ventilator associated pneumonia- care and prevention
DESCRIPTION
VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTIONTRANSCRIPT
DrTVRao MD 1
VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION
DrTVRao MD
DrTVRao MD 2
Introduction to Patient Safety
Definitionbull 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)
DrTVRao MD 3
Introduction to Patient Safety Background
bull Adverse medical events are widespread and preventable (Emanuel et
al 2008) bull Much unnecessary harm is caused by
health-care errors and system failuresndash Ex 1 Hospital acquired infections
from poor hand-washingndash Ex 2 Complications from
administering the wrong medication
DrTVRao MD 4
Required Attitudes
Being an effective team player
Commitment to preventing HAIs
DrTVRao MD 5
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 6
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 7
Remember Some One at Risk with Ventilator
DrTVRao MD 8
Who is Responsible for Ventilator care
bull The registered nurse is responsible for the assessment planning and delivery of care to the patient
bull bull 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
DrTVRao MD 9
Basic Observationsbull Ensure the
endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 2
Introduction to Patient Safety
Definitionbull 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)
DrTVRao MD 3
Introduction to Patient Safety Background
bull Adverse medical events are widespread and preventable (Emanuel et
al 2008) bull Much unnecessary harm is caused by
health-care errors and system failuresndash Ex 1 Hospital acquired infections
from poor hand-washingndash Ex 2 Complications from
administering the wrong medication
DrTVRao MD 4
Required Attitudes
Being an effective team player
Commitment to preventing HAIs
DrTVRao MD 5
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 6
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 7
Remember Some One at Risk with Ventilator
DrTVRao MD 8
Who is Responsible for Ventilator care
bull The registered nurse is responsible for the assessment planning and delivery of care to the patient
bull bull 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
DrTVRao MD 9
Basic Observationsbull Ensure the
endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 3
Introduction to Patient Safety Background
bull Adverse medical events are widespread and preventable (Emanuel et
al 2008) bull Much unnecessary harm is caused by
health-care errors and system failuresndash Ex 1 Hospital acquired infections
from poor hand-washingndash Ex 2 Complications from
administering the wrong medication
DrTVRao MD 4
Required Attitudes
Being an effective team player
Commitment to preventing HAIs
DrTVRao MD 5
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 6
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 7
Remember Some One at Risk with Ventilator
DrTVRao MD 8
Who is Responsible for Ventilator care
bull The registered nurse is responsible for the assessment planning and delivery of care to the patient
bull bull 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
DrTVRao MD 9
Basic Observationsbull Ensure the
endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 4
Required Attitudes
Being an effective team player
Commitment to preventing HAIs
DrTVRao MD 5
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 6
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 7
Remember Some One at Risk with Ventilator
DrTVRao MD 8
Who is Responsible for Ventilator care
bull The registered nurse is responsible for the assessment planning and delivery of care to the patient
bull bull 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
DrTVRao MD 9
Basic Observationsbull Ensure the
endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 5
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 6
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 7
Remember Some One at Risk with Ventilator
DrTVRao MD 8
Who is Responsible for Ventilator care
bull The registered nurse is responsible for the assessment planning and delivery of care to the patient
bull bull 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
DrTVRao MD 9
Basic Observationsbull Ensure the
endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 6
ICU patientsbull Sickest patients (multiple diagnoses
multi-organ failure immunocompromised septic and trauma)
bull Move less bull Malnourished bull More obtunded (Glasgow coma scale)bull Diabetics and Heart failure
DrTVRao MD 7
Remember Some One at Risk with Ventilator
DrTVRao MD 8
Who is Responsible for Ventilator care
bull The registered nurse is responsible for the assessment planning and delivery of care to the patient
bull bull 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
DrTVRao MD 9
Basic Observationsbull Ensure the
endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 7
Remember Some One at Risk with Ventilator
