ventilation associated pneumonia [vap]
TRANSCRIPT
VENTILATION ASSOCIATEDPNEUMONIA
Aneeda Shahimi
Hemodynamic instability
Pneumothorax
VENTILATOR ASSOCIATED PNEUMONIA
Life saving
devices
USED in:Respiratory failure
Protection of airways
Head injuryPost operative
Shock
INTRODUCTIONCOMPLICATION !!
3
OBJECTIVES Definition
TypesEpidemiologyCausative Agents (Microorganism)Risk FactorsClinical PicturesPathogenesis Diagnosis and TreatmentPrevention and Control
DEFINITIONA Nosocomial pneumonia associated with
mechanical ventilation, that develops within 48 hours or more of hospital admission and which
was not present at the time of admission.
48 Hours
Endotracheal
Tube
TracheostomyPneumonia
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TYPES
EARLY ONSET
• Within 3-4 days of MV • Less virulent• community acquired
organism– eg: Str. pneumoneae,
H. influenzae
LATE ONSET
• After 3-4 days of MV • More virulent• hospital acquired
organism– Eg: Pseudomonas,
Acinetobacter, MRSA, Enterobacteriaceae
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EPIDEMIOLOGY
EPIDEMIOLOGY
• Hospital acquired pneumonia (HAP) is the second most common hospital infection.
• VAP is the most common Intensive Care Unit (ICU) infection.
• 90% of all nosocomial infections occurring in ventilated patients are pneumonias.
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CAUSATIVE AGENTS
CAUSATIVE AGENTS
EARLY ONSET• Hemophilus influenza• Streptococcus
pneumoniae• Staphylococcus aureus
(methicillin sensitive)• Escherichia coli• Klebsiella
LATE ONSET• Pseudomonas
aeruginosa• Methicillin resistant-
Staphylococcus aureus (MRSA)
• Acinetobacter
Strains are Antibiotic Sensitive
Strains are Multiple
Antibiotic Resistant
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RISK FACTORS
SEDATIVE
HOST RELAT
ED
Underlying
Medical Conditio
n
Advanced Age
Patients’ body
position
Level of concious
ness
Number of
intubation
Medication
DEVICE
RELATED
MV with Endotrac
heal tube,
tracheostomy
Prolonged MVNumber
of intubatio
ns - reintuba
tion
Use of humidi
fier
Nasogastric or
Orogastric tubes
PERSONNE
L RELAT
ED
Improper hand
washing
Failure to change gloves
between contacts
with patients
Not wearing personal
protective equipment
when antibiotic resistant
bacteria have been
identified.
CLINICAL PICTURES
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PATHOGENESIS
• Bacteria enter the Lower Respiratory Tract via following pathways:
Aspiration of organisms from the Oropharynx and GI tract (most common cause)Direct inoculationInhalation of bacteriaHaematogeneous spread
PATHOGENESIS
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DIAGNOSIS
DIAGNOSIS• Radiographic evidence
for 2 consecutive days– New, progressive or persistent infiltrate– Consolidation, opacity, or cavitation
• Clinical signs, At least 1 of the following:– Fever (>38’C, no other recognized cause)
– Leukopenia (< 4,000 WBC/mm3) or;– Leukocytosis (> 12,000 WBC/mm3)
• At least 2 of the following:– New onset of purulent sputum, or change
in character of secretions.– New onset or worsening cough,
dyspnea, or tachypnea.– Rales or bronchial breath sounds.– Worsening of gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)
• Laboratory Test– It is recommended:
• When it may impact the choice of antibiotic • In patients with a high likelihood of accurate results
Chest X-Ray
Normal Pneumonia X-Ray
TREATMENT
Mechanical Ventilation
Associated
Symptoms
that is not
present before
Emperical Therapy
If the Emperical Therapy has no effect,Plan a treatment specifically suitable,
based on laboratory test result .
However, therapy should be started before results are available.
Choice of Emperical Treatment
• if present risk factor for multidrug resistant bacteria• Antipseudomonal cephalosporin
(cefepime) • antipseudomonal cerbepenem
(imipenem, meropenem) • b-lactam/ b-lactamase inhibitor
(pipercacillin)• Aminoglycoside
• if absence of risk factor for multidrug – resistance bacteria• cefriaxone, quinolones, ampicillin,/
sulbactam ertapenem
CAUSATIVE AGENTS
EARLY ONSET• Hemophilus influenza• Streptococcus
pneumoniae• Staphylococcus aureus
(methicillin sensitive)• Escherichia coli• Klebsiella
LATE ONSET• Pseudomonas
aeruginosa• Methicillin resistant-
Staphylococcus aureus (MRSA)
• Acinetobacter
Strains are Antibiotic Sensitive
Strains are Multiple
Antibiotic Resistant
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PREVENTION AND CONTROL
1. Limit exposure to resistant bacteria by discontinuing mechanical ventilation asap.
2. Proper hand washing and sterile technique for invasive procedures.
3. Limit the amount of sedation that a ventilated person receives.
4.Raise the head of the bed at least 30°. Avoid supine position.
5.Antiseptic mouth wash (chlorhexidine) decrease incidence of VAP.
6.Use of supraglottic secretion drainage (SSD) with a suction lumen EVAC tracheal tube.
7. Use of silver-coated endotracheal tube.
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