VENTILATORASSOCIATED PNEUMONIA VAP: prevention is better than cure ALISON RUFFELL: SISTER CRITICAL C

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VENTILATOR-ASSOCIATED PNEUMONIA
(VAP)prevention is better than cureALISON
RUFFELL SISTER CRITICAL CARE COLCHESTER
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MRSA BACTERAEMIA
C DIFF
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LICENCE TO KILL
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VAP DEFINITION

• a hospital-acquired infection
• A type of pneumonia that
  develops in
• mechanically ventilated patients
  who
• are intubated for more than 48
  hrs
• without the presence or
  likelihood of
• pneumonia at the time of
  intubation
• Fabregas and Torres
  (2000)

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• The leading cause of
• nosocomial mortality in ICU
• Safdar et al (2005)

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VAP CAUSES

• bacterial colonisation of aerodigestive tract
• aspiration of contaminated secretions past the
  cuff to the lower airways
• overwhelming of lung defences
• Craven (2006) Diaz et al (2005)

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VAP ASPIRATION

• Study examining intra-tracheal
• pepsin as marker for gastric aspiration
• in the critically ill intubated patient
• /- 6,000 tracheal aspirates (n360)
• 89 of patients had pepsin detected at some
  
• stage
• ASPIRATION IS THE MOST SIGNIFICANT
  INDEPENDENT RISK FACTOR FOR VAP
• Metheny et al (2006)

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PREVENTION IS BETTER THAN CURE

• VAP has a clear impact on
• hospital stay and therefore
• costs, thus strategies effective
• at preventing VAP are urgently
• needed.
• Safdar et al (2005)

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PREVENTATIVE MEASURES

• hand decontamination/use of gloves oral
  /nasal hygiene
• semi-recumbent positioning sedation hold
• 
  
• deep vein thrombosis prophylaxis
  stress ulcer prophylaxis
• infection control programme reduce
  aspiration of oropharygeal secretions
• oral rather than nasal ETT
  ETT suctioning (open versus closed)
• early extubation
  prevention of unplanned extubation
• aspiration of subglottal secretions
  kinetic therapy
• HME v heated circuits
  transfusion of red blood cells
• frequency of ventilator circuit change
  maintenance of ETT cuff pressure
• adequate nutritional support need for
  early nasogastric feeding

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VENTILATOR CARE BUNDLE

• semi-recumbent positioning
• daily sedation hold
• peptic ulcer disease prophylaxis
• DVT prophylaxis

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• Study involving 35 ICUs
• ventilator care bundle adherence and VAP rates
• 45reduction in VAP rate
• SUPPORT THE IMPLEMENTATION OF
• VENTILATOR BUNDLES IN ICU.
• Resar et al (2005)

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HME v HEATED CIRCUITS

• gt20 studies in past twenty years
• 
  Contradictory but the larger
• trials show no
  statistical
• difference
• However gt 5days ventilated ? reduced
• patency in ETT with HME
• Jaber et
  al (2004)

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HAND DECONTAMINATION

• One of the main causes of VAP as
  infection by pathogens-acquired exogenously from
  the ICU environment especially from the hands of
• healthcare workers.
• Safdar et al (2005)
• 1200 critical care nurses
• 82 washed their
• hands between patients.
• Cason et al (2007)
• 200 didnt !!

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ORAL HYGIENE

• tooth brushing
• mouth rinsing
• oral suctioning
• storage, rinsing and replacement of
• suction devices
• Tablan (2003)
• By 2007 only 56 hospitals in USA had oral
  care
• protocols
• Cason et al (2007)

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ETT SUCTIONING (open v closed)

• 16 trials
  (n1684)
• Neither
  closed or open
  
• suction
  systems had an
• effect on
  risk of VAP or
• mortality
• Subirana
  (2007)

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CHLORHEXIDINE ?

• Numerous studies in past 5 years with differing
  results
• Some indicated reduction in incidence of VAP (gt
  in cardiac medical patients)
• Some did not demonstrate reduction in VAP rates
  but reduction in ventilator days

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SELECTIVE DECONTAMINATION OF THE DIGESTIVE TRACT
(SSD)

• selective eradication in oral cavity
• decontamination of digestive tract
• optimal oral hygiene
• regular cultures of throat swabs and faeces
• Based on the present data, we recommend using
  SDD, combining systemic, topical, oropharyngeal
  and intestinal antibiotics, in critically ill
  patients
• Schultz et al (2003)

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SSD- EFFECTIVE?

• We should be treating patients with
• SSD in areas of low incidence
• of MRSA / VRE
• Liolios (2004)

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EDUCATION PROGRAMMES

• Demonstrated to reduce
• incidences of VAP by /- 50
• Apisarnthanarak et al (2007) Zack et al
  (2002)

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THE WAY FORWARD?
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WHAP VAP

• W early weaning
• H hand hygiene
• A aspiration precautions
• P prevention of contamination

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YOUNG LoTRACH SYSTEM
ETT
TT
CPC
www.lotrach.com
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APPROPRIATE STRATEGIES

• A one-size-fits-all strategy may be neither
  effective nor
• cost-effective
• Wunderink (1999, p1156)
• It might be prudent therefore for a
  multi-disciplinary approach to be used with the
  aim of considering prevention strategies
  appropriate to individual patient requirements
• Ruffell and Adamcova(2008,p50)

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?

• Alison.Ruffell_at_colchesterhospital.nhs.uk