Ventilator Associated Pneumonia (VAP) Practice Alert Ventilator Associated Pneumonia (VAP) Issued...

Ventilator Associated Pneumonia (VAP) Practice Alert

Ventilator Associated Pneumonia Ventilator Associated Pneumonia (VAP) (VAP)

Issued 01/2008Issued 01/2008

Author: Author: Marianne Chulay, Marianne Chulay, RN, DNSc, FAAN

Consultant, Clinical Research and Critical Care Nursing

Reviewers: Suzi Burns, Mary Jo Grap,Reviewers: Suzi Burns, Mary Jo Grap,Judy Verger, and Lori JacksonJudy Verger, and Lori Jackson


Prevention of Ventilator Prevention of Ventilator Associated Pneumonia (VAP)Associated Pneumonia (VAP)

2

Ventilator Associated Pneumonia (VAP) Practice Alert3

Lecture Content

Epidemiology of VAP Prevention strategies

HOB elevation Ventilator equipment changes Continuous removal of subglottic secretions Handwashing


Epidemiology of Epidemiology of Ventilator Associated Pneumonia Ventilator Associated Pneumonia

(VAP)(VAP)

4


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 2004Craven, Chest 2000; 117:186S-187S.


Susceptibility to Nosocomial Pneumonias

IntubationIntubationAlteredAltered

HostHost

DefensesDefenses

TrachealTracheal

ColonizationColonization

IncreasedIncreased

NosocomialNosocomial

PneumoniasPneumonias


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


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


CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004Heyland et al, Am J Respir Crit Care Med 1999; 159:1249Bercault et al, Crit Care Med 2001; 29:2303

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

Significance of Nosocomial Pneumonias


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 - > $11,000 per episode

Estimates of VAP cost / year for nation > $ 1.2 billion

Heyland et al, Am J Respir Crit Care Med 1999;159:1249Craven, Chest 2000;117:186-187SRello et al, Chest 2002;122:2115Safdar et al, Critical Care Medicine 2005;33:2184-93


VAP PreventionVAP Prevention

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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


Continuous Removal of Subglottic Secretions Mahul et al. Int Care Med 1992;18:20-25

Valles et al. Ann Int Med 1995;122:179-186

Kollef et al. Chest 1999;116:1339-1346

Smulders et al. Chest 2002;121:858-862

Dezfulian et al. Am J Med 2005;118:11-18 (meta-analysis)


VAP Reduction with ET Suction Above the Cuff

0

5

10

15

20P

erce

nt

(%)

No Suction Suction

Smulders et al. Chest;121:858-862


HOB Elevation

HOB at 30-45º

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


HOB Elevation

HOB at 30-45º

Torres et al, Annals of Int Med 1992;116:540-543 Ibanez et al. JPEN 1992;16:419-422 Orozco-Levi et al. Am J Respir Crit Care Med

1995;152:1387-1390 Drakulovic et al. Lancet 1999;354:1851-1858 Davis et al. Crit Care 2001;5:81-87 Grap et al. Am J of Crit Care 2005 14:325-332


HOB Elevation Leads to Significant Deduction in VAP

0

5

10

15

20

25

% V

AP

Supine HOB Elevation

Dravulovic et al. Lancet

1999;354:1851-1858


Is HOB Elevation Done?

Despite effectiveness

of HOB elevation,

compliance is poor.

Grap et al. Am J Crit Care 1999;8:475-480

Grap et al. Am J Crit Care 2005;14:325-332

0

20

40

60

% w

ith

HO

B E

lev

ati

on

0 to 20

21 to 30

31 to 40

> 40

Degrees ofHOB Elevation


CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004

Frequency of Equipment Changes

VentilatorVentilator

TubingTubing

AmbuAmbu

BagsBags

Inner Inner Cannulas Cannulas of Trachsof Trachs

No Routine Changes

BetweenPatients

Not EnoughData


Handwashing

What role does handwashing playin nosocomial pneumonias?

Albert, NEJM 1981; Preston, AJM 1981; CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004


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 2004AACN Practice Alert for VAP, 2007


VAP Protection

Use a continuous subglottic suction ET tube for intubations expected to be > 24 hours

Keep the HOB elevated to at least 30 degrees unless medically contraindicated

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


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


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 2004Grap M. Amer J of Critical Care 2003;12:113-119.


For more information or further assistance, please contact a clinical practice specialist with the AACN Practice Resource Network.

Need Further Assistance?

Email:[email protected]

Phone:

(800) 394-5995

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