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Ventilator Associated Pneumonia (VAP) Abdelrahman Al-daqqa 05/09/2022 1

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Page 1: Ventilator associated pneumonia VAP

Ventilator Associated Pneumonia

(VAP)Abdelrahman Al-daqqa

05/02/2023 1

Page 2: Ventilator associated pneumonia VAP

What is VAP? A Nosocomial pneumonia

associated with mechanical ventilation (either by Endotracheal tube or Tracheostomy) that develops within 48 hours or more of hospital admission and which was not present at the time of admission.

National institute of health excellence (NICE)-2007

center for disease control and prevention

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EPIDEMIOLOGY• Hospital acquired pneumonia (HAP) is the second most common hospital infection.

• VAP is the most common intensive care unit (ICU) infection.• 90% of all nosocomial infections occurring in ventilated patients are pneumonias.

•Added costs of $40,000 - $50,000 per stay

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Early–Onset Pneumonia (< 96 hours of intubation or ICU admission) Community-acquired Pathogens:

Streptococcus pneumoniaeHaemophilus influenzaeStaphylococcus aureus

Antibiotic-sensitive

TYPES--

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Late-Onset Pneumonia (> 96 hours of intubation or ICU admission) Hospital-acquired Pathogens:

Pseudomonas aeruginosa Methicillin resistant Staphylococcus aureus

(MRSA) Acinetobacter Enterobacter

Antibiotic-resistant

TYPES--

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INCIDENCE VAP occurs in 10 - 65% of all

ventilated patients Crit Care Clin (2002)

Incidence increases with duration of MV

3% /day for first 5days, 2%/day for 6-10days and 1%/day after 10 days.

Mortality rate is 27% &43%with antibiotic resistant organism. critical care societies collaborative(CCSCs)

Mortality rate in VAP caused by Pseudomonas or Acinetobacter is as high as 76% Crit Care Med (2004)

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Cont…VAP Increases ventilatory support

requirements and ICU stay by 4.3 days

Increases hospital LOS by 4 to 9 days

Increases medical cost Chest 2002;122:2115

Critical Care Medicine 2005;33:2184-93

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RISK FACTORS HOST RELATE D Medical /surgical disease, Immunosuprssion, Malnutrition (Alb<2.2g/dl ), Advanced age, Supine position, Level of conciousness, Medication-NMB, sedation, steroids, Previous antibiotic use

DEVICE RELATED

MV with ETT or TRACHEOSTOMY TUBE , MV>48 hrs, Reintubations, NGT or Oro- gastric tube, Use of Humidifier

HEALTHCARE PERSONNEL RELATEDImproper hand washing, Failure to change gloves and use mask gown when ever required .

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PATHOGENESIS Bacteria enter the lower respiratory

tract via following pathways: Aspiration of organisms from the

oropharynx and GI tract (most common cause)

Direct inoculation Inhalation of bacteria Haematogeneous spread

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HOW DO WE DIAGNOSE? 2-1-2 Radiographic evidence x 2 consecutive

days New, progressive or persistent infiltrate Consolidation, opacity, or cavitation

Clinical sings At least 1 of the following:

Fever (> 38 degrees C) with no other recognized cause

Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000 WBC/mm3)

At least 2 of the following: New onset of purulent sputum or change in

character of secretions New onset or worsening cough, dyspnea, or

tachypnea Rales or bronchial breath sounds Worsening of gas exchange (↓ sats, P:F ratio <

240, ↑ O2 req.)

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CONT…Microbiological criteria (optional)At least one of the following:• Positive growth in blood culture not related to another source of infection.• Positive growth culture pleural fluid.• Bronchoaleveolar lavage > 105colony forming units/ml. sensivity &specificity 42-93% &45-100% Protected specimen brushing >103cfu/ml

(33-100% & 50-100%) chest.Apr2000;117(4suppl2):198-2002)•Histopathological evidence of pneumonia

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Cont--• RADIOLOGICAL FINDING AND 2 CLINICAL CRITERIA SENCIVITY OF DIAGNOSING VAP IS 69% AND THE SPECIFICITY IS 75%• SAMPLING OF RESPIRATORY SECREATION can be obtained from distal or proximal airway however the sensivity and specificity is more with distal airway sample(Bronchoalveolar lavage(BAL) , Protected specimen brush sampling(PAB).• ABSENCE OF RADIOLOGICAL FINDING HELPFUL FOR EXCLUDING THE DIAGNOSIS OF VAP