DrTVRao MD 8
Who is Responsible for Ventilator care
bull The registered nurse is responsible for the assessment planning and delivery of care to the patient
bull bull 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
DrTVRao MD 9
Basic Observationsbull Ensure the
endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 8
Who is Responsible for Ventilator care
bull The registered nurse is responsible for the assessment planning and delivery of care to the patient
bull bull 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
DrTVRao MD 9
Basic Observationsbull Ensure the
endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 9
Basic Observationsbull Ensure the
endotracheal tube (ETT) or tracheostomy tube is held securely in position but not too tightly to result in pressure area lesions
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 10
Always check the patient first
bull Observe the patientrsquos facial expression colour respiratory effort vital signs and ECG tracing
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 11
What is Mechanical Ventilator
bull Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator
bull A ventilator delivers gas to the lungs with either negative or positive pressure
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 12
Purposesbull To maintain or
improve ventilation amp tissue oxygenation
bull To decrease the work of breathing amp improve patientrsquos comfort
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 13
Intensive Care Unit Nosocomial Pneumonia
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
bull VAP is the leading cause of nosocomial infection in the ICU and reflects 60 of all deaths attributable to nosocomial infections
bull Pneumonia rates are much higher in mechanically ventilated patients due to the artificial airway which increases the opportunity for aspiration and colonization
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 15
Definition- ldquoKnow thy enemyrdquoPneumonia 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
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 16
Who gets VAP (Risk factors)bull Study of 1014 patients receiving mechanical
ventilation for 48 hours or more and free of pneumonia at admission to ICU
bull Increased risk associated with admitting diagnosis of ndash Burns (risk ratio=509)ndash Trauma (risk ratio=50)ndash Respiratory disease (risk ratio=279)ndash CNS disease (risk ratio=34)
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 17
Risk factors for bacterial pneumonia
Host Factors Factors that facilitate refluxamp aspiration into the lower RT
bull Elderlybull Severe Illnessbull Underlying Lung Disease - Mechanical ventilationbull Depressed Mental Status - Tracheostomybull Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Positionbull Viral Respiratory Tract Factors that impede normal
Infection Pulmonary ToiletColonisation - Abdominal or thoracic surgerybull Intensive Care Setting - Immobilisationbull Use of Antimicrobial Agentsbull Contaminated handsbull Contaminated Equipment
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 18
Incidence of VAPbull The exact incidence of HAP is usually between
5 and 15 cases per 1000 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)
bull HAP accounts for up to 25 of all ICU infections bull In ICU patients nearly 90 of episodes of HAP
occur during mechanical ventilation
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 19
Resistant Bacteria leading Cause
bull Many patients with HAP VAP and HCAP are at increased risk for colonization and infection with MDR pathogens (Level II)
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 20
Pathogenesisbull Where do the bacteria come from
ndash Tracheal colonization- via oropharengeal colonization or GI colonization
ndash Ventilator systembull How do they get into the lung
ndash Breakdown of normal host defensesndash Two main routes
bull Through the tubebull Around the tube- micro aspiration around ETT cuff
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 21
Etiologybull Bacteria cause most cases of HAP VAP and
HCAP and many infections are polymicrobial rates are especially high in patients with ARDS (Level I)
bull 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)
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 22
Predisposing causes in Pneumonia
ndash Pseudomonas aeruginosabull the most common MDR gram-negative bacterial
pathogen causing HAPVAP has intrinsic resistance to many antimicrobial agents
ndash Klebsiella Enterobacter and Serratia speciesbull Klebsiella species
ndash intrinsically resistant to ampicillin and other aminopenicillins and can acquire resistance to cephalosporins and aztreonam by the production of extended-spectrum ndashlactamases (ESBLs)
ndash ESBL-producing strains remain susceptible to carbapenemsbull Enterobacter speciesbull Citrobacter and Serratia species
