2. VAP
• difficult to diagnose
• expensive to treat
• increased patient mortality
and hospital stay
• MANY CASES
PREVENTABLE
3. Definition
• hospital acquired pneumonia after 48h on
ventilator (endotracheal or tracheotomy)
• EARLY ONSET - <96 hours on ventilator
• LATE ONSET - >96 hours on ventilator
4. Incidence
• Difficult to determine 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 increased but % 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 RCCM 1999, 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 RCCM 1999, 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
8.
9. Pathogenesis
Isakov. Seminars RCCM 1999, 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
10.
11. Pathogenesis
Isakov. Seminars RCCM 1999, 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
16. Diagnosis
Clinical Suspicion of VAP
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
19. Tracheal Aspirate vs BAL
• 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
22. Treatment
• start early and 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
24. Antibiotics
• No Risk Factors for Resistance
– Ceftriaxone/Cefotaxime, fluroquinolone,
ampicillin/sulbactam, ertapenem
25. Antibiotics
• Risk Factors for 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 looking at 8d vs 14d found no
difference in recurrence or mortality
Chastre. JAMA 2003, 290, 2588-98
• if Pseudomonas or Acinetobacter, treat 14d
32. VAP Prevention
Hand Washing
Appropriate Nurse: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
Appropriate Nurse: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
Appropriate Nurse: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
Appropriate Nurse: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
Appropriate Nurse: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 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
Minimize Sedation
•use when appropriate
(COPD exacerbation)
•reduces the incidences
of VAP when used
correctly
38. Aspiration Prevention
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
•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 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
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 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
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 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
Minimize Sedation
•maintain at > 20 cm
H2O to prevent drainage
42. Aspiration Prevention
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
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 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
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 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
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 CASES OF 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 monitoring of 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 is pneumonia 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
49.
50. Future
• Vaccines
– investigating vaccine against S.aureus
• Nebulized Antibiotics
– shown to reduce colonization with gram
negatives
51. Colonization Prevention
Hand Washing
Appropriate Nurse: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 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
Minimize Sedation
•specialized ET tubes that
allow suctioning of
secretions
•cost 25% more than
normal tubes