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Ventilator Associated Pneumonia (VAP). Issued 01/2008. Author: Marianne Chulay, RN, DNSc, FAAN Consultant, Clinical Research and Critical Care Nursing Reviewers: Suzi Burns, Mary Jo Grap, Judy Verger, and Lori Jackson. Prevention of Ventilator Associated Pneumonia (VAP).

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ventilator associated pneumonia vap

Ventilator Associated Pneumonia (VAP)

Issued 01/2008

Author: Marianne Chulay, RN, DNSc, FAAN

Consultant, Clinical Research and Critical Care Nursing

Reviewers: Suzi Burns, Mary Jo Grap,

Judy Verger, and Lori Jackson

Ventilator Associated Pneumonia (VAP) Practice Alert

prevention of ventilator associated pneumonia vap

Prevention of Ventilator Associated Pneumonia (VAP)

Ventilator Associated Pneumonia (VAP) Practice Alert

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

Ventilator Associated Pneumonia (VAP) Practice Alert

epidemiology of ventilator associated pneumonia vap

Epidemiology of Ventilator Associated Pneumonia (VAP)

Ventilator Associated Pneumonia (VAP) Practice Alert

nosocomial pneumonias
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; 117:186S-187S.

Ventilator Associated Pneumonia (VAP) Practice Alert

susceptibility to nosocomial pneumonias
Susceptibility to Nosocomial Pneumonias

Increased

Nosocomial

Pneumonias

Altered

Host

Defenses

Tracheal

Colonization

Intubation

Ventilator Associated Pneumonia (VAP) Practice Alert

primary route of bacterial entry into lower respiratory tract
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

Ventilator Associated Pneumonia (VAP) Practice Alert

vap etiology
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

Ventilator Associated Pneumonia (VAP) Practice Alert

significance of nosocomial pneumonias
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; 159:1249

Bercault et al, Crit Care Med 2001; 29:2303

Ventilator Associated Pneumonia (VAP) Practice Alert

significance of nosocomial pneumonias10
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;159:1249

Craven, Chest 2000;117:186-187S

Rello et al, Chest 2002;122:2115

Safdar et al, Critical Care Medicine 2005;33:2184-93

Ventilator Associated Pneumonia (VAP) Practice Alert

vap prevention

VAP Prevention

Ventilator Associated Pneumonia (VAP) Practice Alert

continuous removal of subglottic secretions
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

Ventilator Associated Pneumonia (VAP) Practice Alert

continuous removal of subglottic secretions13
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)

Ventilator Associated Pneumonia (VAP) Practice Alert

vap reduction with et suction above the cuff
VAP Reduction with ET Suction Above the Cuff

Smulders et al. Chest;121:858-862

Ventilator Associated Pneumonia (VAP) Practice Alert

hob elevation
HOB at 30-45º

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

HOB Elevation

Ventilator Associated Pneumonia (VAP) Practice Alert

hob elevation16
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

Ventilator Associated Pneumonia (VAP) Practice Alert

hob elevation leads to significant deduction in vap
Dravulovic et al. Lancet

1999;354:1851-1858

HOB Elevation Leads to Significant Deduction in VAP

Ventilator Associated Pneumonia (VAP) Practice Alert

is hob elevation done
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

Degrees of

HOB Elevation

Ventilator Associated Pneumonia (VAP) Practice Alert

frequency of equipment changes
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

Ventilator Associated Pneumonia (VAP) Practice Alert

handwashing
Handwashing

What role does handwashing play

in nosocomial pneumonias?

Albert, NEJM 1981; Preston, AJM 1981;

CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004

Ventilator Associated Pneumonia (VAP) Practice Alert

vap prevention21
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

Ventilator Associated Pneumonia (VAP) Practice Alert

vap protection
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 2004

AACN Practice Alert for VAP, 2007

Ventilator Associated Pneumonia (VAP) Practice Alert

no data to support these strategies
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

Ventilator Associated Pneumonia (VAP) Practice Alert

oral care
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 2003;12:113-119.

Ventilator Associated Pneumonia (VAP) Practice Alert

slide25

Need Further Assistance?

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

Email:

practice@aacn.org

Phone:

(800) 394-5995, x217

Ventilator Associated Pneumonia (VAP) Practice Alert