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 23
Predisposing causes in Pneumonia
ndash Acinetobacter speciesbull More than 85 of isolates are susceptible to
carbapenems but resistance is increasing bull An alternative for therapy is sulbactambull Stenotrophomnonas maltophila and
Burkholderia cepacia ndash resistant to carbapenems ndash susceptible to trimethoprimndashSulphmethoxazole
Ticarcillinndashclavulanate or a fluoroquinolone
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 24
Predisposing causes in Pneumonia
ndash Methicillin-resistant Staphylococcus aureusbull Vancomycin-intermediate S aureus
ndash sensitive to linezolid ndash linezolid resistance has emerged in S aureus but is currently
rare
ndash Streptococcus pneumoniae and Haemophilus influenza
bull sensitive to Vancomycin or linezolid and most remain sensitive to broad-spectrum quinolones
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 25
Initiation of Mechanical Ventilation
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 26
Guidelines in the Initiation of Mechanical Ventilation
bull Primary goals of mechanical ventilation are adequate oxygenationventilation reduced work of breathing synchrony of vent and patient and avoidance of high peak pressures
bull Set initial FIO2 on the high side you can always titrate down
bull Initial tidal volumes should be 8-10mlkg depending on patientrsquos body habitus If patient is in ARDS consider tidal volumes between 5-8mlkg with increase in PEEP
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 27
Guidelines in the Initiation of Mechanical Ventilation
bull Use PEEP in diffuse lung injury and ARDS to support oxygenation and reduce FIO2
bull Avoid choosing ventilator settings that limit expiratory time and cause or worsen auto PEEP
bull When facing poor oxygenation inadequate ventilation or high peak pressures due to intolerance of ventilator settings consider sedation analgesia or neuromuscular blockage
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 28
Ventilatorsbull After every patient
clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 29
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 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
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 31
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 32
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 33
Ventilator cleaning and Decontamination
bull After every patient clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturerrsquos instructions
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 34
If put on Oxygen maskbull Change oxygen
mask and tubing between patients and more frequently if soiled
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 35
Prevalence of VAPbull Occurs in 10-20 of
those receiving mechanical ventilation for greater than 48 hours
bull Rate= 148 cases per 1000 ventilator days
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 36
When does VAP occur
bull Cook et al showed ndash 401 developed before day 5ndash 412 developed between days 6 and 10ndash 113 developed between days 11-15ndash 28 developed between days 16 and 20ndash 45 developed after day 21
Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 37
Time frame of intubation and risk
bull Risk of pneumonia at intubation daysndash 33 per day at
day 5ndash 23 per day at
day 10ndash 13 per day at
day 15 Cook et al Incidence of and risk factors for ventilator-associated pneumoniain critically ill patients
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao 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
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 39
HOB Elevation
HOB at 30-45ordm
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS IDSA Guidelines for VAP 2005
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 40
HOB ElevationReferences
HOB at 30-45ordm
bull Torres et al Annals of Int Med 1992116540-543bull Ibanez et al JPEN 199216419-422bull Orozco-Levi et al Am J Respir Crit Care Med 19951521387-1390bull Drakulovic et al Lancet 19993541851-1858bull Davis et al Crit Care 2001581-87bull Grap et al Am J of Crit Care 2005 14325-332
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 41
HOB UP 30 DEGREES OR HIGHER
bull Recommended elevation is 30-45 degreesbull If semi-recumbent or supine 34 incidence VAPbull If semi-recumbent position 8 incidence VAPbull uarrHOB rarr darrrisk of aspiration of gastrointestinal
contents darrrisk of aspiration of oropharengeal
secretions darrrisk of aspiration of nasopharyngeal
secretions
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 42
HOB UP 30 DEGREES OR HIGHER
bull HOB improves patientsrsquo ventilation
bull Supine patients have lower spontaneous tidal volumes on PS
bull than those seated in upright position
bull uarrHOB may aid ventilatory efforts and minimize atelectasis
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
