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1 vap
Ventilator-associated pneumonia (VAP) is difficult to diagnose and treat, prolongs hospital stays, increases mortality, and is expensive to manage. While up to 28% of ventilated patients may develop VAP, many cases are preventable through measures like hand hygiene, keeping patients semi-erect, minimizing sedation and intubation duration, and using specialized endotracheal tubes that allow subglottic suctioning of secretions. Proper diagnosis and early, targeted antibiotic treatment can improve outcomes for patients who do develop VAP.
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1 vap
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- 2. VAP • difficult todiagnose • expensive to treat • increased patient mortality and hospital stay • MANY CASES PREVENTABLE
- 3. Definition • hospital acquiredpneumonia after 48h on ventilator (endotracheal or tracheotomy) • EARLY ONSET - <96 hours on ventilator • LATE ONSET - >96 hours on ventilator
- 4. Incidence • Difficult todetermine due to definition • Intubated patients have 21 times the risk to develop pneumonia • Estimate that 28% of ventilated patients will get VAP – 1 out of every 4!
- 5. Outcome • Mortality increasedbut % unknown (15-50%) • Increased ICU stay by an average of 4 days Heyland. AJRCCM 1999, 159, 1249-56 • 28% patients x 4 days in ICU =$$$$
- 6. Pathogenesis Isakov. Seminars RCCM1999, 27, 5-17 Gram(–) and staph colonize oropharynx *Colonized tubing/humidifier/neb *From the sinuses and teeth *Biofilm on ETT Secretions pool above ET cuff Mucociliary clearance impaired No cough reflex Edema/hemorrhage good environment
- 7. Pathogenesis Isakov. Seminars RCCM1999, 27, 5-17 Gram(–) and staph colonize oropharynx *Colonized tubing/humidifier/neb *From the sinuses and teeth *Biofilm on ETT Secretions pool above ET cuff Mucociliary clearance impaired No cough reflex Edema/hemorrhage good environment
- 9. Pathogenesis Isakov. Seminars RCCM1999, 27, 5-17 Gram(–) and staph colonize oropharynx *Colonized tubing/humidifier/neb *From the sinuses and teeth *Biofilm on ETT Secretions pool above ET cuff Mucociliary clearance impaired No cough reflex Edema/hemorrhage good environment
- 11. Pathogenesis Isakov. Seminars RCCM1999, 27, 5-17 Gram(–) and staph colonize oropharynx *Colonized tubing/humidifier/neb *From the sinuses and teeth *Biofilm on ETT Secretions pool above ET cuff Mucociliary clearance impaired No cough reflex Edema/hemorrhage good environment
- 12. Risk Factors Hunter. PostgradMed 2006, 82, 172-178
- 13. Risk Factors Hunter. PostgradMed 2006, 82, 172-178 Odds Ratio 5.7 Cerra, CHEST 1997
- 14. Risk Factors 1400 pts 23%supine 5% elevated HOB to 45 degrees Draculovic, Lancet 1999 Hunter. Postgrad Med 2006, 82, 172-178
- 15. Diagnosis 1. Fever, leukocytosis, tachycardia 2.Infiltrate on CXR 3. Purulent Sputum burns, pancreatitis, trauma pulmonary edema, hemorrhage, contusion tracheobronchitis
- 16. Diagnosis Clinical Suspicion ofVAP Infiltrate on CXR + one or more of: •purulent tracheal secretions •fever •Leukocytosis •Reduced PaO2/FIO2 *CLINICAL SUSPICION NOT ENOUGH* Accuracy 50%
- 17. Confirmation of Diagnosis 1.Quantitative Tracheal Aspirate • bedside by therapist/nurse • good agreement with invasive bronch 2. Bronchoalveolar Lavage • more risks than tracheal aspirate • 73% sensitive and 82% specific 3. Protected Brush Specimen • Expensive and need experience • 89% sensitive and 94% specific
- 18. Confirmation of Diagnosis 1.Tracheal Aspirate 2. Bronchoalveolar Lavage 3. Protected Brush Specimen 105 CFUs 104 CFUs 103 CFUs
