VAP Bundle

Department of Critical Care Medicine, Apollo Hospitals

The presentation is solely meant for Academic

purpose


PREVENTING VENTILATOR ASSOCIATED PNEUMONIA

(VAP BUNDLE)


Preventing VAP

Definitions

Pathophysiology of

VAP Risk factors

Prevention of VAP Guidelines

Recent advances

Conclusion


Definitions

Hospital acquired pneumonia (HAP)

48 hours or more after admission

Ventilator associated pneumonia (VAP)

Type of HAP developing > 48 hours after intubation

Early vs Late

Healthcare associated pneumonia (HCAP)

Hospitalization in an acute care hospital for two or more

days within the prior 90 days

Other health care contact

ATS/IDSA 2005 guidelines


Risk Factors

It is NOT the Ventilator


Risk Factors

Host related Age

Lung disease/ARDS

Immunosuppression

Unconsciousness

Body position

Antibiotic exposure

Chest surgery

Re-intubation/prolonged intubation

Device related ETT

Ventilator circuit

Orogastric and nasogastric tube

Personnel related Hand washing, Noncompliance


Bacterial Colonization (Aerodigestive tract, ETT, Ventilator tubings)

Micro-aspiration (Secretions, Vent. Condensate, Aerosols)

Ventilator Associated Pneumonia

Bacteremia

Gut translocation

Bacterial inhalation

Contamination


Bacterial Colonization (Oropharynx, Stomach, Sinus, ETT)

Host Factors Antibiotics Gastric pH

Devices – ETT, NGT

Biofilms

Inadequate

infection control practices

Transmission


Prevention of VAP

General measures

Avoid invasive ventilation

Prevent colonisation

Prevent micro-aspiration

Prevent contamination of equipment

Minimize duration of invasive ventilation

ATS guidelines 2005

SHEA guidelines 2008


General Measures

Adequate staffing

Contact isolation for MDR bugs

Conduct active surveillance for VAP

VAP assessment risk

Audit compliance with VAP bundle

Monitor incidence of VAP

Hand-hygiene

Use non-invasive ventilation

Educate health-care personnel

ATS guidelines 2005

SHEA guidelines 2008


Hand washing

Before and after suctioning

Touching ventilator equipment

Contact with patients and patient environment

Contact with respiratory secretions

AACN Practice Alert for

VAP, 2004


Avoid Nasotracheal

intubation and NG tubes Oral care

Decontamination

Silver coated ETT

Secretion clearance

Closed vs. open suction

Saline instillation

Stress ulcer prophylaxis

SDD Preventing Colonisation


Oral Care and Decontamination

Mouth flora = Lung flora Mechanical cleaning

Decontamination –SDD vs SOD1,2

SDD = SOD2

Mortality benefit only in post-hoc analysis2

SDD- Concern about increasing resistance

Stronger data in cardiothoracic and trauma patients3

1-Chan EY et al. BMJ 2007

2-de Smet AM et al. N Engl J Med. 2009

3-O’Grady NP et al. JAMA 2012

Oral Decontamination with Chorhexidine recommended


Avoid Nasotracheal


Decontamination

Silver coated ETT

Secretion clearance


Saline instillation




Silver Coated ETT

Broad antimicrobial activity

Decreases bacterial adhesion

Decreases Biofilm formation

NASCENT trial – Kollef M et al. JAMA 2008

N=2003

Silver coated vs Uncoated

Primary outcome – VAP by BAL

4.8% vs. 7.5% VAP; P=0.04

NO mortality benefit


Avoid Nasotracheal


Decontamination

Silver coated ETT

Secretion clearance


Saline instillation




Secretion Management

Secretion clearance Open vs closed suction

Saline instillation

HME vs Heated humidifier

No role for prophylactic systemic antibiotics


HOB 30 - 45 degrees Cuff pressure > 20 cm of water

Subglottic suction

Avoid unplanned extubation and re-intubation

Avoid gastric overdistension

Preventing Aspiration


Preventing Aspiration

Supine position increases

risk and frequency of VAP

Drakulovic MB et al.

Lancet 1999

Drainage of subglottic secretions

decreases aspiration and VAP

Muscedere J et al.

Crit Care Med. 2011


Subglottic Suction

Logistics – Low pressure

Continuous vs intermittent suction

NO MORTALITY BENEFIT

? Long-term airway complications


ETT modifications

High volume low-pressure cuffs of ultrathin membrane

Minimize folds

Continuous monitoring of ETT Cuff pressure

Low volume low pressure cuffs

ETT with mucus shaver

Disrupts Biofilm


Prevent Contamination of Equipments

Use sterile water to rinse reusable respiratory

equipment

Remove condensate from ventilatory circuits

Keep the ventilatory circuit closed during condensate

removal

Change the ventilatory circuit only when visibly soiled

or malfunctioning

Store and disinfect respiratory therapy equipment

properly SHEA guidelines 2008


Minimize Duration of Invasive Ventilation

Spontaneous Awakening Trial

(SAT) Spontaneous Breathing Trial

(SBT)

Consider Extubation to NIV

?Tracheostomy


Interventions with unclear Value


Need and type

Monitoring gastric residual volume

Silver coated ETT

Promising but need more data

Saline instillation during suction

Newer ETTs – Rationale robust

Data limited

Take Home


Prevention of VAP - Bottomline

Adhere to good infection control practices

Avoid invasive ventilation when possible Minimize duration

Prevent colonisation Avoid nasal intubation/NGT

Oral care and decontamination – Chlorhexidine

Prevent micro-aspiration HOB elevation 30-45 degrees

Maintain ETT cuff pressure > 20 cm of water

Subglottic suction

Prevent contamination of equipments Minimize disconnections

Routine change of tubings NOT recommended

Take Home

VAP Bundle

Health & Medicine

Transcript of VAP Bundle