Ventilator Associated Pneumonia (VAP) Practice Alert
43
HOB Elevation Leads to Significant Deduction in VAP
Dravulovic et al Lancet 19993541851-1858
0
5
10
15
20
25
V
AP
Supine HOB Elevation
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 44
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Frequency of Equipment Changes
VentilatorTubing
AmbuBags
Inner Cannulas of
Trachs
No Routine Changes
BetweenPatients
Not Enough
Data
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 45
Hand washingWhat role does hand washing play
in nosocomial pneumonias
Albert NEJM 1981 Preston AJM 1981 CDC Guideline for Prevention of Healthcare Associated
Pneumonias 2004
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
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 andor coming into contact with respiratory secretions
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP 2007
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 47
Suctioning mechanically ventilated patients
bull Hand washing before and after the procedurebull Wear clean gloves to prevent cross-
contaminationbull 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
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
VAP Reduction with ET Suction Above the Cuff
0
5
10
15
20
Perc
en
t (
)
No Suction Suction
Ventilator Associated Pneumonia (VAP) Practice Alert
48
Smulders et al Chest121858-862
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 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
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 50
Nebulizersbull Use sterile medications and fluids for nebulizationbull Fill with sterile water only bull Change and reprocess device between patients by
using sterilization or a high level disinfection or use single-use disposable item
bull Small hand held nebulizersndash minimise unnecessary usendash between uses for the same patient disinfect rinse
with sterile water or air dry and store in a clean dry place
bull Reprocess nebulizers daily
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 51
Humidifiersbull Clean and sterilize device between
patientsbull Fill with sterile water which must be
changed every 24 hours or sooner if necessary
bull Single-use disposable humidifiers are available but they are expensive
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 52
Indications for an actively humidified circuit (Westmead ICU)
bull 1048618 minute volume greater than 10 litresbull 1048618 chest trauma with pulmonary contusionbull 1048618 airway burnsbull 1048618 severe asthmabull 1048618 hypothermia (lt340 C)bull 1048618 pulmonary haemorrhagebull 1048618 severe sputum pluggingpulmonary oedema
leading to HME occlusionbull 1048618 consultant order
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 53
Pooling of Secretions
bull Pooled secretions above the ETTtrachi 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
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 54
Suction of an Artificial Airway
bull To maintain a patent airwaybull bull To promote improved gas exchangebull bull To obtain tracheal aspirate specimensbull bull To prevent effects of retained secretions eg
infection consolidation atelectasis increased airway pressures or a blocked tube
bull bull It is important to oxygenate before and after suctioning
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 55
Sterilisation and decontaminationAfter 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 cleanerMedical detergent solution can also be used to
thoroughly to flush the tubings
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 56
Contdhellip2 Glutaraldehyde is used for routine
sterilisation of tubings and other accessoriesPlease follow manufacturerrsquos directions and
recommendationsEthylene Oxide ndash gas sterilisation is also used
Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 57
Contdhellip
Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous
After sterilisation the tubings must be properly aerated to dissipate residual gas absorbed by the materials
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 58
VAP Prevention Wash hands or use
an alcohol-based waterless antiseptic agent before and after suctioning touching ventilator equipment andor coming into contact with respiratory secretions 2004
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 59
VAP Protectionbull Use a continuous subglottic
suction ET tube for intubations expected to be gt 24 hours
bull 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
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 60
Hand Hygiene bull 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
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 61
How to use waterless hand rubbull Apply a palmful of product in cupped handbull Rub hands palm to palm bull Right palm over left hand with interlaced fingersbull Palm to palm with fingers interlacedbull Backs of fingers to opposing palms with fingers
