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Ventilator associated infections VAP
- 1. AL-QUDS University Faculty ofHealth Proffessions Nursing Department VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION . Prepared by:
- 2. Introduction to PatientSafety: Definition • Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events (Emanuel et al., 2008) . 2
- 3. Introduction to PatientSafety: Background • Adverse medical events are widespread and preventable (Emanuel et ai., 2008) . • Much unnecessary harm is caused by health-care errors and system failures. - Ex. 1: Hospital acquired infections from poor hand-washing. - Ex. 2: Complications from administering the wrong medication. 3
- 4. ICU patients • Sickestpatients (multiple diagnoses, multi-organ failure, immunocompromised, septic and trauma) • Move less • Malnourished • More obtunded (Glasgow coma scale) • Diabetics and Heart failure Dr.T.V.Rao MD 5
- 5. ICU patients • Sickestpatients (multiple diagnoses, multi-organ failure, immunocompromised, septic and trauma) • Move less • Malnourished • More obtunded (Glasgow coma scale) • Diabetics and Heart failure Dr.T.V.Rao MD 6
- 6. Remember Some Oneat Risk with Ventilator
- 7. Basic Observations • Ensurethe endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions. Dr.T.V.
- 8. Always check thepatient first. • Observe the patient's facial expression, colour, respiratory effort, vital signs and ECG tracing. Dr.T.V.Rao MD 10
- 9. What is MechanicalVentilator • Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator. • A ventilator delivers gas to the lungs with either negative or positive pressure. Dr.T.V.Rao MD 11
- 10. Purposes: • To maintainor improve ventilation, & tissue oxygenation. • To decrease the work of breathing & improve patient’s comfort.Dr.T.V.Rao MD 12
- 11. VENTILATOR ASSOCIATED PNEUMONIA (VAP) •VAP is the leading cause of nosocomial infection in the ICU and reflects 60% of all deaths attributable to nosocomial infections. Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway, which increases the opportunity for aspiration and colonization. 14
- 12. Definition- "Know thyenemy" Pneumonia that develops in someone who has been intubated -Typically in studies, patients are only included if intubated greater than 48 hours -Early onset= less than 4 days -Late onset= greater than 4 days Endotracheal intubation increases risk of developing pneumonia by 6 to 21 fold Accounts for 90% of infections in mechanically ventilated patients 15
- 13. The estimated riskof VAP is 3.50% 3.00% 3.00% 2.50% 2.00% 2.00% 1.50% 1.00% 1.00% 0.50% 0.00% First 5 days of MV Between 5 to 10 day of MV There after The risk of VAP is highest early in the course of hospital stay Approximately half of all episodes of VAP occur within the first 4 days of mechanical ventilation
- 14. Enterobacteriaceae, Haemophilus influenzae,Staphylococcus aureus, Streptococcus pneumoniae, Candida spp. are common in early-onset VAP Pseudomonas spp. and Acinetobacter spp significantly associated with late-onset VAP
- 15. Sources of VAPpathogens Oropharyngeal colonization Contaminated respiratory instruments Gastric colonization Contaminated hands and Apparels of health Care workers European Journal of Internal Medicine 21 (2010) 360-368
- 16. Who gets VAP?(Risk factors) • Study of 1014 patients receiving mechanical ventilation for 48 hours or more and free of pneumonia at admission to ICU • Increased risk associated with admitting diagnosis of - Burns (risk ratio=5.09) - Trauma (risk ratio=5.0) - Respiratory disease (risk ratio=2.79) - CNS disease (risk ratio=3.4) Cook et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. 16
- 17. Risk factors forbacterial pneumonia Host Factors • Elderly • Severe Illness • Underlying Lung Disease • Depressed Mental Status • Immunocompromising Conditions or Treatments • Viral Respiratory Tract Infection Colonisation • Intensive Care Setting • Use of Antimicrobial Agents • Contaminated hands • Contaminated Equipment Factors that facilitate reflux & aspiration into the lower RT - Mechanical ventilation - Tracheostomy - Use of a Nasogastric Tube - Supine Position Factors that impede normal Pulmonary Toilet - Abdominal or thoracic surgery - Immobilisation Dr.T.V.Rao MD 17
- 18. Pneumonia can bea life threatening condition Nosocomial pneumonia (NP), hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), is an important cause of morbidity and mortality in hospitalized patients. One of the factors contributing to a high mortality rate of HAP andVAP could be antibiotic resistance among the causative agents.
