AACN

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AACN

• Ventilator Associated Pneumonia (VAP)

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Prevention of Ventilator Associated Pneumonia
(VAP)
AACN VAP Practice Alert
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Lecture Content

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

AACN VAP Practice Alert
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Epidemiology of Ventilator Associated Pneumonia
(VAP)
AACN VAP Practice Alert
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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 2003 Cook et al, Ann Intern
Med 1998129433
AACN VAP Practice Alert
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Critical Care Interventions Increase
Susceptibility to Nosocomial Pneumonias
Increased Nosocomial Pneumonias
Altered Host Defenses
Tracheal Colonization
Intubation
AACN VAP Practice Alert
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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-res
  istant organisms
• Late VAP associated with antibiotic-resistant
  organism

AACN VAP Practice Alert
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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 2003 Heyland et al, Am J
Respir Crit Care Med 19991591249 Bercault et
al, Crit Care Med 2001292303
AACN VAP Practice Alert
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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 - 20,000 to 40,000 per episode
• Estimates of VAP cost / year for nation gt 1.2
  billion

Heyland et al, Am J Respir Crit Care Med
19991591249 Craven D. Chest 2000117186-187S R
ello et al, Chest 20021222115
AACN VAP Practice Alert
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VAP Prevention
AACN VAP Practice Alert
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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 2003 Kollef et al, Chest
19991161339
AACN VAP Practice Alert
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HOB Elevation
HOB at 30-45o
CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2003 Drakulovic et al,
Lancet 19993541851
AACN VAP Practice Alert
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Frequency of Equipment Changes
No Routine Changes
Ventilator Tubing
Not Enough Data
Inner Cannulas of Trachs
Between Patients
Ambu Bags
AACN VAP Practice Alert
CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2003
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Handwashing
What role does handwashing play in nosocomial
pneumonias?
AACN VAP Practice Alert
Albert, NEJM 1981 Preston, AJM 1981 Tablan, 1994
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VAP Prevention

• Wash hands before and after suctioning, touching
  ventilator equipment, and/or coming into contact
  with respiratory secretions.

All recommendations are level IA
CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2003 AACN Practice Alert
for VAP, 2004
AACN VAP Practice Alert
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VAP Prevention

• 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

All recommendations are level II
CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2003 AACN Practice Alert
for VAP, 2004
AACN VAP Practice Alert
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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

AACN VAP Practice Alert
CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2003
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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 2003 Grap M. Amer J of
Critical Care 200312113-119.
AACN VAP Practice Alert
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• Thanks
• for your attention