VAP, not on my WATCH !!!

France EllysonANM, MNH ICU

Kuwait 2014

• http://www.youtube.com/watch?v=RueE4or4rMU

Introduction

Mechanical ventilator is one of the most important life saving devices used in conditions like:• Respiratory failure• Protection of airway• Head injury• Postoperative• Shock

What is Ventilator Associated Pneumonia?

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

• Now considered a PREVENTABLE HEALTHCARE ERROR

National institute of health excellence (NICE) -2007center for disease control and prevention

What is VAP?

• Pneumonia that occurs at least 2 days after a patient is intubated (CDC GUIDELINES)

• The presence of the ET-tubes leads to VAP (not the ventilator)

• VAP rate increases with the # of days on mechanical ventilation

• Mortality varies according to the type of organisms

• Multi-resistant organisms have a higher mortality

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 occuring in ventilated patients are pneumonias.

• Causes more death than any of the other healthcare associated infection

Incidence

• VAP occurs in 10-20% of all ventilated patients Crit Care Clin (2002)

• Incidence increases with duration of MV: 3%/day for first 5 days, 2%/day for 6-10 days and 1%/day after 10 days.

• The incidence of VAP is highest in the following groups: Trauma, burns, neurosurgical post-op pts

• Mortality rate is 37% and 43% with antibiotic resistant organism

Critical Care Societies Collaborative (CCSCs)

Incidence Cont….

• Increases ventilatory support requirements and ICU stay by 4.3 days

• Increases hospital LOS (length of stay) by 4 to 9 days

• Increases medical cost ($5,000 to $40,000 per VAP) Critical Care Medicine

2005;33:2184-93

Causative Organisms:

Early onset Late onset

• Hemophilus influenza• Streptococcus

pneumoniae• Staphylococcus aureus

(methicillin sensitive)• Eschrichia coli• Klebsiella

• Pseudomonas aeruginosa

• Acinetobacter• Staphylococcus

aureus (methicillin resistant)

How is the pneumonia happening?

• Most plausible mechanism and source:– Leakage around the ETT cuff (primary route)…

aspiration of bacteria– High rate of the oropharyngeal or

tracheobronchial colonization (gram neg bacilli)– Bacteria from the tongue– Bacteria from environment: caregivers’ hand,

air, water, dust– Contaminated equipment (ventilator tubing,

aerosol, etc.)– Suctioning equipment

Risk Factors: Host Related• Medical / surgical disease• Immunosuppression • Malnutrition (Alb<2.2g/dl)• Advanced age• Pt’s position (supine)• LOC – impaired LOC,

delirium, coma• Medications – sedation,

steroids, previous antibiotic use, NM blockers

• Number of intubations- reintubations

Risk Factors: Device Related

• Mechanically ventilated with ETT or Tracheostomy tube

• Prolonged MV - MV > 48 hours

• Number of intubations, reintubations

• NGT or Orogastric tube• Use of humidifier

Risk Factors: Health Care Personnel Related

• Improper hand washing• Failure to change gloves

between contacts with pts

• Failure to wear personal protective equipment when required

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

Aspiration

ETT/T NGT/OGT

• Holds vocal cords open

• Predispose pt to micro and macro aspiration of colonized bacteria from oropharynx

• Leakage of secretions containing bacteria around ETT cuff

• Interrupts gastro-esophageal sphincter leading to GI reflux and aspiration

• Increase oropharyngeal colonization and stagnation of oropharyngeal and nasal secretions

A New Streamlined Surveillance Definition for Ventilator-Associated Pneumonia Critical Care Med 2012 vol.40, no.1

Any one of the following:

• NO CONSENSUS AMONG PHYSICIANS!!!

