Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Ventilator Associated Pneumonia (VAP) or Hospital Acquired Pneumonia (HAP)

3,173 views

Published on

by Dr. Marion A. Kwek

Published in: Healthcare

Ventilator Associated Pneumonia (VAP) or Hospital Acquired Pneumonia (HAP)

  1. 1. PREVENTION & CONTROL OF COMMON HAIS: THE BUNDLE APPROACH ON HAP/VAP Marion Aurellado Kwek, MD, FPCP, FPSMID 17 Feb 2016
  2. 2. OUTLINE  Definitions  Pathophysiology of Nosocomial Pneumonia  Risk Factors  Prevention  Prevention Bundles
  3. 3. DISCLOSURE  Received honoraria for lectures from Merck Sharp Dohme
  4. 4. INTRODUCTION  Nosocomial pneumonia pneumonia acquired while in a hospital  From the Latin word nosocomium: “hospital”  Classically divided into:  Hospital-acquired pneumonia (HAP)  Ventilator-associated pneumonia (VAP)  Recently has also been applied to health care–associated pneumonia (HCAP) Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases 8th Ed. 2015
  5. 5. INTRODUCTION  HAP is the leading cause of death among HAIs, with estimates of HAP-associated mortality ranging from 20 to 50%  Systematic review of published studies found attributable mortality rate of 13% for VAP Melsen et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis. 2013 Aug;13(8):665-71
  6. 6. INTRODUCTION  Most cases of HAP occur outside of intensive care units.  Highest risk for HAP is in patients on mechanical ventilation (ie, VAP)  Steady decline in reported VAP rates in the US, VAP from 0.0 to 4.4 per 1000 ventilator days depending on the patient care location in 2012 2012 NHSN Annual Report
  7. 7. DEFINITIONS
  8. 8. DEFINITIONS (CLINICAL)  Hospital-acquired (or nosocomial) pneumonia (HAP)  Pneumonia that occurs 48 hours or more after admission  Not incubating at the time of admission  Ventilator-associated pneumonia (VAP)  Develops more than 48 to 72 hours after intubation.  Healthcare-associated pneumonia (HCAP)  Pneumonia in a nonhospitalized patient  With extensive healthcare contact Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med Vol 171. pp 388–416, 2005
  9. 9. DEFINITIONS (CLINICAL)  Healthcare Contact  IVT, wound care, or IV chemotx within the past 30 days  Residence in a nursing home or other long- term care facility  Hospitalization in an acute care hospital for two or more days within the prior 90 days  Attendance at a hospital or hemodialysis clinic within the prior 30 days Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia. Am J Respir Crit Care Med Vol 171. pp 388–416, 2005
  10. 10. http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_by_Organ_System/ Lower/Upper_Respiratory/Hospital-Acquired_Pneumonia_(HAP)/
  11. 11. DEFINITIONS (SURVEILLANCE)  To be discussed on 19 Feb 2016  Surveillance of HAI (Didactic) - Dominga C. Gomez, RN and Dr. Dess Roman  Clinical diagnosis ≠ Surveillance Criteria
  12. 12. PATHOPHYSIOLOGY
  13. 13. PATHOPHYSIOLOGY  Histologic hallmark of VAP is heterogeneity  Lesions vary significantly in age and severity  Dependent areas > nondependent areas  Different organisms can be cultured from different lung segments of the same patient in 25% to 37% of cases  Cultures of histologically benign–appearing lung segments are often positive. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases 8th Ed. 2015
  14. 14. PATHOPHYSIOLOGY  Ventilated patients prone to repeated microaspirations around the ET cuff  Microbiologic, structural, and humoral factors combine to increase the risk of pneumonia in critically ill patients Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases 8th Ed. 2015
  15. 15. PATHOPHYSIOLOGY  Flora of the oral tract rapidly shifts from community respiratory organisms (Strep, Haemophilus) toward “hospital-associated” pathogens (S. aureus, Enterobacteriaceae, Pseudomonas, & Acinetobacter sp.)
  16. 16. PATHOPHYSIOLOGY  Likelihood of organisms being drug resistant steadily increases with time in a hospital, exposure to antimicrobials, and severity of illness.
  17. 17. PATHOPHYSIOLOGY  OGT/NGT disrupt lower esophageal sphincter + increase risk of aspiration of gastric contents  ET disrupts normal ciliary clearance of bronchial secretions + impairs patients’ capacity to cough.  Secretions pool above ET cuff and intermittently seep around folds in the cuff, particularly if the cuff is underinflated or if it shifts during patient movement or repositioning.
  18. 18. PATHOPHYSIOLOGY  Biofilm begins to form both inside and outside the endotracheal tube within a day of placement and serves as a bacterial reservoir within the trachea and oropharynx.  Suctioning or instillation of aerosols through the endotracheal tube can mobilize and embolize bacteria from the biofilm into the lungs.
  19. 19. Photo from slideshare
  20. 20. PATHOPHYSIOLOGY  Critical illness, poor nutrition, and immobilization may increase patients’ susceptibility to infection.  These factors interact and reinforce with one another to enhance the risk of microaspiration and the likelihood that pulmonary parenchymal colonization will lead to invasive infection.
  21. 21. Lifted from Oliveira et al. Prevention of Ventilator associated pneumonia 2014
  22. 22. RISK FACTORS
  23. 23. RISK FACTORS Factors that enhance risk of aspiration increase the likelihood of infection!!!
  24. 24. RISK FACTORS Factors Examples Mechanical factors •Emergency intubation, reintubation, duration of intubation •Supine positioning •Enteral feeding with OGT/NGT •Use of paralytic agents •Underinflation of ET cuff Mental Status •CNS disease •Level of consciousness •Level of sedation
