Transcript Ventilator Associated pneumonia

Linda R Greene
Rochester General Hospital
Rochester, NY
[email protected]
Nothing to Declare
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Describe the epidemiology and pathogenesis of
ventilator associated pneumonia
Compare and contrast the current definition of
ventilator associated pneumonia with the
proposed revised definition
List at least 3 evidence based practices to prevent
ventilator associated pneumonia.
Discuss future trends and strategies in prevention
ventilator associated pneumonia
Early Work On VAP Prevention
GAO Report on HAIs in hospitals April 2008
 Leadership
needed from HHS to
prioritize preventive practices
 Improve central coordination
 Identify priorities
 Increase reliable estimates of
HAIs
The literature supporting high-profile measures
to reduce ventilator-associated pneumonia
(VAP):
Many studies show significant reductions in VAP
rates but almost none show any impact on
patients' duration of mechanical ventilation,
length of stay in the intensive care unit and
hospital, or mortalitY
Klompas M, Platt R. Ventilator-associated pneumonia – the wrong quality
measure for benchmarking. Ann Intern Med. 2007;147:803-805
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Lack of specificity in the VAP definition
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Array of events from critical to benign
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Benign events may actually capture colonization
Pleural effusion or
atelectasis however,
pneumonia cannot be
rule out
Opacities in lower lobe may be
atalectasis, pneumonia or
emphysematous changes
Bibasilar changes
which may
represent
atelectasis ,
pneumonia or
edema
Differences in NYS among IPs collecting data
Must be vetted with
Physicians
Start with sputum specimen
Daily rounding
Daily review of CXR
Determination by ICU
Staff
Prevention Strategies
Bundles
Burden on IP – less time for surveillance
 Pressure to have a VAP outcome
measure for public reporting
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Stakeholder meetings
VAP working group
Objective Definition
Clinically relevant
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Representation from all major stakeholder groups:
CDC
IDSA
CSTE
APIC
SHEA
ATS
Critical Care Society
VAP
sVAP
Valori
VAC
Mechanical ventilation is primary risk factor:
The endotrachel tube acts as a conduit from the upper respiratory
tract to the lower respiratory tract
Secretions collect on and around the cuff causing leakage of fluids into
the lower respiratory tract
Sedation inhibits the natural ability to clear secretions
Patients undergoing mechanical ventilation are frequently fed via
nasogastric tubes contributing to aspiration
Critically ill patients are often maintained in a supine position
Activity is limited
Tube related issues primarily
include aspiration of
contaminated
secretions from
above the cuff
Cuffs: current recommendation is
that cuff pressure should be
maintained at no less than 20 cm H2O
Some controversy that cuff design
may be more important
Than cuff pressure
Location
Defense Mechanism
Upper Airway
Nasopharynx
Nasal Hairs
Turbinates
Upper airway anatomy
Mucociliary apparatus
IgA secretions
Oropharynx
Saliva
Sloughing of epithelial cells
Bacterial Interference
Complement Production
Location
Defense Mechanism
Conducting Airways
Trachea, Brochii
Coughing, epiglottic reflexes
Airway branching
Mucocillary apparatus
Immunoglobulin production
Airway Surface Liquid
Lower Airways
Terminal airways
Alveoli
Alveolar lining fluid
Cytokines
Alveolar Macrophages
Polymorohonuclear Leukocytes
Cell- mediated Immunity
What about Prevention Efforts?
If unable to bend at the hip use Reverse Trendelenberg
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Head of bed elevation: controversial, hard to
maintain, but still recommended by most
authors.
Must be at least 30 degrees, and must measure,
not estimate
Reduced VAP incidence in some studies but
not others, does not hold up in metanalysis
Probably good for reducing length of ventilation
and ICU stay though
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Not part of original bundle
Chlorohexidine recommended in increasing
number of studies:
Oral Decontamination with Chlorhexidine Reduces the
Incidence of Ventilator-associated Pneumonia
Koehman et alAmerican Journal of Respiratory and
Critical Care Medicine Vol 173. pp. 1348-1355, (2006)
© 2006 American Thoracic Society
Oral decontamination for prevention of
pneumonia in mechanically ventilated adults:
systematic review and meta-analysis.
Chan et. Al BMJ 2007, 334:889.
Randomized Controlled Trial and Meta-analysis of Oral
Decontamination with 2% Chlorhexidine Solution for the
Prevention of Ventilator-Associated Pneumonia
Tantipong et L infection control and hospital epidemiology
february 2008, vol. 29, no. 2
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Effect of oral hygiene with o.12% chlorohexidine
gluconate on the Incidence of Nosocomial
Pneumonia in children undergoing cardiac surgery
Jacomo et al. ICHE et al. June 2011 vol 3 no 6
The Basic Bundle
HOB Monitoring
Sedation Vacation
PUD Prophylaxis
DVT prophylaxis
Enhanced Bundle
Mouth Care- consider chlorohexidine
Education and Training Program
New Generation ET tubes
Oral gastric tubes
Ambulation
Antimicrobial coating of ET tubes e.g., silver coating,
silver-sulfadiazene, chlorhexidine- recommended by
some
Rationale
BIOFILM -
Once microorganisms have made contact and
formed an attachment with a living host or
non-living surface or object, development of a
biofilm can take place. Bacteria living in a
biofilm can have significantly different
properties from free-floating bacteria, as the
dense extracellular matrix of biofilm and the
outer layer of cells may protect the bacteria
from antibiotics and normal host defense
mechanisms of the white blood cells, such as
phagocytosis
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Avoid Intubation if possible -Non-invasive
ventilation: avoiding intubation will avoid VAP,
so use NIV whenever possible
Weaning: the longer you are on the ventilator,
the more likely you are to get VAP. Weaning
protocols have been conclusively shown to
improve the rate of weaning from the ventilator
Implementation Science – How do we get
evidence to the bedside ?
We have to take a closer look at processes
http://www.cdc.gov/hicpac/pdf/Nov12_13_HICPAC_web_slides.pdf
Engage
Evaluate
Educate
Execute
Staff Education & Training!
staff feedback!
Sharing Data
Months
without
a VAP
10 mo
1 mo
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Look at other outcomes
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Mortality, readmission rates , length of stay
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Use data to continually evaluate effectiveness of
interventions
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Communicate consistently: disseminate results
of process and outcome measures.
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Connect to purpose: help staff understand how
simple actions connect to outcomes.
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Review Deviations: review all cases to identify
opportunities and system issues.
http://youtu.be/Pk7yqlTMvp8