interlockedbull Rub between thumb and forefingerbull Rotational rubbing backwards and forwards with
clasped fingers of right hand in left palm and vice versa
bull Once dry your hands are safe
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 62
HAND HYGIENEbull The best method to prevent
healthcare acquired infections including VAP is to practice good Hand Hygiene including use of
bull Antimicrobial soap and water bull Alcohol Based Hand Rub (Isagel)
when there is no visible soiling on hands
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 63
Compliance with Isolation Precautions
bull 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
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 64
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 66
How Does Aspiration Pneumonia
(including VAP) Occur ASPIRATION
+
GRAM - BACTERIA
+
OVERWHELM IMMUNE SYSTEM
MUST HAVE ALL 3
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 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 ndash organisms including Pathogens that cause VAP and Aspiration Pneumonia
American Journal of Critical Care (2004)
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 68
Oral Care ResearchTreatment with oral hygiene alone reduced occurrence of pneumonia in older adults in nursing homes by 30 Yoneyama etal (2002)
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 69
Oral decontaminationbull Chan et al investigated antibiotics and
antisepticsndash Antibiotics were not found to be beneficialndash Antiseptics were found to be beneficial in 6 out of
7 studiesbull Chlorhexidine studied in 6 five of which showed
benefitndash Note that mortality ICU stay and duration of
mechanical ventilation were not statistically significant
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 70
Oral Cleansingbull 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
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 71
Current Oral Care Practices Continuedhellip
Foam swabs are commonly used to provide mouth care to patients who cannot providetheir own care
SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL AND ONLY PROVIDE MOISTURE REFIEF
Journal of Advanced Nursing (1996)Nursing Times (1996)
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 72
Why should hospitals care somuch 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 infections20-50 of all infected patients will die as a result of the infection
JCanDentAssoc(2002)
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 73
Oral Carebull 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
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 74
Oral Carebull 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)
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 75
Oral Care AACN
bull AACN 5th Edition 2005 Scott JM Vollman KMbull Endotracheal Tube and Oral Care Procedure 4 bull Unit One Pulmonary System
bull Perform ET suctioning only when clinically indicatedbull Oral hygiene should be performed every 2-4 hours and should
includebull Toothbrushing at least two times a daybull Oral swabs with 15 hydrogen peroxide solution every 2-4
hoursbull Mouth moisturizer to oral mucosa and lipsbull Subglottic suctioning continuously or intermittently
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 76
Oral Care plaque Grap MJ Munro CL 2004
bull Tooth brushing is the most effective means of mechanical removal of plaque
Munro CL Grap MJ Elswick RK el al 2006Am J Crit Care15
bull Higher plaque scores confer greater risk for VAP
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 77
Procedure - Brushing
bull Wash hands and put on glovesbull Obtain PLAC VAC BRUSHbull Attach suction to toothbrush moisten toothbrush and
apply baking sodabull Brush patientrsquos teeth gums tongue palate and
inside cheeksbull Apply suction to cleansed areasbull Rinse brush in water repeat step 4-5bull Soak dentures in denture solution
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 78
Alternate Procedure Chlorhexidine 012
1 Place 15ml of chlorhexidine in medication cup
2 Soak toothette in chlorhexidine3 Rub teeth tongue gums and sides of mouth
in circular motion4 Suction oral cavity and do not rinse5 Apply oral moisturizer to lips
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 79
Oral Care use of antiseptics
Fourrier 2005 Crit Care Med 33
bull CHG ndash reduced colonization but not VAP
Munro amp Grap 2006 Crit Care Med 34
bull CHG ndash effective in reducing VAP
Seguin 2006 Crit Care Med 34
bull Povidone-Iodine - decreased prevalence of VAP in head trauma
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD80
Oral Carebull Role of oral care colonization of the
oropharynx and VAP unclear ndash dental plaque may be involved as a reservoir
bull Limited research on impact of rigorous oral care to alter VAP rates
