Ventilator-associated pneumonia (VAP) is a common nosocomial infection that occurs in patients on mechanical ventilation. It can develop within the first 5 days of intubation or later after the 10th day. Risk factors include prolonged mechanical ventilation, comorbidities, and improper infection control practices. Common causative organisms include Streptococcus pneumoniae, Haemophilus influenzae, and methicillin-sensitive Staphylococcus aureus for early-onset VAP and Pseudomonas, MRSA, and drug-resistant Gram-negative rods for late-onset VAP. Diagnosis is based on clinical, microbiological, and radiological criteria though there is no gold standard. Treatment involves administering appropriate

1. VENTILATOR ASSOCIATED
PNEUMONIA
DR. C S ARAVIND (IST YEAR PG RESIDENT)
UNIT CHIEF – DR. ANBARASU M.D

2. SYNOPSIS
 INTRODUCTION- WAT IS VAP?
 FACTS AND FIGURES
 WHAT ARE THE TYPES OF VAP ?
 WHO ARE AT RISK ?
 HOW DO THE ORGANISMS CAUSE VAP ?
 IS IT BACTERIA / VIRUS / FUNGUS- IF SO , WHAT ARE THE POSSIBLE
ORGANISM ?
 HOW TO DIAGNOSE VAP ?
 HOW TO TREAT ?
 IS THERE ANY PREVENTIVE STRATEGY ?
 CONCLUSION

3. INTRODUCTION- WHAT IS VAP
PNEUMONIA THAT
OCCURS 48-72 HRS
AFTER
ENDOTRACHEAL
INTUBATION

4. FACTS AND FIGURES
½ OF HAP
2ND MC CAUSE OF NOSOCOMIAL
INFECTION IN ICU
MC CAUSE OF NOSOCOMIAL INFECTION
IN VENTILATOR BOUND PATIENTS
MORALITY RATE IS HIGHER IN PATIENT
OF TRAUMA, BURNS, POST OP
60- 70 % MORTALITY IN PATIENTS OF
PSEUDOMONAS AND ACINOBACTOR

5. WHEN IS THE VAP MOST NOTORIOUS
 FIRST 5 DAYS (RISK-3%)
 MEAN DURATION - 3.3 day from the day
of ET intubation
 5TH TO 10TH DAY (RISK 2%)
 THEREAFTER 1%

6. WHEN IS THE VAP MOST NOTORIOUS
 FIRST 5 DAYS (RISK-3%)
 MEAN DURATION - 3.3 day from the day
of ET intubation
 5TH TO 10TH DAY (RISK 2%)
 THEREAFTER 1%

7. WHAT PERCENT OF PATIENTS WITH VAP DIE
CRUDE MORTALITY IS AROUND 60-
70%
ATTRIBUTABLE MORTALITY – 33-50%
Latest lancet 2013 trial on 6284 pts from 24
studies - attributable mortality to 9-13 %

8. EARLY ONSET VS LATE ONSET
EARLY
ONSET VAP
<4 D
LESS
VIRULENT
BUGS
COMMUNITY
AQUIRED
AB SENSITIVE
LATE
ONSET VAP
>4 D
MORE
VIRULENT
HOSPITAL
ACQUIRED
MDR

9. WHO ARE AT RISK
INDEPENDENT RISK FACTORS
VAP
MALE
SEX
UNDERLYING
DISEASE
TRAUMA

10. RISK FACTORS
HOST RELATED Medical
/surgical disease, Immunosuprssion,
Malnutrition (Alb<2.2g/dl ), Advanced
age, Supine position, Level of
conciousness, Medication-NMB,
sedation, steroids, Previous antibiotic
use
DEVICE
RELATED
MV with ETT or
TRACHEOSTOMY TUBE ,
MV>48 hrs, Reintubations,
NGT or Oro- gastric tube,
Use of Humidifier
HEALTHCARE
PERSONNEL RELATED
Improper hand
washing, Failure to
change gloves and use
mask gown when ever
required .

11. RISK FACTORS (CONT.)
HOST RELATED:
-UNDERLYING MEDICAL CONDITIONS-
COPD, OBESITY, ARDS, GERD, BURN,
TRAUMA, MODS ETC--
-IMMUNOSUPPRESSION,
MALNUTRITION(S.ALBUMIN<2.2G/DL)
-ADVANCED AGE
-PATIENTS’ BODY POSITION
-LEVEL OF CONSCIOUSNESS- IMPAIRED
LOC, DELIRIUM, COMA.
-NUMBER OF INTUBATIONS-
REINTUBATIONS
-MEDICATIONS (ANTIBIOTICS, SEDATION,
NM BLOCKERS)

12. RISK FACTORS (CONT.)
Device related:
- MV with Endotracheal tube, trcheostomy
-Prolonged MV
-Number of intubations- reintubation
-Use of humidifier
-Nasogastric or orogastric tubes
Personnel related:
-Improper hand washing
-Failure to change gloves between contacts with pts
-Not wearing personal protective equipment when antibiotic resistant bacteria have been identified.
BJMP jun2009: vol.2,nub.2, 16-19. & Am.jour of Criti care nurse 2007; 27:32-39

