Prevention of Ventilator Associated Pneumonia

Steven Podnos MD

Epidemiology

• Most studies confirm that VAP significantly adds to morbidity and mortality

• Occurrence is about 13/1000 ventilator days• Defined as lower respiratory pneumonia

occurring 48 hours after initiation of mechanical ventilation

• VAP is leading cause of death from hospital acquired infection

Pathophysiology

• “Illness” is followed by a change in bacterial adherence to the oropharyngeal mucosa-gram negative bacteria and Staphlococci in particular increase on throat cultures

• VAP is a result of aspiration of oropharyngeal secretions in most cases

• ETT offers “pathway” to lungs

Microbiology

• Gram negative bacteria and Staphlococci• Often multi-resistant organisms• Requires different spectrum of empiric

antibiotic coverage than for Community Acquired Pneumonia

• Accurate isolation of causative organism difficult due to specimen contamination

Factors/Methods in Preventing VAP

• Intermittent Subglottic Secretions drainage/suctioning

• Continuous suctioning may cause tracheal damage

• Ultra-thin polyurethane cuffs help with tracheal occlusion and reduce VAP incidence

• Cuff pressure seems important, but not yet proven

Methods 2

• Kinetic beds/lateral rotation have been shown to decrease VAP, but are expensive

• Saline instillation before suctioning controversial

• Chest PT-potentially useful-hyperinflation and suctioning, vibration

Oral Hygiene

• Oral Chlorhexidine rinses appear useful, but timing, frequency and concentration are unclear

• Tooth Brushing has unclear benefit in VAP prevention, but probably helps dental outcomes

Antibiotics for VAP Prevention

• Multiple trials of IV and topical antibiotics• To date, any decrease in VAP accompanied by

increase in resistant organisms

Bundles

• Avoid ventilator circuit changes• Strict hand hygiene• Sedation vacation, SBT trials• Oral care with Chlorhexidine• Elevate head of bed-better ventilation,

decreased aspiration?• ? Avoid rings, white coats, ties• DVT prophylaxis-also decreases VAP• GI bleed prophylaxis-also decrease VAP