bull Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Grap M Amer J of Critical Care 200312113-119
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 81
Eye amp Mouth care bull For unconscious patients eyes
are kept closed by taping
bull Goggles can also be used
bull Regular amp proper mouth care should be given
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 82
Eye Care bull 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
bull 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
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 83
SDD- selective decontamination of the digestive tract
bull Multiple studies showing effectivenessbull Big concern is antibiotic resistancebull Most recently- NEJM January 2009
ndash Study of 13 intensive care units in Netherlands showed statistically significant reduction of mortality of 35 in patients receiving SDD
ndash Same study showed that patients receiving SOD (selective oropharengeal decontamination) had decrease of 29
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 84
Monitoring for infection
bull Color consistency and amount of the sputum secretions with each suctioning should be observed
bull Fever and other parameters have to closely observed for any other infection (central line etc)
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 85
Bacteriologic Strategybull 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)
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 86
Comparing Diagnostic Strategybull 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)
bull 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)
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
Imperfect diagnostic testsbull Blood cultures limited role sensitivity is only 8 to 20bull Sputum neither sensitive nor specificbull Tracheo-bronchial aspirates- high sensitivity weakness- does not
differentiate between pathogen and colonizerbull
Hospital-acquired pneumonia Risk factors microbiology and treatment Chest 119 2001 373S-384S BAL PSBrsquos 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
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
HCAP HAP VAPTreatment
bull 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
bull Mortality with prompt antibiotic use 30 vs 91 when delayed Nosocomial pneumonia A multivariate analysis of risk and prognosis Chest 93 1988 318-324
bull 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
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
HCAP HAP VAPTreatment
bull Ceftriaxone or a quinolone (eg ciprofloxacin or levofloxacin) or ampicillin-sulbactam or Ertapenem
bull Fluoroquinolone in the empirical regimen of patients with penicillin allergies
bull Penicillin skin testing ndash a mean to decrease fluoroquinolones use
bull 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
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
Antibiotics for Empirical Therapy of Hospital-Acquired Pneumonia in Patients at Risk for Multidrug-Resistant Pathogens
Antibiotic Adult Dosage dagger Antipseudomonal cephalosporinCefepime 1-2 g every 8-12 hrCeftazidime 2 g every 8 hrCarbapenemsImipenem 500 mg every 6 hr or 1 g every 8 hrMeropenem 1 g every 8 hrBeta-lactamndashbeta-lactamase inhibitorPiperacillin-tazobactam 45 g every 6 hrAminoglycosidesGentamicin 7 mgkgdayTobramycin 7 mgkgdayAmikacin 20 mgkgdayAntipseudomonal quinolonesLevofloxacin 750 mgdayCiprofloxacin 400 mg every 8 hrVancomycin 15 mgkg every 12 hrLinezolid 600 mg every 12 hrGuidelines for the management of adults with hospital-acquired ventilator-associated and healthcare-associated pneumonia Am J Respir Crit Care Med 2005171388-416
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
Duration of treatment
bull 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
bull Guided by severity time to clinical response and the pathogenic organism
bull 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
bull Treat for at least 72 hours after a clinical response is achieved
bull International conference for the development of consensus on the diagnosis and treatment of ventilator-
associated pneumonia Chest 120 2001 955-970
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
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
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
Prevention Measures
bull Based on expert opinion rather than hard databull CDC published a set of 74 recommendations for
preventing NAP only 15 strongly supported by well-designed experimental or epidemiologic studies
bull 14 out of those 15 dealt with surveillance education hand washing sterilization proper use of gloves value of vaccination and sanitation
bull Prophylactic antibiotics not be used routinely only one supported by well-designed studiesbull Centers for Disease Control and Prevention Guidelines for prevention of nosocomial
pneumonia MMWR Morb Mortal Wkly Rep 46 1997 1-79
