VENTILATOR ASSOCIATED INFECTIONS.

1. VENTILATOR ASSOCIATED
PNEUMONIA
CARE AND PREVENTION
Dr.T.V.Rao MD
Dr.T.V.Rao MD 1

2. Introduction to Patient Safety:
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) .
Dr.T.V.Rao MD 2

3. Introduction to Patient Safety:
Background
• Adverse medical events are widespread
and preventable (Emanuel et al., 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.
Dr.T.V.Rao MD 3

4. Required Attitudes
Being an effective team player.
Commitment to preventing HAIs
Dr.T.V.Rao MD 4

5. ICU patients
• Sickest patients (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

6. ICU patients
• Sickest patients (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

7. Remember Some One at Risk with
Ventilator
Dr.T.V.Rao MD 7

8. Who is Responsible for Ventilator care
• The registered nurse is responsible for the
assessment, planning and delivery of care to
the patient.
• • Care of the ventilated patient can vary from
the basic nursing care of activities of daily
living to caring for highly technical invasive
monitoring equipment and managing and
monitoring the effects of interventions.
Dr.T.V.Rao MD 8

9. Basic Observations
• Ensure the
endotracheal tube
(ETT) or
tracheostomy tube is
held securely in
position but not too
tightly to result in
pressure area
lesions.
Dr.T.V.Rao MD 9

10. Always check the patient first.
• Observe the
patient’s facial
expression,
colour,
respiratory
effort, vital signs
and ECG tracing.
Dr.T.V.Rao MD 10

11. What is Mechanical Ventilator
• 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

12. Purposes:
• To maintain or
improve
ventilation, &
tissue
oxygenation.
• To decrease the
work of breathing
& improve
patient’s comfort.
Dr.T.V.Rao MD 12

13. Intensive Care Unit
Nosocomial Pneumonia
Dr.T.V.Rao MD 13

14. 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. Dr.T.V.Rao MD 14

15. Definition- “Know thy enemy”
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
American Thoracic Society, Infectious Diseases Society of America.
Guidelines for the management of adults with hospital-acquired, ventilator-associated,
and healthcare-associated pneumonia.
Dr.T.V.Rao MD 15

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.
Dr.T.V.Rao MD 16

17. Risk factors for bacterial
pneumonia
Host Factors Factors that facilitate reflux
& aspiration into the lower RT
• Elderly
• Severe Illness
• Underlying Lung Disease - Mechanical ventilation
• Depressed Mental Status - Tracheostomy
• Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Position
• Viral Respiratory Tract Factors that impede normal
Infection Pulmonary Toilet
Colonisation - Abdominal or thoracic surgery
• Intensive Care Setting - Immobilisation
• Use of Antimicrobial Agents
• Contaminated hands
• Contaminated Equipment
Dr.T.V.Rao MD 17

18. Incidence of VAP
• The exact incidence of HAP is usually between 5
and 15 cases per 1,000 hospital admissions
depending on the case definition and study
population; the exact incidence of VAP is 6- to 20-
fold greater than in nonventilated patients
(Level II)
• HAP accounts for up to 25% of all ICU infections
• In ICU patients, nearly 90% of episodes of HAP
occur during mechanical ventilation
Dr.T.V.Rao MD 18

19. Resistant Bacteria leading Cause
• Many patients
with HAP, VAP, and
HCAP are at
increased risk for
colonization and
infection with
MDR pathogens
(Level II)
Dr.T.V.Rao MD 19

20. Pathogenesis
• Where do the bacteria come from?
– Tracheal colonization- via oropharengeal
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- micro aspiration around ETT cuff
Dr.T.V.Rao MD 20

21. 21
Etiology
• Bacteria cause most cases of HAP, VAP, and
HCAP and many infections are polymicrobial;
rates are especially high in patients with ARDS
(Level I)
• HAP, VAP, and HCAP are commonly caused by
aerobic gram-negative bacilli, such as P.
aeruginosa, K. pneumoniae, and Acinetobacter
species, or by gram-positive cocci, such as S.
aureus, much of which is MRSA; anaerobes are
an uncommon cause of VAP (Level II)
Dr.T.V.Rao MD