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A new streamlined surveillance defintion for ventilator-associated pneumonia

Any one of the following1. Opacity, infiltrate, or consolidation that appears, evolves, or persists over 72 hrs2. CavitationAny one of the following1. Temperature 100.4°F within past 24 hrs2. White blood cell 4,000 or 12,000 white blood cells/mm3 within past 24 hrsBoth of the following1. Two days of stable or decreasing daily minimum FIO2 followed by increase in daily minimum FIO2 15 points sustained for 2 calendar days OR 2 days of stable or decreasing daily minimum positive end-expiratory pressure followed by increase in daily minimum positive end-expiratory pressure by 2.5 cm H2O sustained for 2 calendar days2. Gram-negative stain of respiratory secretions with moderate (2+) or more neutrophils per low power field within 72 hrs. Critical care med 2012 vol.40,no.1

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TREATMENT• GENERAL APPROACH FOR INFECTION CONTROL• ANTIBIOTICS- Selection of antibiotics:Early onset of VAP and no risk for MDR - Cefrioxone, fluroquinolones, ampicillin-sublactum Late onset of VAP and risk for MDR- Antipseudomonal cephalosporin(cfepime,ceftazidime) Carbapenems(imipenem,meronem), Beta lactam/betalactamase inhibitors- piperacillin-tazobactam Amonoglycocides with vancomycine,linezoid ANTIBIOTCS TO BE ADJUSTED FURTHER ON THE BASIS OF CULTURE REPORT

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Risk Factors for drug resistance ABX in last 14 days Prior culture with MRO Immunocompromised Chronic primary lung pathology Acute or long term care

hospitalization within 14 days Tracheostomy for > 5 day

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DURATION OF TREATMENT- Depends on severity,

- Time to clinical response and micro organism response- Isolation of microorganism- Longer duration >14-21days risk of toxicity and resistance - Shorter duration<7days- risk of recurrence-standard duration of treatment 7-14 days- Longer durtion 14-21 days may be indicated in Multilobular involvement, cavitation, gram-ve necrotising pneumonia, isolation of Pseudomonas, Acnetobacter

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Further inpatient careAbout 30% of pts. Fail to respond-

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EFFECT OF VAP BUNDLE CARE

VAP RATE UPTO 65%VAP BUNDLE: HOB elevation between 30-

45degree, DVT prophylaxis,

Stress ulcer prophylaxis, Daily interruption of sedation,

Daily oral care with Chlorohexidine

VAP rate reduced by

44.5%

05/02/2023 18PREVENTION

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Care Bundle A care bundle is …... “A systematic method of

measuring and improving clinical care processes based on groups of care elements for particular diagnoses and procedures”

NHS Modernization Agency

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Ventilator Associated Pneumonia Care Bundle -Evidence Based Practices

Head Of Bed elevated to 30˚-45˚

Daily sedation vacation &daily assessment of readiness to wean

DVT Prophylaxis Stress Ulcer Prophylaxis Subglottic secretion drainage Daily mouth care with

chlorhexidine05/02/2023 20

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1.HOB UP 30 DEGREES OR HIGHER

Recommended elevation is 30-45 degrees

If semi-recumbent or supine 34% incidence VAP

↑HOB → ↓risk of aspiration of gastrointestinal contents

↓risk of aspiration of oropharyngeal secretions

↓risk of aspiration of nasopharyngeal secretions

↑HOB improves patients’ ventilation Supine patients have lower spontaneous tidal volumes on PS than those seated in upright position ↑HOB may aid ventilatory efforts and

minimize atelectasis

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HOB Elevation > 30 Degrees on all Intubated

Ventilated Patients Contraindications Hypotension MAP <70 Tachycardia >150 CI <2.0 Central line procedure Posterior circulation strokes Cervical spine instability use

reverse trendelenburg Some femoral lines ie: IABP

no higher than 30 degrees use reverse trendelenburg

Increased ICP, No higher than 30 degrees avoid hip flexion

Proning

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2.Daily “Sedation Vacation” and Daily Assessment of

Readiness to Wean Correlated with reduction in rate

of VAP Sedation vacation results in

significant reduction in time on mechanical ventilation

Duration of mv decreased from 7.3 days to 4.9 days-study by Kress et al. (NEJM 2000)

Weaning is easier when patients are able to assist themselves at extubation with coughing and control of secretions

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Conti…. Allow the patient to wake. If the patient is co-operative and able to

understand commands leave the sedation off.