- 19. Tracheal Aspirate vsBAL • Sanchez-Nieto et al, AJRCCM 1998 – No mortality difference and high degree of concordance • Ruiz, AJRCCM 2000 – No benefit to BAL over tracheal aspirate • CCCTG, NEJM 2006 – Similar use of antibiotics, outcome and ICU stay
- 20. Organisms Cerra. CHEST 1997,111, 769-78
- 21. Organisms • EARLY (<96hours) – Staphylococcus, Strep pneumonia, Haemophilus influenza • LATE – (>96 hours, resistant organisms) – Pseudomonas, MRSA, Klebsiella, Acinetobacter
- 22. Treatment • start earlyand before microbiological data is back – delay is associated with increased mortality (69.7 vs 28.4 with 16h delay) Iregui. Chest 2002, 122, 262-8 • start with appropriate regimen – inappropriate initial abx associated with increased mortality and increased length of stay Kolleff. Clin Infect Dis 2000, 31, S131-8
- 23. Antibiotics Risk Factors forResistant Organisms Porzecanski. CHEST 2006, 130, 597-604
- 24. Antibiotics • No RiskFactors for Resistance – Ceftriaxone/Cefotaxime, fluroquinolone, ampicillin/sulbactam, ertapenem
- 25. Antibiotics • Risk Factorsfor Resistance (3 abx) – antipseudomonal cephalosporin (ceftazadime, cefepime) or antipseudomonal carbapenem (imipenem, meropenem) or B-lactam/B- lactamase inhibitor (pip/tazo) PLUS – antipseudomonal fluoroquinolone (ciprofloxacin, levofloxacin) or aminoglycoside (gentamycin, amikacin, tobramycin) PLUS – vancomycin or linazolid
- 26. Antibiotics DURATION • study lookingat 8d vs 14d found no difference in recurrence or mortality Chastre. JAMA 2003, 290, 2588-98 • if Pseudomonas or Acinetobacter, treat 14d
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- 28. Interim Conclusion • VAPcauses significant increase in mortality and ICU stay ($) • Aggressively look for it – new/progressive infiltrate + fever/leukocytosis/purulent secretions • Early appropriate antibiotics – broad coverage for late onset PNA
- 29. Interim Conclusion • Bacteriologicdiagnosis – tracheal aspirate vs bronch • Narrow antibiotics once organism found • Treatment for 8d • Consider algorithm
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- 32. VAP Prevention Hand Washing AppropriateNurse:Pt Ratio Avoid Unnecessary Antibiotics Avoid Unnecessary Stress Ulcer Prophylaxis Sucralafate for Ulcer Prophylaxis Oral Intubation Short Course Antibiotics Digestive Decontamination and Oral Chlorhexidine Staff Education Use of NIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Bacterial Colonization Aspiration
- 33. Colonization Prevention Hand Washing AppropriateNurse:Pt Ratio Avoid Unnecessary Antibiotics Avoid Unnecessary Ulcer Proph Sucralafate for Ulcer Prophylaxis Oral Intubation Short Course Antibiotics Digestive Decontam/Oral Chlorhex Staff Education •most important and easiest way •prevents colonization of patients with “ICU” bacteria
- 34. Colonization Prevention Hand Washing AppropriateNurse:Pt Ratio Avoid Unnecessary Antibiotics Avoid Unnecessary Ulcer Proph Sucralafate for Ulcer Prophylaxis Oral Intubation Short Course Antibiotics Digestive Decontam/Oral Chlorhex Staff Education •nurses more likely to wash hands between patients •more likely to keep the head of the bed elevated •education on VAP helps with prevention (team approach)
- 35. Colonization Prevention Hand Washing AppropriateNurse:Pt Ratio Avoid Unnecessary Antibiotics Avoid Unnecessary Ulcer Proph Sucralafate for Ulcer Prophylaxis Oral Intubation Short Course Antibiotics Digestive Decontam/Oral Chlorhex Staff Education •nasal intubation prevents sinus drainage •sinusitis a source of bacteria for VAP •quick change from nasal to oral intubation
- 36. Colonization Prevention Hand Washing AppropriateNurse:Pt Ratio Avoid Unnecessary Antibiotics Avoid Unnecessary Ulcer Proph Sucralafate for Ulcer Prophylaxis Oral Intubation Short Course Antibiotics Digestive Decontam/Oral Chlorhex Staff Education •8d sufficient in most patients •limits emergence of resistant bacteria
