VENTILATION ASSOCIATEDPNEUMONIA

Aneeda Shahimi

Hemodynamic instability

Pneumothorax

VENTILATOR ASSOCIATED PNEUMONIA

Life saving

devices

USED in:Respiratory failure

Protection of airways

Head injuryPost operative

Shock

INTRODUCTIONCOMPLICATION !!

3

OBJECTIVES Definition

TypesEpidemiologyCausative Agents (Microorganism)Risk FactorsClinical PicturesPathogenesis Diagnosis and TreatmentPrevention and Control

DEFINITIONA Nosocomial pneumonia associated with

mechanical ventilation, that develops within 48 hours or more of hospital admission and which

was not present at the time of admission.

48 Hours

Endotracheal

Tube

TracheostomyPneumonia

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TYPES

EARLY ONSET

• Within 3-4 days of MV • Less virulent• community acquired

organism– eg: Str. pneumoneae,

H. influenzae

LATE ONSET

• After 3-4 days of MV • More virulent• hospital acquired

organism– Eg: Pseudomonas,

Acinetobacter, MRSA, Enterobacteriaceae

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EPIDEMIOLOGY

EPIDEMIOLOGY

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

• VAP is the most common Intensive Care Unit (ICU) infection.

• 90% of all nosocomial infections occurring in ventilated patients are pneumonias.

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CAUSATIVE AGENTS

CAUSATIVE AGENTS

EARLY ONSET• Hemophilus influenza• Streptococcus

pneumoniae• Staphylococcus aureus

(methicillin sensitive)• Escherichia coli• Klebsiella

LATE ONSET• Pseudomonas

aeruginosa• Methicillin resistant-

Staphylococcus aureus (MRSA)

• Acinetobacter

Strains are Antibiotic Sensitive

Strains are Multiple

Antibiotic Resistant

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RISK FACTORS

SEDATIVE

HOST RELAT

ED

Underlying

Medical Conditio

n

Advanced Age

Patients’ body

position

Level of concious

ness

Number of

intubation

Medication

DEVICE

RELATED

MV with Endotrac

heal tube,

tracheostomy

Prolonged MVNumber

of intubatio

ns - reintuba

tion

Use of humidi

fier

Nasogastric or

Orogastric tubes

PERSONNE

L RELAT

ED

Improper hand

washing

Failure to change gloves

between contacts

with patients

Not wearing personal

protective equipment

when antibiotic resistant

bacteria have been

identified.

CLINICAL PICTURES

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PATHOGENESIS

• Bacteria enter the Lower Respiratory Tract via following pathways:

Aspiration of organisms from the Oropharynx and GI tract (most common cause)Direct inoculationInhalation of bacteriaHaematogeneous spread

PATHOGENESIS

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DIAGNOSIS

DIAGNOSIS• Radiographic evidence

for 2 consecutive days– New, progressive or persistent infiltrate– Consolidation, opacity, or cavitation

• Clinical signs, At least 1 of the following:– Fever (>38’C, no other recognized cause)

– Leukopenia (< 4,000 WBC/mm3) or;– Leukocytosis (> 12,000 WBC/mm3)

• At least 2 of the following:– New onset of purulent sputum, or change

in character of secretions.– New onset or worsening cough,

dyspnea, or tachypnea.– Rales or bronchial breath sounds.– Worsening of gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)

• Laboratory Test– It is recommended:

• When it may impact the choice of antibiotic • In patients with a high likelihood of accurate results

Chest X-Ray

Normal Pneumonia X-Ray

TREATMENT

Mechanical Ventilation

Associated

Symptoms

that is not

present before

Emperical Therapy

If the Emperical Therapy has no effect,Plan a treatment specifically suitable,

based on laboratory test result .

However, therapy should be started before results are available.

Choice of Emperical Treatment

• if present risk factor for multidrug resistant bacteria• Antipseudomonal cephalosporin

(cefepime) • antipseudomonal cerbepenem

(imipenem, meropenem) • b-lactam/ b-lactamase inhibitor

(pipercacillin)• Aminoglycoside

• if absence of risk factor for multidrug – resistance bacteria• cefriaxone, quinolones, ampicillin,/

sulbactam ertapenem

CAUSATIVE AGENTS

EARLY ONSET• Hemophilus influenza• Streptococcus

pneumoniae• Staphylococcus aureus

(methicillin sensitive)• Escherichia coli• Klebsiella

LATE ONSET• Pseudomonas

aeruginosa• Methicillin resistant-

Staphylococcus aureus (MRSA)

• Acinetobacter

Strains are Antibiotic Sensitive

Strains are Multiple

Antibiotic Resistant

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PREVENTION AND CONTROL

1. Limit exposure to resistant bacteria by discontinuing mechanical ventilation asap.

2. Proper hand washing and sterile technique for invasive procedures.

3. Limit the amount of sedation that a ventilated person receives.

4.Raise the head of the bed at least 30°. Avoid supine position.

5.Antiseptic mouth wash (chlorhexidine) decrease incidence of VAP.

6.Use of supraglottic secretion drainage (SSD) with a suction lumen EVAC tracheal tube.

7. Use of silver-coated endotracheal tube.

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