Ventilator Associated Pneumonia (VAP)

1
Ventilator Associated Pneumonia (VAP)
Author Marianne Chulay, RN, DNSc,
FAAN Consultant, Clinical Research and
Critical Care Nursing Reviewers Suzi Burns,
Mary Jo Grap, Judy Verger, and Lori Jackson

• Issued 01/2008

2
Prevention of Ventilator Associated Pneumonia
(VAP)
3
Lecture Content

• Epidemiology of VAP
• Prevention strategies
• HOB elevation
• Ventilator equipment changes
• Continuous removal of subglottic secretions
• Handwashing

4
Epidemiology of Ventilator Associated Pneumonia
(VAP)
5
Nosocomial Pneumonias

• Account for 15 of all hospital associated
  infections
• Account for 27 of all MICU acquired infections
• Primary risk factor is mechanical ventilation
  (risk 6 to 21 times the rate for nonventilated
  patients)

CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2004 Craven, Chest 2000
117186S-187S.
6
Susceptibility to Nosocomial Pneumonias
Increased Nosocomial Pneumonias
Altered Host Defenses
Tracheal Colonization
Intubation
7
Primary Route of Bacterial Entry into Lower
Respiratory Tract

• Micro or macro aspiration of
• oropharyngeal pathogens
• Leakage of secretions
• containing bacteria around
• the ET cuff

8
VAP Etiology

• Most are bacterial pathogens, with Gram negative
  bacilli common
• Pseudomonas aeruginosa
• Proteus spp
• Acinetobacter spp
• Staphlococcus aureus
• Early VAP associated with non-multi-antibiotic-
• resistant organisms
• Late VAP associated with antibiotic-resistant
  organism

9
Significance of Nosocomial Pneumonias

• Mortality ranges from 20 to 41, depending on
  infecting organism, antecedent antimicrobial
  therapy, and underlying disease(s)
• Leading cause of mortality from nosocomial
  infections in hospitals

CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2004 Heyland et al, Am J
Respir Crit Care Med 1999 1591249 Bercault et
al, Crit Care Med 2001 292303
10
Significance of Nosocomial Pneumonias

• Increases ventilatory support requirements and
  ICU stay by 4.3 days
• Increases hospital LOS by 4 to 9 days
• Increases cost - gt 11,000 per episode
• Estimates of VAP cost / year for nation gt 1.2
  billion

Heyland et al, Am J Respir Crit Care Med
19991591249 Craven, Chest 2000117186-187S Rell
o et al, Chest 20021222115 Safdar et al,
Critical Care Medicine 2005332184-93
11
VAP Prevention
12
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
13
Continuous Removal of Subglottic Secretions

• Mahul et al. Int Care Med 19921820-25
• Valles et al. Ann Int Med 1995122179-186
• Kollef et al. Chest 19991161339-1346
• Smulders et al. Chest 2002121858-862
• Dezfulian et al. Am J Med 200511811-18
  (meta-analysis)

14
VAP Reduction with ET Suction Above the Cuff
Smulders et al. Chest121858-862
15
HOB Elevation

• HOB at 30-45º

• CDC Guideline for Prevention of Healthcare
  Associated Pneumonias 2004 ATS / IDSA Guidelines
  for VAP 2005

16
HOB Elevation

• Torres et al, Annals of Int Med 1992116540-543
• Ibanez et al. JPEN 199216419-422
• Orozco-Levi et al. Am J Respir Crit Care Med
  19951521387-1390
• Drakulovic et al. Lancet 19993541851-1858
• Davis et al. Crit Care 2001581-87
• Grap et al. Am J of Crit Care 2005 14325-332

• HOB at 30-45º

17
HOB Elevation Leads to Significant Deduction
in VAP

• Dravulovic et al. Lancet
• 19993541851-1858

18
Is HOB Elevation Done?

• Despite effectiveness
• of HOB elevation,
• compliance is poor.
• Grap et al. Am J Crit Care 19998475-480
• Grap et al. Am J Crit Care 200514325-332

Degrees of HOB Elevation
19
Frequency of Equipment Changes
No Routine Changes
Ventilator Tubing
Between Patients
Not Enough Data
Inner Cannulas of Trachs
Ambu Bags
CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2004
20
Handwashing
What role does handwashing play in nosocomial
pneumonias?
Albert, NEJM 1981 Preston, AJM 1981 CDC
Guideline for Prevention of Healthcare
Associated Pneumonias 2004
21
VAP Prevention

• Wash hands or use an alcohol-based waterless
  antiseptic agent before and after suctioning,
  touching ventilator equipment, and/or coming into
  contact with respiratory secretions.

CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2004 AACN Practice Alert
for VAP, 2007
22
VAP Protection

• Use a continuous subglottic suction ET tube for
  intubations expected to be gt 24 hours
• 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
23
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

CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2004
24
Oral Care

• Role of oral care, colonization of the
  oropharynx, and VAP unclear dental plaque may
  be involved as a reservoir
• Limited research on impact of rigorous oral care
  to alter VAP rates
• Surveys indicate most nurses use foam swabs
  rather than toothbrushes in intubated patients

CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2004 Grap M. Amer J of
Critical Care 200312113-119.
25
Need Further Assistance?
For more information or further assistance,
please contact a clinical practice specialist
with the AACN Practice Resource Network.
Email practice_at_aacn.org Phone [phone],
x217