13. HOW DO THE ORGANISM GET IN?

14. HOW DO THE ORGANISM GET IN (CONT)
MICROASPIRATION
BIOFILM
TRICKLING AROUND THE CUFF
IMPAIRED MUCOCILIARY CLEARANCE
POSITIVE PRESSURE FROM VENTILATOR

15. WHAT ARE THE BUGS CAUSING VAP ?
EARLY ONSET
STREP. PNEUMONIAE
H. INFLEUNZA
MSSA
A/B SENSITIVE GRAM NEGATIVE
RODS
LATE ONSET
PSEUDOMONAS
MRSA
ESBL RODS
ACINOBACTER

16. HOW TO DIAGNOSE VAP ?
NO UNVERSALLY
ACCEPTED GOLD
STANDARD
DIAGNOSTIC
CRITERIA!!!!!

17. DIAGNOSIS
CLINICAL
MICROBIOLOGICAL
RADIOLOGICAL

18. WHAT IS CPIS SCORE
CLINICAL PULMONARY INFECTION
SCORE – by johanson et al (213 pts)
Clinical, physiological, microbiological,
radiographic evidence to predict the presence
or absence of VAP
- Score of 6 or more- consistent with diagnosis
DRAWBACK- poor sensitivity n specificity

19. WHAT IS CPIS SCORE

20. WHAT IS CPIS SCORE

21. MICROBIOLOGICAL DIAGNOSIS
ATS/IDSA
QUALITATIVE
CLINICAL
CRITERIA
QUANTITATIVE
ENDOTRACHEAL
ASPIRATE
-BAL
-MINI BAL
- PROTEECTED
SPECIMEN BRUSH

22. CLINICAL CRITERIA VS BACTERIOLOGICAL
CRITERIA- WHICH IS BETTER?????
- ATS/ IDSA GUIDELINES CLAIMS THAT
14- DAY MORTALITY WAS LESS AS
COMPARED TO CLINICAL CRITERIA
- BUT RECENT CANADIAN CLINICAL
TRIALS ON 740 SUSPECTED VAP AND
- COCHRANE METAANALYSIS OF 1367
PTS PROVED THERE IS NO
DIFFERENCE

23. RADIOLOGICAL MIMICS OF PNEUMONIA IN
ICU PATIENTS
CHEMICAL PNEUMONITIS
ATLECTASIS
CHF
ARDS
PLEURAL EFFUSION
INTRA-ALVEOLAR HG

24. RADIOLOGIC DIAGNOSIS
INFILTRATES
SOLITARY DIFFUSE NEW INFILTRATES

25. RADIOLOGICAL EVIDENCE OF PNEUMONIA
THINK BEFORE
LABELLING IT
AS VAP!!

26. RADIOLIGICAL EVIDENCE
IF X RAYS ARE NOT A GOOD PREDICTOR
OF VAP ,,,
THEN WAT IS IT USED FOR
‘’’

27. RADIOLIGICAL EVIDENCE
ANS. It is used to rule out vap. (what else do u
want ?)
Meta-analysis by KLOMPAS ET AL
VERY STRONG NEGATIVE
PREDICTIVE VALUE

28. HOW WILL U TREAT VAP?
BEFORE CHOOSING ANTIBIOTIC, keep in
mind on the following issues
RISK FACTORS OF THE PATIENT
WAS IT EARLY OR LATE ONSET
VIRULENCE OF ORGANISM
ANTIBIOTIC RESISTANCE
COST

29. HOW WILL U TREAT VAP?

30. CHOICE OF ANTIBIOTIC

31. RISK FACTORS for DRUG RESISTANCE

32. WHAT IF CPIS SCORE DOESN’T IMPROVE
CPIS SCORE <6 FOR MORE THAN 3 DAYS
CONSIDER ALTERNATE DIAGNOSIS
OR CONSIDER FUNGAL OR VIRAL
INFECTIONS

33. TREATMENT FAILURE

34. HOW CAN WE PREVENT VAP?
Specific practices have been shown to decrease
VAP
Strong evidence that a collaborative,
multidisciplinary approach incorporating many
interventions is paramount
Intensive education directed at nurses and
respiratory care practitioners resulted in a 57%
decrease in VAP
Crit Care Med (2002)

35. Conventional Infection control Aproach
•DESIGN OF ICU-
Adequate space, lighting, proper function of ventilatory system, facilities
for hand washing, Isolation room.
•STAFFING-
Education, Adequate number, quality, importance of personal cleanliness and
attention to asceptic procedures.
•PERIODICAL BACTERIAL MONITORING POLICY.
• SPECIFIC PROPHYLAXIS- Use Gloves, Gown, Mask.
Use of NIPPV
Minimize duration of MV, checking daily for readiness to weaning/extubation
(Text book of criti care med. 5 the Edit. MitchellP.FinkSHOEMAKER)