How do we Diagnose? 2-1-2

Radiologic evidence X 2 Consecutive days• New, progressive

or persistent infiltrate

• Consolidation, opacity or cavitation

How do we diagnose? 2-1-2Clinical Signs:At least 1of the following:• Fever > 38 °C with no

other recognized cause

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

How do we Diagnose? 2-1-2At 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 sounds• Worsening gas exchange

(decreased sats, increased oxygen requirements)

Treatment Protocol

• Start when VAP is suspected• Do not delay• Individualized to institution – Hospital

epidemiologic data, drug cost and availability

• Individualized to pt - Early onset vs Late onset of VAP, prior antibiotic use, underlying disease, renal, liver, etc

• Surveillance cultures

Duration of Treatment

• Standard duration 7-14 days• Longer duration > 14-21 days risk of toxicity

and resistance• Shorter < 7 days risk of recurrence• Depends on severity• Isolation of microorganism

Prevention

• Specific practices have been shown to decrease VAP

• Strong evidence that a collaborative, multidisciplinary approach incorporating many interventions is paramount

• Intensive education directed at nurse and respiratory care practitioners resulted in a 57% decrease in VAO

Crit Care Med (2002)

The VAP Bundle

BUNDLE

• “Group of evidence based interventions that whenever implemented together result in better outcomes”

Introduction of VAP BUNDLE

1. Elevation of HOB to between 30-45°2. Daily sedative interruption and daily assessment

of readiness to extubate3. The utilization of endotracheal tubes with

subglottic secretion drainage (Not at MNH yet)4. Stress ulcer disease prophylaxis – including

initiation of safe enteral nutrition within 24-48 hours of ICU admission

5. IN 2010 5TH COMPONENT of Daily oral care and decontamination with Chlorhexidine

Crit.Care 2012 vol.40, no.1

Additional Evidence-Based Component of Care:

HANDWASHING• Single most important

and ( easiest!!) method for reducing the transmission of pathogens

• Use of waterless antiseptic preparations is acceptable and may increase compliance

HOB 30-45°

• HOB 30-45° unless contraindicated

• Especially recommended for Neuro population

• To prevent aspiration during enteral feeding

Daily sedative interruption and daily assessment of readiness to extubate

OVERSEDATION predisposes pts to:

• Thromboemboli• Pressure ulcers• Gastric regurgitation and aspiration• VAP• Sepsis

Daily sedative interruption and daily assessment of readiness to extubate

OVERSEDATION predisposes pts to:

• Difficulty in monitoring neuro status• Increased use of diagnostic procedures• Increased ventilator days• Prolonged ICU and Hospital stay

Daily Wake-up

• Every pt must be awakened daily unless contraindicated

• Daily weaning assessments reduce the duration of MV

• If pt becomes symptomatic – rebolus and restart infusion at lower dose than original dose

• Goal is to decrease sedation

Stress Ulcer Prophylaxis

• Sucralfate, H2 receptor blocker and proton pump inhibitor – increases gastric ph and minimize bacterial colonization and reduces risk of VAP

Enteral Feedings

• Initiation of safe enteral nutrition within 24-48 hours of ICU admission

• Early initiation decreases bacterial colonization

• HOB 30-45°• Routinely + PRN

verification tube placement

Additional Evidence-Based Component of Care:

• Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) – TED stockings– SCD machine– Heparin S/C

Deep venous Thrombosis Prophylaxisand early mobility practices

• Pt turning Q 2hours increase pulmonary drainage and decreases risk VAP

• Early mobilization

Daily Oral care• Oral assessment Q shift

• Brushing teeth, tongue and gums with a soft toothbrush (minimally twice daily)

• Moisturizing agent for mouth

• Antiseptic rinse

• Swabs are not effective at removing plaques

• Chlorhexidine decontamination of mouth

• Routine suctioning of mouth to manage oral secretions and minimize risk of aspiration

Sage Oral Care Products

• http://www.youtube.com/watch?v=MYO_MddtYNs

Mouthcare

• Using chlorhexidine gluconate 0.12% (Peridex) solution every 6-12 hours to perform oral care, according to your protocol

• solution is used to rinse the patients’ mouth.

