Ventilator Assoiated Pnemonia

1
VAP(Ventilator Associated Pneumonia)
Ventilator-associated pneumonia (VAP) is a type
of lung infection that occurs in people who are
on mechanical ventilator.
2
Cost Savings

• A financial analysis completed by our infectious
  disease and financial departments concluded that
  a VAP in any of our ICUs adds 57,000 in
  additional costs for additional antibiotics,
  ventilator time and ICU stay.
• Cost avoidance for this project based on
  avoiding 8 VAPs per year is 456,000.

3
VAP SUSPECT

• Patients mechanically ventilated for greater than
  48 hours
• Exhibit at least 3 or 5 following symptoms
• Fever
• Leukocytosis
• Change in sputum (color and/or amount),
• Radiographic evidence of new infiltrates
• Worsening oxygen requirements CDC 2003

4
Potential Reservoirs NosocomialPneumonia
Pathogens

• Oropharynx
• Trachea
• Stomach
• Respiratory therapy equipment
• Paranasal sinuses
• Sanctuary (above cuff below cords)
• Endotracheal intubation decreases the cough
  reflex, impedes mucociliary clearance, injures
  the tracheal epithelial, provides a direct
  conduit for bacteria from URT to the LRT

5
What are the organism affecting usually

• Typically, bacteria causing early-onset VAP includ
  e Streptococcus pneumoniae (as well as other
  streptococcus species), Hemophilus influenzae,
  methicillin-sensitive Staphylococcus aureus
  (MSSA), antibiotic-sensitive enteric
  Gram-negative bacilli, Escherichia coli,
  Klebsiella pneumonia, Enterobacter species.

6
Sources of VAP
7
How we introduce Infection
8
Clinical Pulmonary Infection Score (CPIS) for
Ventilator-Associated Pneumonia (VAP)

• Carolina A.M. Schurink, MD, is a professor of
  medicine and practicing physician at the Erasmus
  University Medical Center in Rotterdam,
  Netherlands.
• To view Dr. Carolina A.M. Schurink's
  publications, visit PubMed

9
(No Transcript)
10
Clinical Pulmonary Infection Score

• Temperature (C)
• 36.5-38.4 0
• 38.5-38.9 1
• 39.0 or 36.0 2
• White blood cell count
• 4000-11000 0
• lt4000 or gt11000 1
• 5000 2

11
Clinical Pulmonary Infection Score

• Tracheal secretions
• Non or Scant
  0
• but Non Purulent
  1
• purulent secretions
  2
• Oxygenation, PaO2/FiO2 mm Hg
• gt240 or ARDS 0
• 240 and no ARDS 2
• Pulmonary radiography
• No infiltrate 0
• Diffuse or patchy infiltrate 1
• Localized infiltrate
  2

12
Clinical Pulmonary Infection Score

• Culture of tracheal aspirate specimen
• Pathogenic bacteria
• cultured 1 or no growth
  0
• Pathogenic bacteria cultured gt1
  1
• Pathogenic bacteria cultured gt1 plus same
  pathogenic bacteria on gram stain gt
  2

13
Chest X-ray VAP Patient
14
Chest X-ray VAP Patient
15
Who are Prone to VAP World federation of
anesthesiologist.

• Increasing age (55 years)
• Chronic lung disease Aspiration/ micro aspiration
  
• Chest or upper abdominal surgery
• Previous antibiotic therapy, especially
  broad-spectrum antibiotics
• Reintubation after unsuccessful extubation, or
  prolonged intubation
• Acute respiratory distress syndrome Frequent
  ventilator circuit changes
• Polytrauma patient Prolonged paralysis Premorbid
  conditions such as malnutrition, renal failure,
  and anaemia

16
Ventilator Bundles for prevention of VAP CDC Guide

• Ventilator-Associated Pneumonia (VAP)Bundle
• DVT prophylaxis
• GI prophylaxis
• Head of bed (HOB) elevated to 30-45?
• Daily Sedation Vacation
• Daily Spontaneous Breathing Trial

17
Prevention

• Intubation should be used when intubation is
  necessary
• NEW circuits for each patient, and changes if the
  circuits become soiled or damaged.
• closed endotracheal suctioning system.
• Unnecessary Suctioning We Subglottic secretion
  drainage
• use of subglollic secretion.,
• raise the head of the bed
• Prone positioning
• Oral antiseptic Chlorhexidine or Povidoneiodine

18
General Preventive Measures

• Education
• Clinical guidelines and care protocols
• Infection prevention and control practice
• Critical care environment
• Intubation
• Positive pressure ventilation NIV
• Prevention of aspiration
• Prevention of contamination of equipment
• Prevention of colonization of the aero digestive
  tract
• Implementation of VAP care bundle
• Staffing

19
General measures

• Thoroughly clean all equipment and devices to be
  sterilized or disinfected
• Whenever possible, use steam sterilization (by
  autoclaving) or high-level
• Preferentially use sterile water for rinsing
  reusable semi critical respiratory equipment and
  devices when rinsing is needed after they have
  been chemically disinfected.

20
General Measures preventing VAP

• Do not routinely sterilize or disinfect the
  internal machinery of mechanical ventilators
• Breathing circuits,
• humidifiers, and heat-and-moisture exchangers
  (HMEs
• Suctioning Procedure
• Using Sterile water for ETT suction
• Using close suction system
• Using Hepa filters around the patient

21
Conclusion

• VAP is a serious healthcare associated infection
  with significant morbidity and mortality
• Risk factors are associated with the host and
  our treatments for critically ill patients.
• Duration of intubation is the most significant
  risk factor.
• Diagnosis of VAP is complex but important for
  surveillance and clinical purposes

22
Conclusion

• VAP bundles contain measures that are not
  specifically related to VAP prevention
• Quantitative cultures can be helpful for
  diagnosis
• There is good evidence for shorter courses of
  antibiotic therapy than have traditionally been
  given for VAP

23
Thanks

• Shams Ali Shah
• RT PSCCQ Saudi Arabia.