Ventilator-associated pneumonia (VAP) is a common nosocomial infection that increases ICU stay and mortality. The document discusses risk factors for VAP and strategies to prevent and diagnose it, including implementing a VAP bundle with elements like elevating the head of bed, daily sedation vacations, and oral care. It emphasizes the importance of staff education to properly implement prevention protocols and decrease VAP rates.

1. Dr Nirmal Jaiswal MD(med);FCCS
ICU Director and Consultant Physician
Suretech Hospital,Nagpur

2. • VAP is the 2nd most common nosocomial
infection = 15% of all hospital acquired
infections
• Incidence = 9% to 70% of patients on
ventilators
• Increased ICU stay by several days
• Increased avg. hospital stay 1 to 3 weeks
• Mortality = 13% to 55%
Centers for Disease Control and Prevention, 2003.
Rumbak, M. J. (2000). Stra te g ie s fo r p re ve ntio n a nd tre a tm e nt. Journal of
Respiratory Disease, 21 (5), p. 321;

3. • “There is no doubt that the
diagnosis and management of
VAP remains one of the most
controversial and challenging
topics in management of
critically ill patients.”
Chan C, Chest 2005;127:425

6. • VAP is a Nosocomial Pneumonia =
Hospital acquired
• Diagnosis is imprecise and usually
based on a Combination of:
– Clinical factors - fever or hypothermia;
change in secretions; cough;
apnea/bradycardia; tachypnea
– Microbiological factors - positive
cultures of blood/sputum/tracheal
aspirate/pleural fluids
– CXR factors - new or changing infiltrates

7. • Pathogens that cause VAP differ
depending on whether the condition
occurs early (less than 96 hours after
intubation or admission to ICU) or
late (greater than 96 hours after
intubation or admission to ICU)
Kollef M, Chest 2005;128:3854-62

8. • Early–Onset Pneumonia (< 96 hours of
intubation or ICU admission)
– Community-acquired
– Pathogens:
• Stre p to c o c c us p ne um o nia e
• Ha e m o philus influe nz a e
• Sta phy lo c o c c us a ure us
– Antibiotic-sensitive

9. • Late-Onset Pneumonia (> 96 hours of
intubation or ICU admission)
– Hospital-acquired
– Pathogens:
• Ps e ud o m o na s a e rug ino s a
• Methicillin resistant Sta phy lo c o c c us a ure us
(MRSA)
• Ac ine to ba c te r
• Ente ro ba c te r
• Antibiotic-resistant

10. • Major risk factor = mechanical intubation
• Factors that enhance colonization of the oropharynx &/or
stomach:
– Administration of antibiotics
– Admission to ICU
– Underlying chronic lung disease
• Conditions favoring aspiration into the respiratory tract
or reflux from GI tract:
– Supine position *GERD
– NGT placement *Coma/delirium
– Intubation and self-extubation
– Immobilization
– Surgery of head/neck/thorax/upper abdomen

11. • Conditions requiring prolonged use of
mechanical ventilatory support with
potential exposure to contaminated
respiratory devices &/or contact with
contaminated hands
• Host Factors:
– Extremes of age
– Malnutrition
– Immunocompromised
– Underlying condition/disease process

12. Four Algorithms :
Algorithm #1: Adolescents and adults
Algorithm #2: Immunocompromised p
Algorithm #3: Children 1 to <12 years
Algorithm #4: Infants (<1 year)

14. Algorithm #2: Diagnosing VAP in Immunocompromised Patients

15. Algorithm #3: Diagnosing VAP in Children (Age >1 and <13 years)

16. Algorithm #4: Diagnosing VAP in Infants (Age <1 year old)

18. • A "bundle" is a group of
evidence-based care
components for a given disease
that, when executed together,
may result in better outcomes
than if implemented individually.

19. • In a bundle, the individual elements are
built around best evidence-based practices.
• The science supporting the individual
treatment strategies in a bundle is
sufficiently mature such that
implementation of the approach should be
considered either best practice or a
reasonable and generally accepted
practice.

20. VAP BUNDLE

21. • Ventilator-Associated Pneumonia
(VAP)Bundle:
– DVT prophylaxis
– GI prophylaxis
– Head of bed (HOB) elevated to 30-45°
– Daily Sedation Vacation
– Daily Spontaneous Breathing Trial connected

22. • Include deep venous prophylaxis as part of your ICU
order admission set and ventilator order set. Make
application of prophylaxis the default value on the form.
• Include deep venous prophylaxis as an item for
discussion on daily multidisciplinary rounds.
• Empower pharmacy to review orders for patients in the
ICU to ensure that some form of deep venous prophylaxis
is in place at all times on ICU patients.
• Post compliance with the intervention in a prominent
place in your ICU to encourage change and motivate
staff.

23. • Include peptic ulcer disease prophylaxis as part of
your ICU order admission set and ventilator order
set. Make application of prophylaxis the default
value on the form.
• Include peptic ulcer disease prophylaxis as an item
for discussion on daily multidisciplinary rounds.
• Empower pharmacy to review orders for patients in
the ICU to ensure that some form of peptic ulcer
disease prophylaxis is in place at all times on ICU
patients.
• Post compliance with the intervention in a
prominent place in your ICU to encourage change
and motivate staff.