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 94
Appropriate staffing levels in the ICU
bull Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP
bull Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control
bull Kollef MH Crit Care Med 200432(6)
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD95
No Data to Support These Strategies
bull Use of small bore versus large bore gastric tubes
bull Continuous versus bolus feeding
bull Gastric versus small intestine tubes
bull Closed versus open suctioning methods
bull Kinetic beds
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
Things to Rememberbull HACP HAP VAP = BAD for the patientbull Quantitative diagnostic microbiology-
controversialbull Cover likely bugs promptlybull Know your local bugsbull De-escalate shorten duration of therapybull Specific regimen combination therapy- no
proven benefits
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 97
Compliance with Isolation Precautions
bull 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
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
Objective 2
Objective 1
Avoid overtreatment
without VAPImmediate
treatment of patients with VAP
Diagnosis and treatment of ventilator-associated
pneumonia
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 99
Brave and Committed Nurses Doctors Save Many Lives
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 100
With Thanks To Many bull 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
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 101
Visit me for Many Topics of Interest on Infectious Diseases
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-
DrTVRao MD 102
bull Programme Created by DrTVRao MD for Medical and Paramedical
Professionals Working in the Intensive Care Units bull Email
bull doctortvraogmailcom
- VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION DrTVRa
- Introduction to Patient Safety Definition
- Introduction to Patient Safety Background
- Required Attitudes
- ICU patients
- ICU patients (2)
- Remember Some One at Risk with Ventilator
- Who is Responsible for Ventilator care
- Basic Observations
- Always check the patient first
- What is Mechanical Ventilator
- Purposes
- Intensive Care Unit Nosocomial Pneumonia
- VENTILATOR ASSOCIATED PNEUMONIA (VAP)
- Definition- ldquoKnow thy enemyrdquo
- Who gets VAP (Risk factors)
- Risk factors for bacterial pneumonia
- Incidence of VAP
- Resistant Bacteria leading Cause
- Pathogenesis
- Etiology
- Predisposing causes in Pneumonia
- Predisposing causes in Pneumonia (2)
- Predisposing causes in Pneumonia (3)
- Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation
- Guidelines in the Initiation of Mechanical Ventilation (2)
- Ventilators
- Suctioning mechanically ventilated patients
- Suction Bottle
- Nebulizers
- Humidifiers
- Ventilator cleaning and Decontamination
- If put on Oxygen mask
- Prevalence of VAP
- When does VAP occur
- Time frame of intubation and risk
- Continuous Removal of Subglottic Secretions
- HOB Elevation
- HOB Elevation References
- HOB UP 30 DEGREES OR HIGHER
- HOB UP 30 DEGREES OR HIGHER (2)
- HOB Elevation Leads to Significant Deduction in VAP
- Frequency of Equipment Changes
- Hand washing
- VAP Prevention and Hand Washing
- Suctioning mechanically ventilated patients (2)
- VAP Reduction with ET Suction Above the Cuff
- Suction Bottle (2)
- Nebulizers (2)
- Humidifiers (2)
- Indications for an actively humidified circuit (Westmead ICU)
- Pooling of Secretions
- Suction of an Artificial Airway
- Sterilisation and decontamination
- Contdhellip
- Contdhellip (2)
- VAP Prevention
- VAP Protection
- Hand Hygiene
- How to use waterless hand rub
- HAND HYGIENE
- Compliance with Isolation Precautions
- Slide 64
- Why should hospitals care so much about the oral cavity
- How Does Aspiration Pneumonia (including VAP) Occur
- When does Colonization occur
- Oral Care Research
- Oral decontamination
- Oral Cleansing
- Current Oral Care Practices Continuedhellip
- Why should hospitals care so much about the oral cavity (2)
- Oral Care
- Oral Care (2)
- Oral Care AACN
- Oral Care plaque
- Procedure - Brushing
- Alternate Procedure Chlorhexidine 012
- Oral Care use of antiseptics
- Oral Care (3)
- Eye amp Mouth care
- Eye Care
- SDD- selective decontamination of the digestive tract
- Monitoring for infection
- Bacteriologic Strategy
- Comparing Diagnostic Strategy
- Imperfect diagnostic tests
- HCAP HAP VAP Treatment
- HCAP HAP VAP Treatment (2)
- Slide 90
- Duration of treatment
- Slide 92
- Prevention Measures
- Appropriate staffing levels in the ICU
- No Data to Support These Strategies
- Things to Remember
- Compliance with Isolation Precautions (2)
- Diagnosis and treatment of ventilator-associated pneumonia
- Brave and Committed Nurses Doctors Save Many Lives
- With Thanks To Many
- Visit me for Many Topics of Interest on Infectious Diseases
- Slide 102
-