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VAP Bundle
This document discusses strategies for preventing ventilator-associated pneumonia (VAP) in intubated patients. It defines VAP and reviews risk factors such as prolonged intubation. Preventative measures include following infection control guidelines, using oral antiseptics to reduce bacterial colonization, maintaining head of bed elevation and cuff pressure to prevent aspiration, and minimizing the duration of mechanical ventilation when possible. Adhering closely to bundles that incorporate these various preventative strategies can help reduce the incidence of VAP.
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VAP Bundle
- 1. The presentation issolely meant for Academic purpose Department of Critical Care Medicine, Apollo Hospitals
- 2. PREVENTING VENTILATOR ASSOCIATED PNEUMONIA (VAP BUNDLE) Department of Critical Care Medicine, Apollo Hospitals
- 3. Preventing VAP Definitions Pathophysiology of VAP Risk factors Prevention of VAP Guidelines Recent advances Conclusion Department of Critical Care Medicine, Apollo Hospitals
- 4. Definitions Hospital acquiredpneumonia (HAP) ATS/IDSA 2005 guidelines 48 hours or more after admission Ventilator associated pneumonia (VAP) Type of HAP developing > 48 hours after intubation Early vs Late Healthcare associated pneumonia (HCAP) Hospitalization in an acute care hospital for two or more days within the prior 90 days Other health care contact Department of Critical Care Medicine, Apollo Hospitals
- 5. Risk Factors It is NOT the Ventilator Department of Critical Care Medicine, Apollo Hospitals
- 6. Risk Factors Hostrelated Age Lung disease/ARDS Immunosuppression Unconsciousness Body position Antibiotic exposure Chest surgery Re-intubation/prolonged intubation Device related ETT Ventilator circuit Orogastric and nasogastric tube Personnel related Hand washing, Noncompliance Department of Critical Care Medicine, Apollo Hospitals
- 7. Bacterial Colonization (Aerodigestive tract, ETT, Ventilator tubings) Micro-aspiration (Secretions, Vent. Condensate, Aerosols) Bacteremia Bacterial inhalation Gut translocation Contamination Ventilator Associated Pneumonia Department of Critical Care Medicine, Apollo Hospitals
- 8. Host Factors Antibiotics Gastric pH Bacterial Colonization (Oropharynx, Stomach, Sinus, ETT) Devices – ETT, NGT Inadequate Transmission Biofilms infection control practices Department of Critical Care Medicine, Apollo Hospitals
- 9. Department ofCritical Care Medicine, Apollo Hospitals
- 10. Prevention of VAP General measures Avoid invasive ventilation Prevent colonisation Prevent micro-aspiration Prevent contamination of equipment Minimize duration of invasive ventilation ATS guidelines 2005 SHEA guidelines 2008 Department of Critical Care Medicine, Apollo Hospitals
- 11. General Measures Adequatestaffing ATS guidelines 2005 SHEA guidelines 2008 Contact isolation for MDR bugs Conduct active surveillance for VAP VAP assessment risk Audit compliance with VAP bundle Monitor incidence of VAP Hand-hygiene Use non-invasive ventilation Educate health-care personnel Department of Critical Care Medicine, Apollo Hospitals
- 12. Hand washing Beforeand after suctioning AACN Practice Alert for VAP, 2004 Touching ventilator equipment Contact with patients and patient environment Contact with respiratory secretions Department of Critical Care Medicine, Apollo Hospitals
- 13. Avoid Nasotracheal Oral care Silver coated ETT intubation and NG tubes Decontamination Secretion clearance Closed vs. open suction Saline instillation Stress ulcer prophylaxis Preventing Colonisation SDD Department of Critical Care Medicine, Apollo Hospitals
