Ventilator Associated Pneumonia

1. PREVENTION OF
VENTILATOR ASSOCIATED PNEUMONIA
(VAP)
K H A L I D Y. A R A B
R E S P I R AT O R Y T H E R A P I S T
P R I N C E S U L T A N A R M E D F O R C E S H O S P I T A L

2. OBJECTIVES
- Definition of ventilator associated pneumonia (VAP)
- Why VAP is Important
- Pathogen's of ventilator associated pneumonia (VAP)
- Diagnosis of ventilator associated pneumonia (VAP)
- WHO GETS VAP?
- Prevention of ventilator associated pneumonia (VAP)
- Summary of ventilator associated pneumonia (VAP)

3. VENTILATOR ASSOCIATED PNEUMONIA
(VAP)
• Ventilator-associated pneumonia (VAP) is a form of
nosocomial pneumonia that occurs in patients
receiving mechanical ventilation for longer than
48 hours.
• VAP is a leading cause of death due to hospital-
acquired infections.
• The incidence of VAP is 22.8% in patients receiving
mechanical ventilation,
3

4. DEFINITION- “KNOW THY ENEMY”
• The risk for pneumonia increases 3- to 10-fold in patients
receiving mechanical ventilation.
• VAP is associated with increases in morbidity and
mortality, hospital length of stay, and costs.
• The mortality rate attributable to VAP is 27% and has
been as high as 43% when the causative agent was
antibiotic resistant
4
American Thoracic Society, Infectious Diseases Society of America.
Guidelines for the management of adults with hospital-acquired, ventilator-associated,
and healthcare-associated pneumonia.

5. CONT….
• Length of stay in the intensive care unit is increased
by 5 to 7 days and hospital length of stay
2- to 3-fold in patients with VAP.
• The cost of VAP is estimated to be an additional
$40000 per hospital admission per patient with
the disease and an estimated $1.2 billion per year.

6. * VAP ....... 25% of all nosocomial infections
in ICU.
* VAP ....... 10 -25% of all mechanical
ventilated patients.
* VAP ........ 20-50% morbidity and mortality.
* VAP ........ is a preventable disease.

7. EARLY VS LATE VAP
The onset of VAP can be divided into 2 types:
• Early-onset VAP occurs 48 to 96 hours after
intubation and is associated with antibiotic-
susceptible organisms.
• Late-onset VAP occurs more than 96 hours after
intubation and is associated with antibiotic-resistant
organisms

8. PATHOGENESIS
The pathophysiology of VAP involves 2 main
processes:
• Colonization of the respiratory and digestive
tracts.
• Aspiration of secretions of the upper and lower
parts of the airway.
8

9. Colonization of the respiratory and digestive tracts
• Bacterial colonization of the lungs can be due to
spread of organisms from many different sources,
including the oropharynx, sinus cavities, nares,
dental plaque, gastrointestinal tract, patient-to-
patient contact, and the ventilator circuit.
• Inhalation of colonized bacteria from any of these
sources can cause an active host response and,
ultimately, VAP.

10. ASPIRATION OF SECRETIONS
The presence of an endotracheal tube provides a direct route for
colonized bacteria to enter the lower respiratory tract.
Upper airway and oral secretions can pool above the cuff of an
endotracheal tube and line the tube, forming a biofilm. Starting
as early as 12 hours after intubation,
The biofilm contains large amounts of bacteria that can be
disseminated into the lungs by ventilator-induced breaths.

11. Biofilm on ETT
Dispersal of Biofilm With
Ventilation
Endotracheal Tube
Subglottic
Secretions
Endotracheal
Tube Cuff
Pooled Secretions in
Airway
VAP PATHOGENESIS

13. DIAGNOSIS
• Every patient who is intubated and receiving ventilatory
support is at risk for VAP, making an accurate diagnosis
of this disease and starting treatment is critical.
• Diagnosing VAP remains difficult and controversial. The
diagnosis can be made on the basis of radiographic
findings, clinical findings, results of microbiological tests
of sputum, or invasive testing such as bronchoscopy.