Distressed or agitated patients require re-sedating.

Administer boluses as appropriate to achieve safety.

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3.Peptic Ulcer Disease (PUD)

Prophylaxis It is an appropriate intervention in all

sedentary patients Critically ill intubated patients lack

the ability to defend their airway Decreasing pH of gastric contents

may protect against greater pulmonary inflammatory response to aspiration of gastrointestinal contents

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More on PUD Prophylaxis

Surviving Sepsis Campaign Guidelines reviewed literature on PUD prophylaxis:

“H2 receptor inhibitors are more efficacious that sucralfate and are the preferred agents. Proton Pump Inhibitors have not been assessed in direct comparison with H2 receptor antagonists and, therefore their relative efficacy is unknown. They do demonstrate equivalency in ability to increase gastric pH.”

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4.Deep Vein Thrombosis (DVT) Prophylaxis

Higher incidence of DVT in critical illness

Risk of venous thromboembolism is reduced if prophylaxis is consistently applied

TARGET: patients undergoing surgery, trauma patients, acutely ill medical patients, and ICU patients

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5.Subglottal Suctioning

Should be done using a 14 Fr sterile suction catheter:Prior to ETT rotationPrior to lying patient supine

Prior to extubation 2805/02/2023

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Suctioning In line suction:

Maintain closed systemUse separate suction tubing

Normal saline:Should not be routinely used to suction pts

Causes desaturationDoes not increase removal of secretions

Can potentially dislodge bacteriaShould be used to rinse the suction catheter after suctioning

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Suctioning

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Best Practices to Achieve a High Level

of Compliance in ICUs Daily Multi-disciplinary Rounds including:

Head Nurse(Unit in-charge)Reg.Nurse assigned to patientClinical Pharmacist / Pharmacy ResidentsInfection Control SpecialistRespiratory TherapistRegistered DieticianNurse Case ManagerSpeech TherapistNursing student / Instructor

Use of Ventilator Bundle Audit Tool addressing the bundle items daily

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The best method to prevent healthcare acquired infections including VAP is to practice good Hand Hygiene including use of

Antimicrobial soap and water Alcohol Based Hand Rub (Isagel)

when there is no visible soiling on hands

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HAND HYGIENE

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Compliance with Isolation Precautions

Stringent adherence to the use of Personal Protective Equipment (PPE) such as Gowns, Masks, Gloves will decrease the transmission of pathogenic microorganisms to ventilated patients when patients are identified as requiring Contact and Droplet Precautions

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Enteral Feedings Early enternal feeding decrease

bacterial colonization and rate of VAP

Bolus feeding should be avoided to minimize the risk of aspiration

Elevate HOB 30 - 45 degrees Routinely verify tube placement No CDC recommendations for:

Preferential use of small bore tubes Continuous versus intermittent feeding Post pyloric placement CDC (2003)

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PATIENT TURNING-

Routine turning of patient for every 2 hrs increase pulmonary drainage and decrease the risk of VAP.Use of beds with continues lateral rotation can decrease the incidence of pneumonia but do not decreases mortality or duration of MV (critical care 2002;30(9):1983-1986)

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No Data to Support These Strategies• Use of small bore versus large

bore gastric tubes• Continuous versus bolus feeding• Gastric versus small intestine tubes.• Closed versus open suctioning methods.• Kinetic beds.

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SUMMARYNosocomial pneumonia and especially VAP are the most frequent infectious complications in the ICU, and they significantly contribute to morbidity and mortality. VAP is an important determinant of ICU and hospital lengths of stay and healthcare costs.

No standard to diagnose.

Several simple preventive measures(VAP bundle) and timely initiation of appropriate antibiotics ensure better outcomes in patients with VAP.

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