VENTILATOR ASSOCIATED PNEUMONIA.ppt

1. VENTILATOR
ASSOCIATED
PNEUMONIA
Monday, March
13, 2023
1
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

2. VAP (VENTILATOR ASSOCIATED PNEUMONIA)
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.
Monday, March 13, 2023
2
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

3. Epidemiology
 Hospital acquired pneumonia (HAP) is the second most
common hospital infection.
 VAP is the most common intensive care unit (ICU) infection.
 90% of all nosocomial infections occurring in ventilated
patients are pneumonias.
Monday, March 13, 2023
3
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

4. VAP…….
Monday, March 13, 2023
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.
4
TYPES
Early–Onset (< 96 hours of intubation or
ICU admission)
• Community-acquired
• Pathogens: Streptococcus pneumoniae,
Haemophilus influenzae, Staphylococcus
aureus
• Antibiotic-sensitive
Late-Onset (> 96 hours of intubation or ICU
admission)
• Hospital-acquired
• Pathogens: Pseudomonas
aeruginosa,MRSA, Acinetobacter
Enterobacter.
• Antibiotic-resistant

5. INCIDENCE
 VAP occurs in 10 - 65% of all ventilated patients.
 Incidence increases with duration of MV 3% /day for first
5days, 2%/day for 6-10days and 1%/day after 10 days.
 Mortality rate is 27% & 43%with antibiotic resistant organism.
 Mortality rate in VAP caused by Pseudomonas and
Acinetobacter is as high as 76%
 Increases ventilatory support requirements , LOS, MEDICAL
COST
Monday, March 13, 2023
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Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

6.  HOST RELATED:- Medical /surgical disease, Immunosuprssion,
Malnutrition (Alb<2.2g/dl ), Advanced age, Supine position, Level
of conciousness, Medication-NMB, sedation, steroids, Previous
antibiotic use.
 HEALTHCARE PERSONNEL RELATED:- Improper hand
washing, Failure to change gloves and mask gown when ever
required.
 DEVICE RELATED:- MV with ETT or TRACHEOSTOMY TUBE,
MV>48 hrs, Reintubations, NGT or Oro- gastric tube,Use of
Humidifier.
RISK FACTORS
Monday, March 13, 2023
6
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

7. PATHOGENESIS
 Bacteria enter the lower respiratory tract via following pathways:
Aspiration of organisms from the oropharynx and GI
tract (most common cause)
Direct inoculation (through improper suctioning)
Inhalation of bacteria
Haematogeneous spread
Monday, March 13, 2023
7
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

8. 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.)
Monday, March 13, 2023
8
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

9. Ventilator Associated Pneumonia Care
Bundle -Evidence Based Practices
 Head Of Bed elevated to 30˚-45˚
 Daily sedation vacation & daily assessment of readiness to
wean off.
 DVT Prophylaxis
 Stress Ulcer Prophylaxis
 Subglottic secretion drainage
 Daily mouth care with chlorhexidine
Monday, March 13, 2023
9
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

10. HOB UP 30 DEGREES OR
HIGHER
 Recommended elevation is 30-45 degrees,
 If semi-recumbent or supine ↑34% incidence VAP,
 ↑HOB → ↓risk of aspiration of gastrointestinal contents,
↓risk of aspiration of oropharyngeal secretions,
↓risk of aspiration of
 ↑HOB improves patients’ ventilation,
 ↑HOB may aid ventilatory efforts and minimize atelectasis
 unless contraindiacated,
Monday, March 13, 2023
10
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

11.  Sedation vacation results in significant reduction in time on
mechanical ventilation.
 If the patient is co-operative and able to understand
commands leave the sedation off.Distressed or agitated
patients require re-sedating.
 Administer boluses as appropriate to achieve safety.
Monday, March 13, 2023
11
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

12. 3. Peptic Ulcer Disease (PUD) Prophylaxis
 Critically ill intubated patients lack the ability to defend their
airway.
 Decreasing pH of gastric contents may protect against
greater pulmonary inflammatory response to aspiration of
gastrointestinal contents.
Monday, March 13, 2023
12
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

13. 4.Deep Vein Thrombosis (DVT) Prophylaxis
 Mechanically-ventilated patients are at high risk for VTE. Riskfactors include
immobility and a stress inflammatory response resulting in hypercoagulation.
Although there is no evidence to suggest VTE prophylaxis reduces VAP risk, it
is appropriate to include VTE prophylaxis in a bundle that promotes improved
care of mechanically-ventilated patients due to their high risk for VTE.
Monday, March 13, 2023
13
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

14. 5.Subglottal Suctioning
 Should be done using a 14 Fr sterile suction catheter:
 Prior to ETT rotation
 Prior to lying patient supine
 Prior to extubation
Monday, March 13, 2023
14
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

15. 6. mouth care with chlorhexidine
 Most bacterial nosocomial pneumonias are caused by aspiration
OF bacteria colonizing the oropharynx and upper GI tract of the
patient.
 Gram-positive bacteria often constitute the oral microflora of healthy individuals.
However, the balance of oral microflora of patients hospitalized in ICUs for more than
48 h tends to change. These changes lead to a prevalence of Gram-negative
bacteria such as Staphylococcus aureus, Streptococcus pneumoniae,
Acinetobacter baumanii, Haemophilus influenzae, and Pseudomonas
aeruginosa. These bacteria have all been associated with nosocomial pneumonia
 Mouth care should be given in every shift or every 6 hrs.
Monday, March 13, 2023
15
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

16. GENERAL INSTRUCTIONS
 HAND WASHING
 STERILE SUCTIONING (DO NOT REUSE SUCTION
CATHETER)
 2 ND HOURLY POSITIONING.
 ENTERAL FEEDING
Monday, March 13, 2023
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Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.