22. 22
Predisposing causes in Pneumonia
– Pseudomonas aeruginosa.
• the most common MDR gram-negative bacterial
pathogen causing HAP/VAP, has intrinsic resistance to
many antimicrobial agents
– Klebsiella, Enterobacter, and Serratia species.
• Klebsiella species
– intrinsically resistant to ampicillin and other aminopenicillins
and can acquire resistance to cephalosporins and aztreonam
by the production of extended-spectrum –lactamases (ESBLs)
– ESBL-producing strains remain susceptible to carbapenems
• Enterobacter species
• Citrobacter and Serratia species
Dr.T.V.Rao MD

23. 23
Predisposing causes in Pneumonia
–Acinetobacter species
• More than 85% of isolates are susceptible to
carbapenems, but resistance is increasing
• An alternative for therapy is sulbactam
• Stenotrophomnonas maltophila, and
Burkholderia cepacia:
– resistant to carbapenems
– susceptible to trimethoprim–Sulphmethoxazole,
Ticarcillin–clavulanate, or a fluoroquinolone
Dr.T.V.Rao MD

24. 24
Predisposing causes in Pneumonia
– Methicillin-resistant Staphylococcus aureus
• Vancomycin-intermediate S. aureus
– sensitive to linezolid
– linezolid resistance has emerged in S. aureus, but is currently
rare
– Streptococcus pneumoniae and Haemophilus
influenza.
• sensitive to Vancomycin or linezolid, and most remain
sensitive to broad-spectrum quinolones
Dr.T.V.Rao MD

25. Initiation of Mechanical
Ventilation
Dr.T.V.Rao MD 25

26. Guidelines in the Initiation of
Mechanical Ventilation
• Primary goals of mechanical ventilation are
adequate oxygenation/ventilation, reduced work
of breathing, synchrony of vent and patient, and
avoidance of high peak pressures
• Set initial FIO2 on the high side, you can always
titrate down
• Initial tidal volumes should be 8-10ml/kg,
depending on patient’s body habitus. If patient is
in ARDS consider tidal volumes between 5-8ml/kg
with increase in PEEP
Dr.T.V.Rao MD 26

27. Guidelines in the Initiation of
Mechanical Ventilation
• Use PEEP in diffuse lung injury and ARDS to
support oxygenation and reduce FIO2
• Avoid choosing ventilator settings that limit
expiratory time and cause or worsen auto PEEP
• When facing poor oxygenation, inadequate
ventilation, or high peak pressures due to
intolerance of ventilator settings consider
sedation, analgesia or neuromuscular blockage
Dr.T.V.Rao MD 27

28. Ventilators
• 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 28

29. Suctioning mechanically
ventilated patients
• Hand washing before and after the procedure.
• Wear clean gloves to prevent cross-
contamination
• 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

30. Suction Bottle
 Use single-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

31. Nebulizers
• Use sterile medications 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

32. Humidifiers
• Clean and sterilize 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

33. 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

34. If put on Oxygen mask
• Change oxygen
mask and tubing
between
patients and
more frequently
if soiled
Dr.T.V.Rao MD 34

35. Prevalence of VAP
• Occurs in 10-20% of
those receiving
mechanical
ventilation for
greater than 48
hours
• Rate= 14.8 cases per
1000 ventilator days
Cook et al. Incidence of and risk factors for ventilator-associated pneumonia
in critically ill patients.
Dr.T.V.Rao MD 35

36. When does VAP occur?
• 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.
Dr.T.V.Rao MD 36

37. Time frame of intubation and risk
• Risk of pneumonia
at intubation days
–3.3% per day at
day 5
–2.3% per day at
day 10
–1.3% per day at
day 15
Cook et al. Incidence of and risk factors for ventilator-associated pneumonia
in critically ill patients.
Dr.T.V.Rao MD 37