24. • Elevate HOB to 30 to 45 degrees (if no
contraindications):
• Aspiration can occur even with a properly inflated
ET cuff.
Bacterial counts higher in aspirated secretions obtained
while pts were in the supine (flat) position than in those
obtained while patients were in the semirecumbent
position (45 degrees).
Torres et al. Ann Int Med 1992;116:540-3.
■ Time spent with HOB in low position on day 1 of
mechanical ventilation is most predictive of VAP in
patients with high APACHE II scores.
Grap MJ, Munro CL, et al. 2005 Am J Crit Care 14(4)

25. • Use visual cues so it is easy to identify when
the bed is in the proper position, such as a line
on the wall that can only be seen if the bed is
below a 30-degree angle.
• Include this intervention on order sets for
initiation and weaning of mechanical
ventilation, delivery of tube feedings, and
provision of oral care.
• Post compliance with the intervention in a
prominent place in your ICU to encourage
change and motivate staff.

27. • Implement a protocol to lighten sedation
daily at an appropriate time to assess for
neurological readiness to extubate.
– Include precautions to prevent self-extubation such as
increased monitoring and vigilance during the trial.
• Include a sedation vacation strategy in your
overall plan to wean the patient from the
ventilator
– if you have a weaning protocol, add "sedation vacation" to
that strategy.

28. • Assess that compliance is occurring each
day on multidisciplinary rounds.
• Consider implementation of a sedation
scale such as Riker or Ramsay scoring
scale to avoid oversedation.
• Post compliance with the intervention in a
prominent place in your ICU to encourage
change and motivate staff.

29. • Appropriate antibiotic use
• Attention to proper ET and TT cuff pressures
• Avoided intubation(BiPAP)
• Hand hygiene-chlorhexidine
• Closed endotracheal suctioning syst
• Condensation management in vent circuit
• Conversion to TT for long term ventilation
• Enteral feeding instead of TPN
• Minimize duration of MV
• Oral hygiene x 4 hrly
• Subglotic suctioning before deflating the cuff of
ET/TT
• Strict glucose control
• Wearing gloves

32. • Analysis of 10 studies of small bowel
feeding found that small bowel feedings
are associated with reduction in
gastroesophageal regurgitation, increase in
protein and calories delivered, and shorter
time to target dose of nutrition.
• Results of 7 randomized trials: small bowel
feeding compared to gastric had.
• Heyland, et al. JPEN 2002;26:S51-S55.
• Kollef MH Crit Care Med 2004:32(6)
• Heyland, el al. Crit Care Med 2001;29:1495-1501
lower incidence of pneumonia

33. • AACN 5 th Ed itio n, 2 0 0 5 Sc o tt JM, Vo llm a n KM
• End o tra che a l Tube a nd Ora l Ca re , Pro c e dure # 4
• Unit One Pulm o na ry Sy s te m
• Perform ET suctioning only when clinically
indicated
• Oral hygiene should be performed every 2-4
hours and should include:
• Toothbrushing at least two times a day;
• Oral swabs with 1.5% hydrogen peroxide soln
every 2-4 hours;
• Mouth moisturizer to oral mucosa and lips
• Subglottic suctioning continuously or
intermittently

34. Gra p MJ, Munro CL 2 0 0 4:
• Toothbrushing is the most effective
means of mechanical removal of plaque.
Munro CL, Grap MJ, Elswick RK, el al: 2006;Am J Crit
Ca re ;15
• Higher plaque scores confer greater risk
for VAP

35. Munro & Grap 2006 Crit Care Med 34
• CHG – effective in reducing VAP

36. Mouth Care Compliance and VAP Rate Trends for ICU

37. • Educational programs for RNs and RTs
addressing VAP etiology and infection
control procedures is associated with
decreased VAP rates in the ICU setting.
• Zack JE, Garrison T, Trovillion E, et al. Effect of an education program
aimed at reducing the occurrence of ventilator-associated pneumonia.
Critical Care Medicine. 2002; 30(11): 2407-2412.
• “Staff education….is a cornerstone for
efforts to reduce the incidence of VAP.”
Craven,D. Chest 2006;130
• Ventilator bundle staff educational sessions
have a significant effect on clinical practice.
• Tolentino-DelosReyes, Ruppert, Shyang-Yun, et al Am J Crit Care 2007; 16

38. • Hand hygiene-chlorhexidine
• HOB – HEAD OF BED ELEVATION – 30-45
DEGREE
• Condensation management in vent circuit
• Attention to proper ET and TT cuff pressures
• Oral hygiene x 4 hrly
• Closed endotracheal suctioning syst
• Daily sedation vacation and spontaneous breathing
trial
• Enteral feeding instead of TPN
• GI prophylaxis
• Strict glucose control
• Subglotic suctioning before deflating the cuff of
ET/TT
•

39. DEDICATE “URself” to the
protocol
Ventilator Associated Pneumonia
Morbidity and Mortality