41. Daily Sedative Interruption and Daily
Assessment of Readiness to Extubate
OVERSEDATION
Predisposes patients to:
 Thromboemboli
 Pressure ulcers
 Gastric regurgitation and aspiration
 VAP
 Sepsis
Consequences include:
 Difficulty in monitoring neuro status
 Increased use of diagnostic procedures
 Increase ventilator days
 Prolonged ICU and hospital stay

42. STRESS ULCER PROPHYLAXIS
Increases gastric ph and minimize bacterial colonization that reduces
the risk of VAP and GI bleeding
SUCRALFATE- Decreases the VAP rate but increases the risk of GI
bleeding by 4%.
H2 receptor blockers/PP inhibitors- Increase rate of VAP by
increasing gastric Ph leading to colonization of bacteria and decreases
the risk of GI bleeding.
H2 receptor blocker, PP inhibitor preferred over
sucralfate
Am J Respir Crit Care Med. 2005;171(4):388-
416.

43. Airway Management
 Mechanical ventilation
 Avoidance of Endotracheal intubation
 Mask ventilation trials , NIPPV
 Minimize duration on MV
 Orotracheal intubation
 Nasotracheal intubation slightly increase the risk for VAP
 Avoid Reintubations- increases risk of VAP 6 fold
(Am resp.criti car med.1995;152(1):137-141)
 Maintain at 25-30 cm H2O

44. SUBGLOTTAL SUCTIONING
Should be done using a 14 Fr sterile suction
catheter:
 Prior to ETT rotation
 Prior to lying patient supine
 Prior to Extubation
Continuous subglottic suctioning
 ETT WITH DEDICATED LUMEN IS USED FOR CONTINUOUS OR INTERMITTED
SUBGLOTTIC SUCTIONING

45. Enteral Feedings
Early enternal feeding decrease bacterial
colonization and rate of VAP
Bolus feeding should be avoided to minimize
the risk of aspiration
Elevate HOB 30 - 45 degrees
Routinely verify tube placement

46. PATIENT TURNING-
Routine turning of patient for every 2 hrs increase pulmonary
drainage and decrease the risk of VAP.
Use of beds with continues lateral rotation can decrease the
incidence of pneumonia but do not decreases mortality or duration
of MV (critical care 2002;30(9):1983-1986)

48. NEW DEVELOPMENT• National healthcare safety(NHSN) and CDC proposed-
VAP terminology changed to VAC (ventilated associated
conditions and complications) not necessarily limited VAP.
• VAP Surveillance definination algorithm.
Chest x ray is not included ,
And diagnosis is mainly depend on worsening of gas
exchange, clinical features, isolation of microorganism in
resp.secreation.
• ETT-- with continuous subglottic suction, ployurethrene
cuff,Sponge cuff , Silver nitrate and antibiotic coated ETTs.
• VAP industrial complex- kinetic beds, inlines suction
catheters
• VAP bunddle with 7 components – 5+ Replacing NGT to
Orogastric tube and Hand washing by health care personnel.
IMPLEMENTATION and ENFORCEMENT of VAP bundle

49. VAP TO VAC
 NOVEL SURVEILLANCE CRITERIA BY CDC
- to include other complication in ventilated patients
 WHAT IS VENTILATOR ASSOCIATED CONDITION
- defined by 2 days of stable or decreasing ventilators
setting
- followed by consistently higher ventilator settings

50. VAP TO VAC
NOW IF IT IS ASSOCIATED BY SIGNS OF INFLAMMATION AND
INFECTION ----
“IVAC”
(INFECTION RELATED VENTILATOR
ASSOCIATED CONDITION)

51. POSSIBLE OR PROBABLE VAP
Based on presence of PURULENT SECRETION AND
PATHOGENIC CULTURE DATA
IVAC
PURULENT
SECRETION
PATH.
CULTURE
POSSIBLE
VAP
IVAC
PURULENT
SECRETION
PATH.
CULTURE PROBABLE
VAP
or

52. CONCLUSION
- SIGNIFICANT MORTALITY IN ICU PATIENTS
- NO GOLD STANDARD CRITERIA
- EARLY DIAGNOSIS AND USE OF ANTIBIOTICS
- PREVENTION IS THE CORNERSTONE OF DECREASING THE
INCIDENCE OF VAP
- APPLYING VAP BUNDLE PROTOCOL
- APPROPRIATE ANTIBIOTIC SELECTION

53. TAKE HOME MESSAGE
- DIAGNOSE VAP WHEN THERE IS SUSPICION
- CLASSIFY AND START EMPIRICAL ANTIBIOTIC AT THE EARLIEST
- DON’T FORGET TO SEND CULTURE SAMPLES
- PREVENTION IS THE KEY
- APPLY VAP BUNDLE PROTOCOL
- XRAYS ARE NOT DIAGNOSTIC ACCORDING TO NEW
PROTOCOL
- WEAN THE PATIENT EARLY
- STOP ANTIBIOTIC RESISTANCE
- FINALLY PLS DO WASH UR HANDS ***- SIMPLE BUT EFFECTIVE

54.  “THANK YOU”