38. Dr.T.V.Rao MD 38
Continuous Removal of Subglottic
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

39. Dr.T.V.Rao MD 39
HOB Elevation
HOB at 30-45º
CDC Guideline for Prevention of Healthcare Associated Pneumonias
2004 ATS / IDSA Guidelines for VAP 2005

40. Dr.T.V.Rao MD 40
HOB Elevation
References
HOB at 30-45º
• Torres et al, Annals of Int Med 1992;116:540-543
• Ibanez et al. JPEN 1992;16:419-422
• Orozco-Levi et al. Am J Respir Crit Care Med 1995;152:1387-1390
• Drakulovic et al. Lancet 1999;354:1851-1858
• Davis et al. Crit Care 2001;5:81-87
• Grap et al. Am J of Crit Care 2005 14:325-332

41. HOB UP 30 DEGREES 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

42. HOB UP 30 DEGREES 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

43. Ventilator Associated
Pneumonia (VAP)
Practice Alert
43
HOB Elevation Leads to
Significant Deduction in VAP
Dravulovic et al. Lancet
1999;354:1851-1858
0
5
10
15
20
25
%
VAP
Supine HOB Elevation

44. Dr.T.V.Rao MD 44
CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
Frequency of
Equipment Changes
Ventilator
Tubing
Ambu
Bags
Inner
Cannulas of
Trachs
No Routine
Changes
Between
Patients
Not
Enough
Data

45. Dr.T.V.Rao MD 45
Hand washing
What role does hand washing play
in nosocomial pneumonias?
Albert, NEJM 1981; Preston, AJM 1981;
CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004

46. Ventilator Associated
Pneumonia (VAP)
Practice Alert
46
VAP Prevention and Hand Washing
Wash hands or use an alcohol-
based waterless antiseptic agent
before and after suctioning,
touching ventilator equipment,
and/or coming into contact with
respiratory secretions.
CDC Guideline for Prevention of Healthcare Associated Pneumonias
2004
AACN Practice Alert for VAP, 2007

47. Suctioning mechanically
ventilated patients
• Hand washing before and after the procedure.
• Wear clean gloves to prevent cross-
contamination
• 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 47

48. VAP Reduction with ET Suction
Above the Cuff
0
5
10
15
20
Percent
(%)
No Suction Suction
Ventilator Associated Pneumonia
(VAP) Practice Alert
48
Smulders et al.
Chest;121:858-862

49. Suction Bottle
 Use single-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 49

50. Nebulizers
• Use sterile medications 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 50

51. Humidifiers
• Clean and sterilize 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 51

52. Indications for an actively humidified
circuit (Westmead ICU)
• 􀀪 minute volume greater than 10 litres
• 􀀪 chest trauma with pulmonary contusion
• 􀀪 airway burns
• 􀀪 severe asthma
• 􀀪 hypothermia (<340 C)
• 􀀪 pulmonary haemorrhage
• 􀀪 severe sputum plugging/pulmonary oedema
leading to HME occlusion
• 􀀪 consultant order
Dr.T.V.Rao MD 52

53. Pooling of Secretions
• Pooled secretions above the ETT/trachi cuff
are associated with ventilator associated
pneumonia (VAP). This is a result of aspiration
of bacteria colonizing the oropharynx or GIT
and subsequently leaking below the cuff into
the trachea. Therefore thorough
oropharyngeal suctioning should be
performed before letting down the cuff to
reposition the ETT or to check cuff pressure.
Dr.T.V.Rao MD 53

54. Suction of an Artificial 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

55. Sterilisation and decontamination
After use, the patient circuit should be
detached from the ventilator and
disassembled to expose all surfaces prior to
cleaning.
Thoroughly clean to remove all blood,
secretions, thick mucus and other residue.
You may use multi enzyme cleaner.
Medical detergent solution can also be used
to thoroughly to flush the tubing's.
Dr.T.V.Rao MD 55

56. Contd…
2% Glutaraldehyde is used for routine
sterilisation of tubing's and other
accessories.
Please follow manufacturer’s directions and
recommendations.
Ethylene Oxide – gas sterilisation is also
used. Ethylene oxide may cause superficial
crazing of plastic components and will
accelerate the aging of rubber components.
Dr.T.V.Rao MD 56

