ventilator associated pneumonia- care and prevention

102
VENTILATOR ASSOCIATED PNEUMONIA CARE AND PREVENTION Dr.T.V.Rao MD Dr.T.V.Rao MD 1

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VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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Page 1: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 2: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 3: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 4: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 5: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 6: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 7: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 8: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 9: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 10: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 11: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 12: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 13: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 14: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 15: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 16: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 17: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 18: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 19: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 20: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 21: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 22: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 23: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 24: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 25: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 26: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 27: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 28: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 29: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 30: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 31: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 32: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 33: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 34: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 35: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 36: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 37: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 38: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 39: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 40: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 41: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 42: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 43: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 44: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 45: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 46: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 47: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 48: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 49: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 50: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 51: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 52: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 53: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 54: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 55: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 56: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 57: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 58: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 59: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 60: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 61: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 62: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 63: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 64: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 65: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 66: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 67: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 68: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 69: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 70: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 71: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 72: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 73: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 74: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 75: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 76: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 77: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 78: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 79: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 80: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 81: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 82: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 83: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 84: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 85: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 86: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 87: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 88: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 89: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 90: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 91: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 92: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 93: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 94: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 95: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 96: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 97: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 98: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 99: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 100: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 101: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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
Page 102: VENTILATOR ASSOCIATED PNEUMONIA- CARE AND PREVENTION

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