- 14. Oral Care andDecontamination Mouth flora = Lung flora Mechanical cleaning Decontamination –SDD vs SOD1,2 SDD = SOD2 Oral Decontamination only in post-hoc analysis2 Mortality benefit with Chorhexidine recommended SDD- Concern about increasing resistance Stronger data in cardiothoracic and trauma patients3 1-Chan EY et al. BMJ 2007 2-de Smet AM et al. N Engl J Med. 2009 3-O’Grady NP et al. JAMA 2012 Department of Critical Care Medicine, Apollo Hospitals
- 15. Avoid Nasotracheal Oral care Silver coated ETT intubation and NG tubes Decontamination Secretion clearance Closed vs. open suction Saline instillation Stress ulcer prophylaxis Preventing Colonisation SDD Department of Critical Care Medicine, Apollo Hospitals
- 16. Silver Coated ETT Broad antimicrobial activity Decreases bacterial adhesion Decreases Biofilm formation N=2003 Silver coated vs Uncoated Primary outcome – VAP by BAL 4.8% vs. 7.5% VAP; P=0.04 NO mortality benefit NASCENT trial – Kollef M et al. JAMA 2008 Department of Critical Care Medicine, Apollo Hospitals
- 17. Avoid Nasotracheal Oral care Silver coated ETT intubation and NG tubes Decontamination Secretion clearance Closed vs. open suction Saline instillation Stress ulcer prophylaxis Preventing Colonisation SDD Department of Critical Care Medicine, Apollo Hospitals
- 18. Secretion Management Secretionclearance Open vs closed suction Saline instillation HME vs Heated humidifier No role for prophylactic systemic antibiotics Department of Critical Care Medicine, Apollo Hospitals
- 19. HOB 30 -45 degrees Cuff pressure > 20 cm of water Subglottic suction Avoid unplanned extubation and re-intubation Avoid gastric overdistension Preventing Aspiration Department of Critical Care Medicine, Apollo Hospitals
- 20. Preventing Aspiration Supineposition increases Drainage of subglottic secretions risk and frequency of VAP decreases aspiration and VAP Drakulovic MB et al. Muscedere J et al. Lancet 1999 Crit Care Med. 2011 Department of Critical Care Medicine, Apollo Hospitals
- 21. Subglottic Suction Logistics – Low pressure Continuous vs intermittent suction NO MORTALITY BENEFIT ? Long-term airway complications Department of Critical Care Medicine, Apollo Hospitals
- 22. ETT modifications Highvolume low-pressure cuffs of ultrathin membrane Minimize folds Continuous monitoring of ETT Cuff pressure Low volume low pressure cuffs ETT with mucus shaver Disrupts Biofilm Department of Critical Care Medicine, Apollo Hospitals
- 23. Prevent Contamination ofEquipments Use sterile water to rinse reusable respiratory equipment Remove condensate from ventilatory circuits Keep the ventilatory circuit closed during condensate removal Change the ventilatory circuit only when visibly soiled or malfunctioning Store and disinfect respiratory therapy equipment properly SHEA guidelines 2008 Department of Critical Care Medicine, Apollo Hospitals
- 24. Minimize Duration ofInvasive Ventilation Spontaneous Awakening Trial Spontaneous Breathing Trial (SAT) (SBT) Consider Extubation to NIV ?Tracheostomy Department of Critical Care Medicine, Apollo Hospitals
- 25. Interventions with unclearValue Take Home Stress ulcer prophylaxis Need and type Monitoring gastric residual volume Silver coated ETT Promising but need more data Saline instillation during suction Newer ETTs – Rationale robust Data limited Department of Critical Care Medicine, Apollo Hospitals
- 26. Prevention of VAP- Bottomline Take Home Adhere to good infection control practices Avoid invasive ventilation when possible Minimize duration Prevent colonisation Avoid nasal intubation/NGT Oral care and decontamination – Chlorhexidine Prevent micro-aspiration HOB elevation 30-45 degrees Maintain ETT cuff pressure > 20 cm of water Subglottic suction Prevent contamination of equipments Minimize disconnections Routine change of tubings NOT recommended Department of Critical Care Medicine, Apollo Hospitals
- 27. Department ofCritical Care Medicine, Apollo Hospitals
- 28. Department ofCritical Care Medicine, Apollo Hospitals