles </li></ul><ul><li>Best way to prevent VAP is to avoid invasive ventilation </li></ul><ul><li>Education and implementation of protocols significantly reduced VAP rates </li></ul>
    28. 39. <ul><li>“ The best time to plant a tree is 20 years ago. The second best time is now.” </li></ul><ul><li>African Proverb </li></ul>Thank You