linda r greene rochester general hospital rochester, ny [email protected]
TRANSCRIPT
Nothing to Declare
Describe the epidemiology and pathogenesis of ventilator associated pneumonia
Compare and contrast the current definition of ventilator associated pneumonia with the
proposed revised definition List at least 3 evidence based practices to
prevent ventilator associated pneumonia. Discuss future trends and strategies in
prevention ventilator associated pneumonia
Early Work On VAP Prevention
GAO Report on HAIs in hospitals April 2008
Leadership needed from HHS to prioritize preventive practices Improve central coordination Identify priorities Increase reliable estimates of
HAIs
The literature supporting high-profile measures to reduce ventilator-associated pneumonia (VAP):
Many studies show significant reductions in VAP rates but almost none show any impact on patients' duration of mechanical ventilation, length of stay in the intensive care unit and hospital, or mortalitYKlompas M, Platt R. Ventilator-associated pneumonia – the wrong quality measure for benchmarking. Ann Intern Med. 2007;147:803-805
Lack of specificity in the VAP definition
Array of events from critical to benign
Benign events may actually capture colonization
Pleural effusion or atelectasis however,
pneumonia cannot be rule out
Opacities in lower lobe may be atalectasis, pneumonia
or emphysematous changes
Bibasilar changes which may represent
atelectasis , pneumonia or
edema
Must be vetted withPhysicians
Start with sputum specimen
Daily rounding
Daily review of CXR
Determination by ICUStaff
Differences in NYS among IPs collecting data
Prevention Strategies BundlesBurden on IP – less time for surveillance
Pressure to have a VAP outcome measure for public reporting
Stakeholder meetings VAP working group Objective Definition Clinically relevant
Representation from all major stakeholder groups:
CDC IDSA CSTE APIC SHEA ATS Critical Care Society
VAPsVAP
VACValori
Mechanical ventilation is primary risk Mechanical ventilation is primary risk factor:factor:
The endotrachel tube acts as a conduit from the upper respiratorytract to the lower respiratory tract
Secretions collect on and around the cuff causing leakage of fluids into the lower respiratory tract
Sedation inhibits the natural ability to clear secretions
Patients undergoing mechanical ventilation are frequently fed via nasogastric tubes contributing to aspiration
Critically ill patients are often maintained in a supine position
Activity is limited
Cuffs: current recommendation is that cuff pressure should be maintained at no less than 20 cm H2OSome controversy that cuff design may be more importantThan cuff pressure
Tube related issues primarily include aspiration of contaminated secretions from above the cuff
Location Defense Mechanism
Upper Airway
Nasopharynx Nasal Hairs
Turbinates
Upper airway anatomy
Mucociliary apparatus
IgA secretions
Oropharynx Saliva
Sloughing of epithelial cells
Bacterial Interference
Complement Production
Location Defense Mechanism
Conducting Airways
Trachea, Brochii Coughing, epiglottic reflexes
Airway branching
Mucocillary apparatus
Immunoglobulin production
Airway Surface Liquid
Lower Airways
Terminal airways
Alveoli
Alveolar lining fluid
Cytokines
Alveolar Macrophages
Polymorohonuclear Leukocytes
Cell- mediated Immunity
What about Prevention Efforts?
If unable to bend at the hip - use Reverse Trendelenberg
Head of bed elevation: controversial, hard to maintain, but still recommended by most authors.
Must be at least 30 degrees, and must measure, not estimate
Reduced VAP incidence in some studies but
not others, does not hold up in metanalysis
Probably good for reducing length of ventilation
and ICU stay though
Not part of original bundle Chlorohexidine recommended in
increasing number of studies: Oral Decontamination with Chlorhexidine Reduces the
Incidence of Ventilator-associated Pneumonia
Koehman et alAmerican Journal of Respiratory and Critical Care Medicine Vol 173. pp. 1348-1355, (2006)© 2006 American Thoracic Society
Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. Chan et. Al BMJ 2007, 334:889.
Randomized Controlled Trial and Meta-analysis of Oral Decontamination with 2% Chlorhexidine Solution for the Prevention of Ventilator-Associated Pneumonia
Tantipong et L infection control and hospital epidemiologyfebruary 2008, vol. 29, no. 2
Effect of oral hygiene with o.12% chlorohexidine
gluconate on the Incidence of Nosocomial Pneumonia in children undergoing cardiac surgery
Jacomo et al. ICHE et al. June 2011 vol 3 no 6
The Basic Bundle
HOB Monitoring
Sedation Vacation
PUD Prophylaxis
DVT prophylaxis
Enhanced Bundle
Mouth Care- consider chlorohexidine
Education and Training Program
New Generation ET tubes
Oral gastric tubes
Ambulation
Antimicrobial coating of ET tubes e.g., silver coating, silver-sulfadiazene, chlorhexidine- recommended by some
BIOFILM - Once microorganisms have made contact and formed an attachment with a living host or non-living surface or object, development of a biofilm can take place. Bacteria living in a biofilm can have significantly different properties from free-floating bacteria, as the dense extracellular matrix of biofilm and the outer layer of cells may protect the bacteria from antibiotics and normal host defense mechanisms of the white blood cells, such as phagocytosis
Rationale
Avoid Intubation if possible -Non-invasive ventilation: avoiding intubation will avoid VAP, so use NIV whenever possible
Weaning: the longer you are on the ventilator, the more likely you are to get VAP. Weaning protocols have been conclusively shown to improve the rate of weaning from the ventilator
Implementation Science – How do we get
evidence to the bedside ?
We have to take a closer look at processes
http://www.cdc.gov/hicpac/pdf/Nov12_13_HICPAC_web_slides.pdfhttp://www.cdc.gov/hicpac/pdf/Nov12_13_HICPAC_web_slides.pdf
Staff Education & Training!
staff feedback!
Sharing Data
Monthswithouta VAP
10 mo
1 mo
Look at other outcomes
Mortality, readmission rates , length of stay
Use data to continually evaluate effectiveness of interventions
Communicate consistently: disseminate results of process and outcome measures.
Connect to purpose: help staff understand how simple actions connect to outcomes.
Review Deviations: review all cases to identify opportunities and system issues.
http://youtu.be/Pk7yqlTMvp8