ET Tube Care

• Cuff pressure (between 20-30cm H2O)

• Oral intubation preferred

• Continuous or intermittent sub-glottic aspiration

• Avoid unnecessary disconnection of MV circuit

• Open vs close suctioning… benefits is not demonstrated yet

Prevent micro-aspiration of secretions

• 100-150ml of oral secretion can accumulate in patient mouth in 24hrs

• Mouth can colonize as quickly as 24hr after admission

• Intermittent and continuous subglottic suctioning

• Suctioning of the mouth before position change

Suctionning of Oral Secretions

• Suction oropharyngeal secretions Q 2hours, before repositionning, before suctionning ETT, before mobilizing patient and PRN

• Gently follow tongue to suction back of throat

• Use yankauer suction

SuctioningOral suction devices (Yankauer)• Follow policy for use

and storage• ?Harbor potentially

pathogenic bacteria within 24 hours

• Date and change Q day

• Rinse with sterile water after each use

• Allow to air dry

Subglottal Suctioning

Should be done using a 14 French sterile suction catheter• Prior to ETT

suctionning• Prior to pt change of

position• Prior to extubation* Continuous subglottic ETT with dedicated lumen above cuff may reduce risk of VAP

Prevent contamination of equipment

• Ventilator tubing

• Heat and moisture exchangers (green filters) are preferred over humidifiers (CDC B-II)

• Sterile suctioning

• Be careful with the tubing of the ventilator when you suction patient…

• Remove contaminated condensate from ventilator circuit (CDC, A-II)

Summary• Nosocomial 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 preventative measures (VAP

bundle) and timely initiation of appropriate antibiotics ensure better outcomes in pts with VAP

• http://www.youtube.com/watch?v=Ehi2Vt8UdRc

References

National Guideline Clearinghouse (current). Guideline Summary NGC-6634: Prevention of ventilator-associated pneumonia. Retrieved from: http://files.i-md.com/medinfo/material/f97/4eb0b88d44aece1112f7bf97/4eb0b8a944aece1112f7bf9a.pdf

Niel-Weise, B. & all. (2011). An evidence-based recommendation on bed head elevation for mechanically ventilated patients. Critical Care 2011, 15:R111.

Postma, D.F., Sankatsing, S.U.C., Thijsen, S.F.T. & Enderman, H. (2012). Effetcs of chlorhexidine oral decomtamination on respiratory colonization during mechanical ventilation in intensive care unit patients. Infection Control and Hospital Epidemiology, vol 33 no.5, pp.527-530.

Safer Healthcare now (2012). Ventilator associated pneumonia. Retrived from: http://www.saferhealthcarenow.ca/en/interventions/vap/pages/default.aspx

Safer Healthcare now (2012). Getting Started Kit. Retrieved from http://www.saferhealthcarenow.ca/EN/Interventions/VAP/Documents/VAP%20Getting%20Started%20Kit.pdf

ReferencesAlhazzani, W. & all. (2013) Tooth brushing for critically ill mechanically ventilated patients: a

systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia. DOI: 10.1097/ccm.0b013e3182742d45

Center for Disease Control and prevention(2011). Improving Surveillance for Ventilator-Associated Events in Adults. Obtain from MUHC Infection Control Departement.

Chan, E.Y., Ruest, A., Omeade, M. & Cook, D.J (2007). Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ, doi: 10.1136/bmj.39136.528160.BE

Fagon, J-Y. (2011). Biological markers and diagnosis of ventilator-assocaited pneumonia. Critical Care 20111, 15:130.

Koenig, S.M. & Truwit, J.D. (2006) Ventilator-assocaited pneumonia: diagnosis, treatment, and prevention. Clinical Microbiology Reviews, doi: 10.1123/CMR.00051-05

Hillier B. Wilson C. Chamberlain D. King L. (2013). Preventing ventilator-associated pneumonia through oral care, product selection, and application method: a literature review. AACN Advanced Critical Care. 24(1):38-58.

Insitute for Healthcare Improvement (2011). IHI ventilator bundle: daily oral care with chlorhexidine. Retrieved from http://www.ihi.org/knowledge/pages/changes/dailyoralcarewithchlorhexidine.aspx