14. HOW DO WE DIAGNOSE? 2-1-2
• Radiographic evidence x 2 consecutive days
 New, progressive or persistent infiltrate
 Consolidation, opacity, or cavitation
• 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 gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)

15. Host Environment
•Age
•Sex (M>F)
•Underlying
disease
state
(chronic
disease,
conscious
level, sepsis
etc)
•Intubation
•Length of
ventilation
•Tube cuff pressure
•Reintubation
•Sedation
•Body postion*
•Use of gastric
protection*
•NG feeding
•Unit hygiene*
WHO GETS VAP?

16. PREVENTION
Bundles Methodology
• Bundles are group of intervention related to a disease that
when providing together give better outcomes than when
done individually.
• Provide a mechanism to enhance teamwork and
enhance outcome.
• The guideline become as road map to enhance outcome.

17. • Nurses are the first line of defense in preventing
bacterial colonization of the oropharynx and the
gastrointestinal tract.
• Meticulous hand washing for 10 seconds should
be performed before and after all contact with
patients.
• Gloves should be worn when contact with oral
or endotracheal secretions is possible.

18. CONT….
• Strategically placing a sign on a patient’s door to remind health-
care workers to wash their hands and wear gloves is an easy
and cost-effective measure that can help minimize
transmission of bacteria between patients.
• The use of protective gowns is not recommended as routine
practice, but gowns should be used when antibiotic-resistant
pathogens have been isolated and identified.

19. Hand
1 - Elevation of the bed between 30-45 degree at all time
(unless contraindicated).
2 - Oral care
3 - Sedation interruption and Mechanical ventilation
weaning protocol.
4 - Deep venous thrombosis (DVT) prophylaxis (unless
contraindicated).
5 - Peptic ulcer disease (PUD) prophylaxis.
6 - Airway/ventilator management
(Chlebicki, Crit Care Med,2007)

20. HOB at 30-
45º
20
HOB ELEVATION
CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005

21. CONT….
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
21

22. • HOB improves patient’s ventilation.
• Supine patients have lower spontaneous
tidal volumes on PS than those seated in
upright position.
• ↑HOB may aid ventilatory efforts and
minimize atelectasis.
22
CONT….

23. 0
5
10
15
20
25
%VAP
Supine HOB Elevation
VENTILATOR ASSOCIATED PNEUMONIA
(VAP)
23
HOB ELEVATION LEADS TO
SIGNIFICANT DEDUCTION IN VAP

24. 24

25. 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

26. ORAL CARE
1- Perform ET suctioning only when clinically indicated
2- Oral hygiene should be performed every 2-4 hours and
should include:
a- Tooth brushing at least two times a day;
b- Oral swabs with 1.5% hydrogen peroxide solution
every 2-4 hours;
c- Mouth moisturizer to oral mucosa and lips
d- Subglottic suctioning continuously or intermittently
26

27. Sedation in ICU has the benefit of reducing psychological
problems to the patients .
However heavy sedation is harmful and predispose to
VAP by :
1- Inhibiting coughing.
2- Inhibiting mobilization.
3- Decreasing immune function.
4- Promoting aspiration.
5- Prolongs time on ventilator.

28. NURSE-DRIVEN SEDATION WEANING
PROTOCOLS
- Multiple research studies have shown that nurse driven
sedation protocols improve patient outcomes
- Routine assessments and response to therapy should be
incorporated in the protocol
- A sedation goal should be defined for each individual patient
Without a goal, adequate levels of sedation will not be
achieved

29. CONTINUOUS INFUSIONS:
DAILY WAKE UP
- All infusions should be at the lowest rate to
achieve effect
- IV bolus therapy should be used to supplement
infusion when necessary
- Every patient must be awakened daily unless
contraindicated!