- 37. Aspiration Prevention Use ofNIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •use when appropriate (COPD exacerbation) •reduces the incidences of VAP when used correctly
- 38. Aspiration Prevention Use ofNIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports •3% per day for 1st week, 2% per day for 2nd week •Shorter ventilation equals less VAP •protocols for weaning and minimizing sedation
- 39. Aspiration Prevention Use ofNIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •supine position causes aspiration (especially during tube feeds) •3 fold reduction in VAP when patients kept at 45° •need trained nursing staff
- 40. Aspiration Prevention Use ofNIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •reintubation carries significant increase in VAP risk •VAP in 30% patients with unexpected extubation vs 13.8% in controls de Lassence. Anesthesiology 2002, 97, 148-56
- 41. Aspiration Prevention Use ofNIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •maintain at > 20 cm H2O to prevent drainage
- 42. Aspiration Prevention Use ofNIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation 1. check residuals 2. minimize narcotics 3. use prokinetic agents like metoclopramide 4. small bore feeding tubes post pyloric reduces VAP 5. ?delay feeds in high risk patients
- 43. Aspiration Prevention Use ofNIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •circuit changes DO NOT prevent VAP •condensate in tubing leads to VAP if it goes down the ETT tube •drain condensate •change circuit only for emesis, blood or purulence
- 44. Aspiration Prevention Use ofNIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •Allows patients cough reflex to assist in secretion clearance
- 45. Other Prevention Steps •Minimize blood transfusions – associated with increased risk VAP Shorr, Crit Care Med 2004, 32, 666-674 • Tight control of blood glucose – reduces mortality, sepsis, ICU stay – no data in VAP but suspected effect van den Berghe. NEJM 2001, 345, 1359-67
- 46. Concusions • MANY CASESOF VAP ARE PREVENTABLE! • Simple techniques – hand washing, elevated head of bed, attention to tube feed residuals, bld glc control • Minimizing interventions – transfusions, abx courses, tubing changes, duration of ventilation
- 47. Implementation 1. Strict monitoringof monthly cases of VAP 2. Staff education (doctors, nurses, technicians) 3. Protocols for all patients on ventilators that address patient and ventilator management 4. Documentation of success in decreasing incidence of VAP
- 48. Conclusion • VAP ispneumonia after 48 hours on a vent • It is difficult to diagnose and treat • It prolongs stay and increases mortality • It results from aspiration of contaminated secretions • Simple measures decrease the incidence • Appropriate treatment improves outcome
- 50. Future • Vaccines – investigatingvaccine against S.aureus • Nebulized Antibiotics – shown to reduce colonization with gram negatives
- 51. Colonization Prevention Hand Washing AppropriateNurse:Pt Ratio Avoid Unnecessary Antibiotics Avoid Unnecessary Ulcer Proph Sucralafate for Ulcer Prophylaxis Oral Intubation Short Course Antibiotics Digestive Decontam/Oral Chlorhex Staff Education •higher acidity favors microbial growth •H2 blockers and antacids associated with increased VAP •unclear what to do given benefits of stress ulcer proph •sucralafate better for VAP prevention but conflicting studies
- 52. Aspiration Prevention Use ofNIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •specialized ET tubes that allow suctioning of secretions •cost 25% more than normal tubes