  25. 25. RISK FACTORS Factors Examples Bacterial bioburden in the upper respiratory and orogastric tracts •Duration of hospitalization •Nasogastric intubation •Prolonged antibiotic exposures •Use of PPIs or other gastric acid suppressants Increased handling or breaking of the ventilator circuit Inhaled β-agonist therapy
  26. 26. RISK FACTORS Factors Examples Patient factors •Age > 70 yrs •Preexisting lung disease •Severity of illness •Surgical patients, (burn and trauma) higher VAP rates than medical patients Others •Intensive care staffing levels •Transportation out of ICU for diagnostic imaging or procedures
  27. 27. PREVENTION  Most prevention strategies are designed to decrease volume of regurgitant secretions or decrease the bacterial burden in and around oropharynx and ET, or both  Many interventions lower VAP rates, but few improve concrete outcomes such as duration of ventilation, ICU length of stay, or hospital mortality
  28. 28. PREVENTION BUNDLES
  29. 29. PREVENTION BUNDLES  Grouping multiple interventions together into VAP prevention “bundles” may enhance their effectiveness by exploiting synergies between interventions or by enhancing their visibility, immediacy, and hence performance by frontline providers.  VAP prevention bundles have become a standard of care in most hospitals
  30. 30. Recommendation Rationale Intervention Quality of evidence Basic practices Good evidence that intervention Decreases average duration of MV, length of stay, mortality, and/or costs; benefits likely outweigh risks Use NIPPV in selected populations Manage pxs w/o sedation whenever possible Interrupt sedation daily Assess readiness to extubate daily Perform spontaneous breathing trials w/ sedatives turned off High Moderate High High High Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Adult Patients. SHEA/IDSA 2014
  31. 31. Recommendation Rationale Intervention Quality of evidence Basic practices Good evidence that intervention Decreases average duration of MV, length of stay, mortality, and/or costs; benefits likely outweigh risks Facilitate early mobility Utilize ET with subglottic secretion drainage ports for patients expected to require greater than 48 or 72 hrs of MV Change the ventilator circuit only if visibly soiled or malfunctioning Elevate the head of the bed to 30–45 Moderate Moderate High Low Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Adult Patients. SHEA/IDSA 2014
  32. 32. Recommendation Rationale Intervention Quality evidence Special approaches Good evidence that the intervention improves outcomes but insufficient data available on possible risks May lower VAP rates but insufficient data to determine impact on duration of mechanical ventilation, length of stay, or mortality Selective oral or digestive decontamination Regular oral care with chlorhexidine Prophylactic probiotics Ultrathin polyurethane endotracheal tube cuffs Automated control of ET cuff pressure Saline instillation before tracheal suctioning Mechanical tooth brushing High Moderate Moderate Low Low Low Low Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Adult Patients. SHEA/IDSA 2014
  33. 33. Recommendation Rationale Intervention Quality evidence Generally not recommended Lowers VAP rates but ample data suggest no impact on duration of mechanical ventilation, length of stay, or mortality No impact on VAP rates, average duration of mechanical ventilation, length of stay, or mortality Silver-coated Ets Kinetic beds Prone positioning Moderate Moderate Moderate Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Adult Patients. SHEA/IDSA 2014
  34. 34. Recommendation Rationale Intervention Quality evidence No recommendation No impact on VAP rates or other patient outcomes, unclear impact on costs Closed/in-line ET suctioning Moderate Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Adult Patients. SHEA/IDSA 2014
  35. 35. PREVENTION BUNDLES  Involve implementation of various measures in an attempt to reduce the incidence of VAP among at risk patients  Measures often include educational programs, technical measures, surveillance, and feedback  Practical way to enhance care
  36. 36. PREVENTION BUNDLES: EVIDENCE  Eight practices: hand hygiene, glove and gown compliance, elevation of the head of the bed, oral care with chlorhexidine, maintaining an ET cuff pressure >20 cm H20, orogastric rather than nasogastric feeding tubes, avoiding gastric overdistention, and eliminating nonessential tracheal suctioning  Rate of VAP decreased from 23 to 13 VAP episodes per 1000 ventilator-days  No differences in total duration of mechanical ventilation or the ICU and hospital death rates. Bouadma L, et al. Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit. Clin Infect Dis. 2010;51(10):1115.
  37. 37. PREVENTION BUNDLES: EVIDENCE  Five interventions: semirecumbent position, stress ulcer prophylaxis, DVT prophylaxis, adjustment of sedation, and daily assessment for extubation  Tested in 112 ICUs with 550,800 ventilator-days  VAP rate from a median of 5.5 cases per 1000 ventilator-days at baseline to a median of 0 cases at 16 to 18 months after implementation Berenholtz SM et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;32(4):305.
  38. 38. PREVENTION BUNDLES  Wide variability in their components and definitions for adherence  No consensus about which care processes to include
  39. 39. SUMMARY  Definitions  Pathophysiology  Risk Factors  Prevention  Prevention Bundles
  40. 40. CHALLENGE  Formulate bundles  Implement  Monitor  RCTs

×