30. DAILY WAKE UP
- 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.
- Goal is to decrease sedation

31. PEPTIC ULCER DISEASE (PUD)
PROPHYLAXIS
Appropriate intervention in all sedentary patients,
however,
↑ incidence of stress ulceration in critical illness
Decreasing pH of gastric contents may protect
against greater pulmonary inflammatory response
to aspiration of gastrointestinal contents

32. CONT….
- Aspiration causes either pneumonitis or pneumonia
and can be prevented
- Effects of aspirating acidic contents may be worse
than those with higher pH.

33. CONT….
While it is unclear if there is any association
between PUD prophylaxis and decreasing rates
of VAP, experience shows that when PUD
prophylaxis is applied as part of a package of
interventions for vent care, the rate of
pneumonia decreases precipitously.

34. DEEP VEIN THROMBOSIS (DVT)
PROPHYLAXIS
- Higher incidence of DVT in critical illness
- Risk of venous thromboembolism is reduced
if prophylaxis is consistently applied
- TARGET: patients undergoing surgery,
trauma patients, acutely ill medical patients,
and ICU patients

35. CONT….
It is unclear if there is any association
between DVT prophylaxis and decreasing
rates of VAP.
Experience shows that when DVT prophylaxis
is applied as part of a package of
interventions for ventilator care, the rate of
pneumonia decreases precipitously.

36. DVT PROPHYLAXIS – RISK OF BLEEDING
Important considerations include that the risk of
bleeding may increase if anticoagulants are used to
accomplish the prophylaxis.
Often, sequential compression devices
(ie. SCDs, “venodynes” or “pneumoboots”) are not
applied to patients when they go to or return from
procedures.

37. AIRWAY MANAGEMENT
Mechanical ventilation
 Avoidance
 Mask ventilation trials
 Orotracheal intubation
 Nasotracheal intubation may slightly increase the risk for VAP
 Ventilator circuit changes
 Change only when soiled or malfunctioning
 Cuff management
 Maintain at 25-30 cm H2O

38. CONT….
Suctioning
 In-line suctioning using closed technique
 Normal saline
 Should not be routinely used to suction pts
 Causes desaturation
 Does not increase removal of secretions
 Can potentially dislodge bacteria
 Should be used to rinse the suction catheter after suctioning

39. VAP REDUCTION WITH ET SUCTION
ABOVE THE CUFF
0
5
10
15
20
Percent(%)
No Suction Suction
VENTILATOR ASSOCIATED PNEUMONIA
(VAP)
39

40. SUBGLOTTIC 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 the cuff may reduce the risk of VAP

41. VENTILATOR CIRCUIT
 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
 In the event of ineffective ventilation, manual ventilation with
AMBU bag may be used
 Expiratory condensation should be removed
via the trap in the tubing
 Inspiratory condensation – if clean, may
be drained back into the water reservoir

42. VENTILATOR CIRCUITS
HUMIDIFICATION SYSTEMS
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
 VT < 300 cc or > 750 cc

43. RAPID,SPECIFIC TREATMENT
Start treatment early when suspected
Broad-spectrum antibiotic (with
antipseudomonal activity) +/-
aminoglycoside recommended

44. SUMMARY
Ventilator associated pneumonia (VAP) can
be defined as new X-ray changes with
one of:
Fever
Leukocytosis
Increasingly purulent secretions
Occurring after 48 hours of instituting mechanical
ventilation.
This definition is arguable, however

45. SUMMARY
- VAP is associated with a high mortality
- VAP has potential as a key performance indicator in
ICU
- It occurs due to aspiration, either at time of
intubation or during ventilation
- Risk factors are both patient and environment
related

46. SUMMARY
Management focuses on identifying those at risk, minimising risk,
accurate diagnosis and prompt treatment
Risk is minimised using a ventilator care bundle recommended
by CDC Guideline , which is (mostly) evidence based
Treatment should not be delayed if the patient is septic

47. SUMMARY

48. BRAVE AND COMMITTED NURSES, RT , DOCTORS SAVE
MANY LIVES
D R . T . V . R A O M D 48