57. Contd…
Ensure complete dryness of the tubes
before sending for gas sterilisation as
ethylene glycol may be formed which is
poisonous.
After sterilisation, the tubing's must be
properly aerated to dissipate residual
gas absorbed by the materials.
Dr.T.V.Rao MD 57

58. VAP Prevention
Wash hands or use
an alcohol-based
waterless antiseptic
agent before and
after suctioning,
touching ventilator
equipment, and/or
coming into contact
with respiratory
secretions.
Dr.T.V.Rao MD 58
2004

59. Dr.T.V.Rao MD 59
VAP Protection
• Use a continuous subglottic
suction ET tube for intubations
expected to be > 24 hours
• Keep the HOB elevated to at least
30 degrees unless medically
contraindicated
CDC Guideline for Prevention of Healthcare Associated Pneumonias
2004
AACN Practice Alert for VAP, 2007

60. Hand Hygiene
• leading cause of infection in health care
settings is the lack of proper hygiene practices
by health care professionals. The CDC VAP
protocol guidelines recommend improved
hand hygiene practices by health care workers
including alcohol based antiseptic solutions.
Changing disposable gloves and washing the
hands before putting on another pair can also
lower the risk of VAP.
Dr.T.V.Rao MD 60

61. How to use waterless hand rub
• Apply a palmful of product in cupped hand
• Rub hands palm to palm
• Right palm over left hand with interlaced fingers
• Palm to palm with fingers interlaced
• Backs of fingers to opposing palms with fingers
interlocked
• Rub between thumb and forefinger
• Rotational rubbing, backwards and forwards with
clasped fingers of right hand in left palm and vice versa
• Once dry your hands are safe.
Dr.T.V.Rao MD 61

62. HAND HYGIENE
• The best method to prevent
healthcare acquired infections
including VAP is to practice good
Hand Hygiene including use of :
• Antimicrobial soap and water
• Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on
hands Dr.T.V.Rao MD 62

63. 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
Dr.T.V.Rao MD 63

64. Dr.T.V.Rao MD 64

65. Why should hospitals care so
much about the oral cavity ?
Most bacterial nosocomial pneumonia are
caused by aspiration of bacteria colonizing the
oropharynx or upper GI tract of the patient.
Centres for Disease Control (1997)
Nosocomial pneumonia accounts for 10-15% of
all hospital acquired infections.
20-50% of all infected patients will die as a
result of the infection
J.Can.Dent.Assoc.(2002)

66. How Does Aspiration Pneumonia
(including VAP) Occur?
ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM
IMMUNE SYSTEM
MUST HAVE ALL 3
Dr.T.V.Rao MD 66

67. When does Colonization occur?
Within 48 hours of admission to hospital the
oropharengeal flora of critically ill patients
changes from
 the usual gram + streptococci and dental
pathogens to
 gram – organisms including Pathogens that
cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
Dr.T.V.Rao MD 67

68. Oral Care Research
Treatment with oral
hygiene alone,
reduced occurrence
of pneumonia in
older adults in
nursing homes by
30%
Yoneyama et.al. (2002)
Dr.T.V.Rao MD 68

69. Oral decontamination
• Chan et al. investigated antibiotics and
antiseptics
– Antibiotics were not found to be beneficial
– Antiseptics were found to be beneficial in 6 out of
7 studies
• Chlorhexidine studied in 6, five of which showed
benefit
– Note that mortality, ICU stay and duration of
mechanical ventilation were not statistically
significant
Dr.T.V.Rao MD 69

70. Oral Cleansing
• Bacteria in the mouth
can cause intubated
patients to get
infections or
pneumonia.
Establishing regular oral
cleansing and
disinfection of patients
receiving respiratory
ventilation reduces the
risk of infection.
Dr.T.V.Rao MD 70

71. Current Oral Care
Practices Continued…
Foam swabs are commonly used to provide
mouth care to patients who cannot provide
their own care.
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND
ONLY PROVIDE MOISTURE REFIEF.
Journal of Advanced Nursing (1996)
Nursing Times (1996)
Dr.T.V.Rao MD 71

