Ventilator-Associated Pneumonia Prevention - Patientsafetycouncil ...

Ventilator-Associated
Pneumonia Prevention
December 15, 2010

Definitions ATS/IDSA 2005
• Hospital-acquired Pneumonia (HAP) –
pneumonia that occurs ≥ 48 hr after admission,
and did not appear to be incubating at time of
admission
• Ventilator-associated Pneumonia (VAP) – type
of HAP that develops more than 48 – 72 hr after
endotracheal intubation
Am J Respir Crit Care Med 2005; 171:388

Ventilator
Ventilator Circuit
Humidification device
Closed-suction device
Endotracheal tube
Oro-gastric tube

Risk Factors for VAP
• Age >70 years
• Chronic lung disease
• Depressed consciousness
• Aspiration
• Chest surgery
• Presence of an intracranial
pressure monitor or NG tube
• Hospitalization during fall / winter
• Underlying illness
• Mechanical ventilation for ARDS
• Transport from the ICU for
diagnostic or therapeutic
procedures
• Previous antibiotic exposure,
esp. 3 rd gen. cephalosporins
• Reintubation or prolonged
intubation
• H2 blocker or antacid therapy
• Frequent vent. circuit changes
• Paralytic agents
Kollef Crit Care Med 2004; 32:1396

Highest Rates of VAP
• Trauma ICU
• Burn ICU
• Neurosurgical ICU
• SICU
NNIS Am J Infect Control 2004; 32:470

Strategic Approaches to VAP
Prevention
• Minimize the need for intubation
• Minimize duration of mechanical ventilation
• Reduce bacterial colonization of
oropharynx, stomach, sinuses
• Prevent reflux, micro-aspiration around ETT
• Avoid use of contaminated equipment

Guidelines for VAP Prevention
• CDC 2003
• AARC 2003
• ATS/IDSA 2005
• AMMI/CTS (Canada) 2008
• CCCTG (Canada) 2008
• AHRQ 2008
• SHEA/IDSA 2008
• IHI

Specific Strategies to Reduce VAP Incidence:
Beyond the “Ventilator Bundle”
Recommended -
• Hand hygiene per CDC, WHO guidelines (IDSA, CDC, ATS)
• Educate clinicians about VAP risks and prevention (IDSA, CDC, AHRQ, ATS, AARC)
• Provide adequate staffing levels in ICU for vent patients (ATS)
• NIV instead of intubation whenever possible (IDSA, CDC, AHRQ, ATS)
• Daily sedation vacation or awakening (IHI, ATS)
• Daily assess ability to tolerate spontaneous breathing (IHI, IDSA, ATS)
• Keep head of bed elevated 30 - 45° (IHI, IDSA, CDC, AHRQ, ATS, CCCTG, AMMI)
• Continuous aspiration subglottic secretions (IDSA, CDC, AHRQ, ATS, CCCTG, AMMI)
• Antiseptic oral care (e.g. chlorhexidine 0.12%) (IDSA, CDC, AHRQ, CCCTG, AMMI)
• Avoid unplanned extubation and reintubation (IDSA, CDC, ATS)
• Maintain ETT cuff pressure at least 20 cmH 2 O (less than 30) (IDSA, ATS)
• Oral, not nasal intubation (IDSA, CDC, ATS, CCCTG, AMMI)
• Store, disinfect respiratory therapy equipment properly (IDSA, CDC)
• Change vent circuit only if soiled, or new patient (IDSA, CDC, CCCTG, AMMI, AARC)

Specific Strategies to Reduce VAP Incidence:
Beyond the “Ventilator Bundle”
Probably Helpful –
• Use PEEP in all ventilated patients
• Drain circuit excess condensation (IDSA, CDC, ATS, AARC)
• Avoid breaking the vent circuit as feasible (AARC)
• Avoid antacids unless high risk stress ulcer (IDSA, ATS)
• Early removal NGT, prefer OGT (ATS, CDC)
• Minimize patient transport from ICU
• Avoid gastric overdistention (IDSA)
• Vaccination – pneumococcal, influenza (CDC)
• Antimicrobial coated ETT (e.g. silver)
• Use of polyurethane-cuffed ETTs
• Limit antibiotic use

Specific Strategies to Reduce VAP Incidence:
Beyond the “Ventilator Bundle”
Unclear Role, Possibly Beneficial –
• HME vs active humidification systems (AMMI)
• Closed-system suction device vs open suctioning (CCCTG, AMMI, AARC)
• Selective use of continuous lateral rotation beds (CCCTG, AMMI)
• Early mobilization of the vent patient
• Small-volume saline installation vs no saline with routine suctioning
• Selective digestive decontamination
• Probiotics
• Prophylactic antibiotics at intubation, head injury

Getting From the Many Elements of VAP
Prevention to an Organized Approach
• Active surveillance program
• Educate clinicians involved
• Bundles
• Order sets
• Checklists
• Teams
• Audits of compliance
• ? Other techniques