- 19. Definition- Ventilator Associate Pneumonia Pneumoniathat develops in someone who has been intubated -Typically in studies, patients are only included if intubated greater than 48 hours -Early onset= less than 4 days -Late onset= greater than 4 days Endotracheal intubation increases risk of developing pneumonia by 6 to 21 fold Accounts for 90% of infections in mechanically ventilated patients
- 20. Prevalence of VAP Occursin 10-20% of those receiving mechanical ventilation for greater than 48 hours Rate= 14.8 cases per 1000 ventilator days
- 21. When does VAPoccur? Cook et al showed . . . 40.1% developed before day 5 41.2% developed between days 6 and 10 11.3% developed between days 11-15 2.8% developed between days 16 and 20 4.5% developed after day 21 Cook et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients.
- 23. Resistant Bacteria leadingCause MDR pathogens 19
- 24. Pathogenesis - Entryof Pathogens Where do the bacteria come from? Tracheal colonization- via oropharyngeal colonization or GI colonization Ventilator system How do they get into the lung? Breakdown of normal host defenses Two main routes Through the tube Around the tube- microaspiration around ETT cuff
- 25. Etiology Bacteria cause most casesof HAP, VAP, and many infections are polymicrobial; rates are especially high in patients with ARDS 19
- 26. Fungal pathogens cancause VAP Fungal pathogens. Aspergillus species Candida albicans
- 27. Causative Organisms Early onset: Hemophilusinfluenza Streptococcus pneumoniae Staphylococcus aureus (methicillin sensitive) Escherichia coli Klebsiella pneumoniae Late onset: Pseudomonas aeruginosa Acinetobacter spp. Staphylococcus aureus (methicillin resistant) Most strains responsible for early onset VAP are antibiotic sensitive. Those responsible for late onset VAP are usually multiple antibiotic resistant Am J Resp Crit Care (1995)
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- 29. Sources of VAPpathogens Oropharyngeal colonization Contaminated respiratory instruments Gastric colonization Contaminated hands and Apparels of health Care workers European Journal of Internal Medicine 21 (2010) 360-368
- 30. VAP pathogenesis Aspiration of Bacterial colonizationof Aerodigestive tract contaminated Bacteria entered in to secretions past the Lower the cuff to the respiratory tract lower airways Incidence of VAP The magnitude of this response is dependent on the type of the inoculum and its size, the virulence of the pathogen, and the competence of the host's immune system Aspiration is the most significant risk factor for VAP European Journal of Internal Medicine 21 (2010) 360-368
- 31. Prevention strategies ofVAP • Prior to intubation • During intubation • After intubation • VAP care bundles • General prophylaxis Staff education
- 32. Prevention strategies priorto intubation Avoid unplanned extubation and re-intubation Noninvasive mechanical ventilation (NIV) has been associated with more favorable outcomes CLINICAL MICROBIOLOGY REVIEWS, Oct. 2006, p. 637-657
- 33. Prevention strategies atprocess of intubation Use cuffed Endotracheal Tube (ETT) with inline or subglottic suctioning Use non-invasive ventilation methods when possible CLINICAL MICROBIOLOGY REVIEWS, Oct. 2006, p. 637-657
- 34. Prevention strategies afterintubation Heat and Moisture Exchangers (HMEs) Encourage early mobilization of patients with physical/occupational therapy Conduct “sedation vacations” Change ventilatory circuit only when malfunctioning or visibly soiled Review lines daily and remove unnecessary catheters Prevent patient contamination by circuit condensate CLINICAL MICROBIOLOGY REVIEWS, Oct. 2006, p. 637-657
- 35. The key componentsof a Ventilator Bundle are Elevation of the head of the bed Daily interruption of sedation and assessment of readiness to extubate Peptic Ulcer Disease Prophylaxis Deep Venous Thrombosis (DVT) Prophylaxis Daily Oral Care with Chlorhexidine Hand hyigene http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm
- 36. Elevation of thehead of the bed The recommended elevation is 30 to 45 degrees May decrease chances of aspiration of gastric contents Reduce the rate of VAP http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm
- 37. Daily interruption ofsedation and assessment of readiness to extubate Lightening sedation decreases the time spent on MV In a study interruption of sedation leads to decreased MV from 7.3 days to 4.9 days But, may be an increased potential for pain and anxiety associated with lightening sedation http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm
- 38. Daily Oral Carewith Chlorhexidine Dental plaques are covered by a biofilm which are colonized by bacteria and leads to VAP The recommended chlorhexidine solution Recommended strength is 0.12% Nursing staff needs to be educated regarding use of chlorhexidine oral rinse http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm
- 39. Continuous Removal ofSubglottic Secretions Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation Mahul et al. Int Care Med 1992;18:20-25
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- 41. Appropriate hand hygiene Appropriatetime for hand washing includes •Before and after touching a patient •Before and after an invasive procedure •After removing gloves •If contamination is suspected Washing hands or using an alcohol- based waterless hand cleaner can help to prevent contamination http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm
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- 43. Suctioning mechanically ventilated patients •Hand washing before and after the procedure. • Wear clean gloves to prevent crosscontamination • Use a sterile single-use catheter ; if it is not possible then rinse catheter with sterile water and store it in a dry, clean container between uses and change the catheter every 8 -12 hours. Dr.T.V.Rao MD 29
- 44. Suction Bottle • Usesingle-use disposable, if possible • Non-disposable bottles should be washed with detergent and allowed to dry. Heat disinfect in washing machine or send to Sterile Service Department. Dr.T.V.Rao MD 30
- 45. Nebulizers • Use sterilemedications and fluids for nebulization • Fill with sterile water only. • Change and reprocess device between patients by using sterilization or a high level disinfection or use single-use disposable item. • Small hand held nebulizers — minimise unnecessary use — between uses for the same patient disinfect, rinse with sterile water, or air dry and store in a clean, dry place • Reprocess nebulizers daily Dr.T.V.Rao MD 31
- 46. Humidifiers • Clean andsterilize device between patients. • Fill with sterile water which must be changed every 24 hours or sooner, if necessary. • Single-use disposable humidifiers are available but they are expensive. Dr.T.V.Rao MD 32
- 47. Ventilator cleaning and Decontamination •After every patient, clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturer's instructions. Dr.T.V.Rao MD 33
- 48. If put onOxygen mask • Change oxygen mask and tubing between patients and more frequently if soiled Dr.T.V.Rao MD 34
- 49. Continuous Removal ofSubglottic Secretions Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation. CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005 Dr.T.V.Rao MD 38
- 50. HOB Elevation HOB at30-453 CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005 Dr.T.V.Rao MD 39
- 51. HOB UP 30DEGREES OR HIGHER • Recommended elevation is 30-45 degrees • If semi-recumbent or supine 34% incidence VAP • If semi-recumbent position 8% incidence VAP* • ^HOB -> ^risk of aspiration of gastrointestinal contents ^risk of aspiration of oropharengeal secretions ^risk of aspiration of nasopharyngeal secretions Dr.T.V.Rao MD 41
- 52. HOB UP 30DEGREES OR HIGHER HOB improves patients' ventilation Supine patients have lower spontaneous tidal volumes on PS than those seated in upright position ^HOB may aid ventilatory efforts and minimize atelectasis Dr.T.V.Rao MD 42
- 53. Suction of anArtificial Airway • To maintain a patent airway • • To promote improved gas exchange • • To obtain tracheal aspirate specimens • • To prevent effects of retained secretions eg. infection, consolidation , atelectasis, increased airway pressures or a blocked tube. • • It is important to oxygenate before and after suctioning Dr.T.V.Rao MD 54
- 54. Compliance with Isolation Precautions •Stringent adherence to the use of Personal Protective Equipment (PPE) such as Gowns, Masks, Gloves will decrease the transmission of pathogenic microorganisms to ventilated patients when patients are identified as requiring Contact and Droplet Precautions 63
- 55. Eye & Mouthcare For unconscious patients eyes are kept closed by taping. • Goggles can also be used. 81 Regular & proper mouth care should be given. Dr.T.V.Rao MD ^
- 56. Monitoring for infection •Color, consistency, and amount of the sputum / secretions with each suctioning should be observed. • Fever and other parameters have to closely observed for any other infection. (central line, etc) 84
- 57. Centres for Diseaseand Control The diagnosis of pneumonia in mechanically ventilated patients is difficult, and still there is no "gold-standard" diagnostic method. It is usually based on the combination of clinical, radiological, and microbiological criteria defined by Centres for Disease and Control (CDC)
- 58. Diagnosis is impreciseand 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
- 59. Clinical Strategy in Diagnosisof VAP Clinical Strategy The presence of a new or progressive radiographic infiltrate At least two of three clinical features fever greater than 38_C, leukocytosis or leukopenia, purulent secretions Represents the most accurate combination of criteria for starting empiric antibiotic therapy. 41
- 60. Strategies in Diagnosisin VAP are multifaceted Clinical Strategy Bacteriologic Strategy Comparing Diagnostic Strategy
- 61. Summary Clinical evidence suggeststhat early use of appropriate empiric antibiotic therapy improves patient outcomes in terms of: reduced mortality reduced morbidity reduced duration of hospital stay
- 62. Summary ● VAP isa common, morbid ICU complication of ventilated patients ● Diagnosis of VAP is very challenging with high inter-observer variability ● Focus on prevention - Elevate head of the bed - Regular oral care with antiseptic - Daily sedation interruption and assessment of readiness to extubate - Regularly audit prevention practices and Staff education
- 63. Required Attitudes Being aneffective team player. Commitment to preventing HAIs 4