72. Why should hospitals care so
much about the oral cavity ?
Most bacterial nosocomial pneumonia are
caused by aspiration of bacteria colonizing the
oropharynx or upper GI tract of the patient.
Centres for Disease Control (1997)
Nosocomial pneumonia accounts for 10-15% of all
hospital acquired infections.
20-50% of all infected patients will die as a result of
the infection
J.Can.Dent.Assoc.(2002)
Dr.T.V.Rao MD 72

73. Oral Care
• Common medical knowledge that poor oral
care and suctioning leads to (HAP) and (VAP).
Research has shown that (HAP) and (VAP) can
be reduced with suctioning of subglottic
secretions and improved oral hygiene in both
non-ventilated and ventilated patients.
Unfortunately some patients tend to bite
down and resist oral hygiene and tracheal
suctioning.
Dr.T.V.Rao MD 73

74. Oral Care
• Also tracheal suction catheters
commonly inserted nasally, tend to coil
upon insertion, causing multiple
unsuccessful attempts, nasal trauma and
bleeding. These problems make oral
hygiene and tracheal suctioning difficult
or even impossible, increasing a patients
risk to develop (HAP) and (VAP).
Dr.T.V.Rao MD 74

75. Oral Care: AACN
• AACN 5th Edition, 2005 Scott JM, Vollman KM
• Endotracheal Tube and Oral Care, Procedure # 4
• Unit One Pulmonary System
• 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 solution every 2-4
hours;
• Mouth moisturizer to oral mucosa and lips
• Subglottic suctioning continuously or intermittently
Dr.T.V.Rao MD 75

76. Oral Care: plaque
Grap MJ, Munro CL 2004:
• Tooth brushing is the most effective means of
mechanical removal of plaque.
Munro CL, Grap MJ, Elswick RK, el al: 2006;Am J Crit Care;15
• Higher plaque scores confer greater risk for VAP
Dr.T.V.Rao MD 76

77. Procedure - Brushing
• Wash hands and put on gloves
• Obtain PLAC VAC BRUSH
• Attach suction to toothbrush, moisten toothbrush and
apply baking soda
• Brush patient’s teeth, gums, tongue, palate and
inside cheeks
• Apply suction to cleansed areas
• Rinse brush in water, repeat step 4-5
• Soak dentures in denture solution
Dr.T.V.Rao MD 77

78. Alternate Procedure
Chlorhexidine 0.12%
1. Place 15ml of chlorhexidine in medication
cup
2. Soak toothette in chlorhexidine
3. Rub teeth, tongue, gums, and sides of
mouth in circular motion
4. Suction oral cavity and do not rinse
5. Apply oral moisturizer to lips
Dr.T.V.Rao MD 78

79. Oral Care: use of antiseptics
Fourrier 2005 Crit Care Med 33
• CHG – reduced colonization but not VAP
Munro & Grap 2006 Crit Care Med 34
• CHG – effective in reducing VAP
Seguin 2006 Crit Care Med 34
• Povidone-Iodine - decreased prevalence of VAP in
head trauma
Dr.T.V.Rao MD 79

80. Dr.T.V.Rao MD
80
Oral Care
• Role of oral care, colonization of the
oropharynx, and VAP unclear – dental plaque
may be involved as a reservoir
• Limited research on impact of rigorous oral
care to alter VAP rates
• Surveys indicate most nurses use foam swabs
rather than toothbrushes in intubated
patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Grap M. Amer J of Critical Care 2003;12:113-119.

