Ventilator associated pnemonia is a cause of concern in today's medical practice due to wide spread of Gram negative pathogens in hospitals and lack of good hygienic practices due to high occupancy rate in ICUs.

1. VAP causes andVAP causes and
preventive strategiespreventive strategies

2. VAP is defined as pneumonia that occurs more than
48 to 72 hours after endotracheal intubation
VAP definition
Am J Respir Crit Care Med Vol 171. pp 388–416, 2005

3. The estimated risk of VAP is
First 5 days of MV Between 5 to 10 day of MV There after
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
3.00%
2.00%
1.00%
Risk per Day

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
Am J Respir Crit Care Med Vol 171. pp 388–416, 2005

4. HAP/VAP incidence in India: A bird's eye view
The incidence of VAP in India is up to 30.67 cases per 1000 patient
ventilator days.2
1. Gupta D, Agarwal R, et al Lung India 2012;29:27-62 2. Pravin C MV et al.Australasian Medical Journal [AMJ 2013, 6, 4, 178-182
3.J Infect Dev Ctries. 2009;3:771–7

5. Pathogens of VAP in different ICUs of a
tertiary hospital in India: in 2010
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
J Infect Dev Ctries 2010; 4(4):218-225

6. Recent updates on major pathogens
associated in VAP
Ranjan N et al. Int J Res Med Sci. 2014 Feb;2(1):228-233

7. Various diagnosis criteria for VAP

8. Sources of VAP pathogens
Contaminated
respiratory
instruments
Contaminated hands
and Apparels of health
Care workers
Oropharyngeal
colonization
Gastric
colonization
European Journal of Internal Medicine 21 (2010) 360–368

9. VAP pathogenesis

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
BacterialBacterial
colonization ofcolonization of
Aerodigestive tractAerodigestive tract
Aspiration ofAspiration of
contaminatedcontaminated
secretions pastsecretions past
the cuff to thethe cuff to the
lower airwayslower airways
Bacteria entered in toBacteria entered in to
the Lowerthe Lower
respiratory tractrespiratory tract
Incidence ofIncidence of
VAPVAP
European Journal of Internal Medicine 21 (2010) 360–368

10. Role of oropharyngeal & gastric colonization in VAP
Oropharyngeal colonization:

Aspiration of oropharyngeal pathogens around the
endotracheal tube cuff is the primary routes of bacterial
entry into the lower respiratory tract

ETT is commonly made of PVC & bacteria easily
adhere to its internal surface and from Biofilm
Gastric colonization:
The stomach is potential reservoirs for MDR Gr -ve
pathogens
The chief predisposing factors for gastric colonization are
reduced gastric pH, enteral nutrition
European Journal of Internal Medicine 21 (2010) 360–368

11. But.......
VAP is a
Preventable disease

12. Prevention strategies of VAP
• Prior to intubation
• During intubation
• After intubation
• VAP care bundles
• General prophylaxis
Staff education

13. Prevention strategies prior to 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

14. Prevention strategies at process 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

15. Prevention strategies after intubation

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
Heat and Moisture Exchangers (HMEs)
CLINICAL MICROBIOLOGY REVIEWS, Oct. 2006, p. 637–657

16. VENTILATOR CAREVENTILATOR CARE
BUNDLEBUNDLE

17. 
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
The key components of a Ventilator Bundle are
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm

18. Elevation of the head 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

19. Daily interruption of sedation and assessment of
readiness to extubate
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm
 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

20. Peptic Ulcer Disease Prophylaxis
Stress induced GI erosions and ulcer
are common in ICU patients
H2- receptor inhibitors are more
preferred than sucralfate
Raise gastric pH may promote the
growth of bacteria in the stomach
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm

21. DVT prophylaxis
Ventilated patients are at a high risk of
developing DVT
The risk of venous thromboembolism is
reduced if prophylaxis is consistently
applied
But, Risk of bleeding may increase if
anticoagulants are used to accomplish
prophylaxis
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm

22. Daily Oral Care with 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

23. Appropriate hand hygiene
Appropriate time 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

24. Continuous Removal of Subglottic 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

25. Staff education

27. Summary
●
VAP is a 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