81. Eye & Mouth care
• For unconscious patients eyes
are kept closed by taping.
• Goggles can also be used.
• Regular & proper mouth care
should be given.
Dr.T.V.Rao MD 81

82. Eye Care
• The unconscious, sedated or paralyzed patient
is at risk of developing eye problems ranging
from mild conjunctivitis to serious corneal
injury and ulceration. Permanent eye damage
may result from ulceration, perforation,
vascularization and scarring of the cornea
• 2nd hourly eye care using saline soaked gauze
to clean the eye and the application of
lactrilube regularly in the ventilated patient is
recommended to help reduce the risk of
complications
Dr.T.V.Rao MD 82

83. SDD- selective decontamination of the
digestive tract
• Multiple studies showing effectiveness
• Big concern is antibiotic resistance
• Most recently- NEJM January 2009
–Study of 13 intensive care units in
Netherlands showed statistically significant
reduction of mortality of 3.5% in patients
receiving SDD
–Same study showed that patients receiving
SOD (selective oropharengeal
decontamination) had decrease of 2.9%
Dr.T.V.Rao MD 83

84. 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)
Dr.T.V.Rao MD 84

85. 85
Bacteriologic Strategy
• Quantitative cultures can be performed
on endotracheal aspirates or samples
collected either bronchoscopically or
nonbronchoscopically, and each
technique has its own diagnostic
threshold and methodologic limitations.
The choice of method depends on local
expertise, experience, availability, and
cost (Level II)
Dr.T.V.Rao MD

86. 86
Comparing Diagnostic Strategy
• A patients with suspected VAP should have a
lower respiratory tract sample sent for culture,
and extra pulmonary infection should be excluded,
as part of the evaluation before administration of
antibiotic therapy (Level II)
• If there is a high pretest probability of pneumonia,
or in the 10% of patients with evidence of sepsis,
prompt therapy is required, regardless of whether
bacteria are found on microscopic examination of
lower respiratory tract samples (Level II)
Dr.T.V.Rao MD

87. Imperfect diagnostic tests
• Blood cultures, limited role, sensitivity is only 8% to 20%
• Sputum neither sensitive, nor specific
• Tracheo-bronchial aspirates- high sensitivity, weakness- does not
differentiate between pathogen and colonizer
• Hospital-acquired pneumonia: Risk factors, microbiology, and treatment. Chest. 119: 2001; 373S-384S.
BAL, PSB’s do not differ from less invasive tests in terms of sensitivity,
specificity or, more importantly, morbidity and mortality
luck of consensus on the role of invasive diagnostic testing for HAP,
subject of ongoing debate
- Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: Evaluation of outcome. Am J Respir
Crit Care Med. 162: 2000; 119-125.
- Invasive and noninvasive strategies for management of suspected ventilator-associated pneumonia: A randomized trial. Ann
Intern Med. 132: 2000; 621-630.

88. HCAP, HAP, VAP
Treatment
• Delay in empiric antibiotics use, worse
outcome International conference for the development of consensus on the diagnosis and
treatment of ventilator-associated pneumonia. Chest. 120: 2001; 955-970.
• Mortality with prompt antibiotic use 30%
vs. 91 % when delayed Nosocomial pneumonia: A multivariate analysis of
risk and prognosis. Chest. 93: 1988; 318-324
• Regimens in patients with no known risk
factors for MDR pathogens, and who have
early-onset pneumonia (within 5 days of
hospitalization) should include coverage for
Enterobacter spp., E. coli, Klebsiella spp.,
Proteus spp., and Serratia marcescens),
Haemophilus influenza and Streptococcus
pneumoniae, MSS. aureus

89. HCAP, HAP, VAP
Treatment
• Ceftriaxone or a quinolone (e.g.,
ciprofloxacin or levofloxacin) or
ampicillin-sulbactam or Ertapenem
• Fluoroquinolone in the empirical regimen
of patients with penicillin allergies
• Penicillin skin testing – a mean to
decrease fluoroquinolones use
• A pilot study of penicillin skin testing in patients with a history of penicillin allergy admitted to
a medical ICU. Chest. 118: 2000; 1106-1108.

90. Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia * in
Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage †
Antipseudomonal cephalosporin
Cefepime1-2 g every 8-12 hr
Ceftazidime 2 g every 8 hr
Carbapenems
Imipenem 500 mg every 6 hr or 1 g every 8 hr
Meropenem 1 g every 8 hr
Beta-lactam–beta-lactamase inhibitor
Piperacillin-tazobactam 4.5 g every 6 hr
Aminoglycosides
Gentamicin 7 mg/kg/day
Tobramycin 7 mg/kg/day
Amikacin 20 mg/kg/day
Antipseudomonal quinolones
Levofloxacin 750 mg/day
Ciprofloxacin 400 mg every 8 hr
Vancomycin 15 mg/kg every 12 hr
Linezolid 600 mg every 12 hr
Guidelines for the management of adults with hospital-acquired, ventilator-associated, and
healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.

91. Duration of treatment
• No consensus, initial low suspicion, no
change in clinical status- dc in 72 hrs Short-course
empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for
indiscriminate antibiotic prescription. Am J Respir Crit Care Med. 162: 2000; 505-511.
• Guided by severity, time to clinical
response, and the pathogenic organism
• Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare
associated-pneumonia. Am J Respir Crit Care Med. 171: 2005; 388-416.
• Treat for at least 72 hours after a clinical
response is achieved
• International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia. Chest. 120: 2001; 955-970.

92. Recommendations for Assessing Response to
Treatment
-Modifications of empirical therapy should be based on results of microbiology
testing in conjunction with clinical parameters.
-Clinical improvement of HCAP usually takes 2 to 3 days and therefore therapy
should not be changed during this period unless there is a rapid clinical decline.
-Narrowing therapy to the most focused regimen possible on the basis of culture
data (de-escalation of antimicrobials) should be considered for the responding
patient.
-The nonresponding patient should be evaluated for possible MDR pathogens,
extrapulmonary sites of infection, complications of pneumonia and its therapy, and
mimics of pneumonia.
-Testing should be directed to whichever of these causes is likely after physical
examination of the patient.

93. Prevention Measures
• Based on expert opinion rather than hard data
• CDC published a set of 74 recommendations for
preventing NAP , only 15 strongly supported by well-
designed experimental or epidemiologic studies
• 14 out of those 15 dealt with surveillance, education,
hand washing, sterilization, proper use of gloves,
value of vaccination, and sanitation
• Prophylactic antibiotics not be used routinely , only
one supported by well-designed studies
• Centers for Disease Control and Prevention. Guidelines for prevention of nosocomial
pneumonia. MMWR Morb Mortal Wkly Rep. 46: 1997; 1-79.

94. Appropriate staffing levels in the
ICU
• Inverse relationship
between the adequacy of
staffing levels and
duration of stay and
subsequent development
of VAP.
• Increased workloads for
RNs and RTs lead to
reliance on less trained
personnel that may
result in lapses in
infection control
• Kollef MH Crit Care Med 2004:32(6)
Dr.T.V.Rao MD 94

95. Dr.T.V.Rao MD
95
No Data
to Support These Strategies
• Use of small bore versus large bore gastric
tubes
• Continuous versus bolus feeding
• Gastric versus small intestine tubes
• Closed versus open suctioning methods
• Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias
2004

96. Things to Remember
• HACP, HAP, VAP = BAD for the patient
• Quantitative diagnostic microbiology-
controversial!
• Cover likely bugs promptly
• Know your local bugs
• De-escalate, shorten duration of therapy
• Specific regimen, combination therapy- no
proven benefits

97. 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
Dr.T.V.Rao MD 97

98. Objective 2
Objective 1
Avoid
overtreatment
without VAP
Immediate
treatment of
patients with VAP
Diagnosis and treatment of
ventilator-associated pneumonia

99. Brave and Committed Nurses,
Doctors Save Many Lives
Dr.T.V.Rao MD 99

100. With Thanks .. To Many
• I am grateful for
several references in
World Wide Web
particularly from
Central Disease
Control Atlanta USA
for propagating the
knowledge on a very
complex topic is
simple formats Dr.T.V.Rao MD 100

101. Visit me for Many Topics of
Interest on Infectious Diseases
Dr.T.V.Rao MD 101

102. • Programme Created by Dr.T.V.Rao MD
for Medical and Paramedical
Professionals Working in the Intensive
Care Units
• Email
• doctortvrao@gmail.com
Dr.T.V.Rao MD 102