ventilator associated pneumonia
TRANSCRIPT
VENTILATOR ASSOCIATED
PNEUMONIA
DR. C S ARAVIND (IST YEAR PG RESIDENT)
UNIT CHIEF – DR. ANBARASU M.D
SYNOPSIS
INTRODUCTION- WAT IS VAP?
FACTS AND FIGURES
WHAT ARE THE TYPES OF VAP ?
WHO ARE AT RISK ?
HOW DO THE ORGANISMS CAUSE VAP ?
IS IT BACTERIA / VIRUS / FUNGUS- IF SO , WHAT ARE THE POSSIBLE
ORGANISM ?
HOW TO DIAGNOSE VAP ?
HOW TO TREAT ?
IS THERE ANY PREVENTIVE STRATEGY ?
CONCLUSION
FACTS AND FIGURES
½ OF HAP
2ND MC CAUSE OF NOSOCOMIAL
INFECTION IN ICU
MC CAUSE OF NOSOCOMIAL INFECTION
IN VENTILATOR BOUND PATIENTS
MORALITY RATE IS HIGHER IN PATIENT
OF TRAUMA, BURNS, POST OP
60- 70 % MORTALITY IN PATIENTS OF
PSEUDOMONAS AND ACINOBACTOR
WHEN IS THE VAP MOST NOTORIOUS
FIRST 5 DAYS (RISK-3%)
MEAN DURATION - 3.3 day from the day
of ET intubation
5TH TO 10TH DAY (RISK 2%)
THEREAFTER 1%
WHEN IS THE VAP MOST NOTORIOUS
FIRST 5 DAYS (RISK-3%)
MEAN DURATION - 3.3 day from the day
of ET intubation
5TH TO 10TH DAY (RISK 2%)
THEREAFTER 1%
WHAT PERCENT OF PATIENTS WITH VAP DIE
CRUDE MORTALITY IS AROUND 60-70%
ATTRIBUTABLE MORTALITY – 33-50%
Latest lancet 2013 trial on 6284 pts from 24 studies - attributable mortality to 9-13 %
EARLY ONSET VS LATE ONSET
EARLY ONSET VAP
<4 D
LESS VIRULENT
BUGS
COMMUNITY AQUIRED
AB SENSITIVE
LATE ONSET VAP
>4 D
MORE VIRULENT
HOSPITAL ACQUIRED
MDR
RISK FACTORS
HOST RELATED Medical /surgical disease, Immunosuprssion, Malnutrition (Alb<2.2g/dl ), Advanced age, Supine position, Level of conciousness, Medication-NMB, sedation, steroids, Previous antibiotic use
DEVICE RELATED
MV with ETT or TRACHEOSTOMY TUBE , MV>48 hrs, Reintubations, NGT or Oro- gastric tube, Use of Humidifier
HEALTHCARE PERSONNEL RELATED
Improper hand washing, Failure to change gloves and use mask gown when ever required .
RISK FACTORS (CONT.)
HOST RELATED:
-UNDERLYING MEDICAL CONDITIONS-COPD, OBESITY, ARDS, GERD, BURN,
TRAUMA, MODS ETC--
-IMMUNOSUPPRESSION, MALNUTRITION(S.ALBUMIN<2.2G/DL)
-ADVANCED AGE
-PATIENTS’ BODY POSITION
-LEVEL OF CONSCIOUSNESS- IMPAIRED LOC, DELIRIUM, COMA.
-NUMBER OF INTUBATIONS-REINTUBATIONS
-MEDICATIONS (ANTIBIOTICS, SEDATION, NM BLOCKERS)
RISK FACTORS (CONT.)
Device related:
- MV with Endotracheal tube, trcheostomy
-Prolonged MV
-Number of intubations- reintubation
-Use of humidifier
-Nasogastric or orogastric tubes
Personnel related:
-Improper hand washing
-Failure to change gloves between contacts with pts
-Not wearing personal protective equipment when antibiotic resistant bacteria have been identified.
BJMP jun2009: vol.2,nub.2, 16-19. & Am.jour of Criti care nurse 2007; 27:32-39
HOW DO THE ORGANISM GET IN (CONT)
MICROASPIRATION
BIOFILM
TRICKLING AROUND THE CUFF
IMPAIRED MUCOCILIARY CLEARANCE
POSITIVE PRESSURE FROM VENTILATOR
WHAT ARE THE BUGS CAUSING VAP ?
EARLY ONSET
STREP. PNEUMONIAE
H. INFLEUNZA
MSSA
A/B SENSITIVE GRAM NEGATIVE RODS
LATE ONSET
PSEUDOMONAS
MRSA
ESBL RODS
ACINOBACTER
WHAT IS CPIS SCORE
CLINICAL PULMONARY INFECTION
SCORE – by johanson et al (213 pts)
Clinical, physiological, microbiological,
radiographic evidence to predict the presence
or absence of VAP
- Score of 6 or more- consistent with diagnosis
DRAWBACK- poor sensitivity n specificity
MICROBIOLOGICAL DIAGNOSIS
ATS/IDSA
QUALITATIVE
CLINICAL CRITERIA
QUANTITATIVE
ENDOTRACHEAL ASPIRATE
-BAL
-MINI BAL
- PROTEECTED SPECIMEN BRUSH
CLINICAL CRITERIA VS BACTERIOLOGICAL
CRITERIA- WHICH IS BETTER?????
- ATS/ IDSA GUIDELINES CLAIMS THAT 14- DAY MORTALITY WAS LESS AS COMPARED TO CLINICAL CRITERIA
- BUT RECENT CANADIAN CLINICAL TRIALS ON 740 SUSPECTED VAP AND
- COCHRANE METAANALYSIS OF 1367 PTS PROVED THERE IS NO DIFFERENCE
RADIOLOGICAL MIMICS OF PNEUMONIA IN
ICU PATIENTS
CHEMICAL PNEUMONITIS
ATLECTASIS
CHF
ARDS
PLEURAL EFFUSION
INTRA-ALVEOLAR HG
RADIOLIGICAL EVIDENCE
ANS. It is used to rule out vap. (what else do u
want ?)
Meta-analysis by KLOMPAS ET AL
VERY STRONG NEGATIVE
PREDICTIVE VALUE
HOW WILL U TREAT VAP?
BEFORE CHOOSING ANTIBIOTIC, keep in
mind on the following issues
RISK FACTORS OF THE PATIENT
WAS IT EARLY OR LATE ONSET
VIRULENCE OF ORGANISM
ANTIBIOTIC RESISTANCE
COST
WHAT IF CPIS SCORE DOESN’T IMPROVE
CPIS SCORE <6 FOR MORE THAN 3 DAYS
CONSIDER ALTERNATE DIAGNOSIS
OR CONSIDER FUNGAL OR VIRAL
INFECTIONS
HOW CAN WE PREVENT VAP?
Specific practices have been shown to decrease VAP
Strong evidence that a collaborative, multidisciplinary approach incorporating many interventions is paramount
Intensive education directed at nurses and respiratory care practitioners resulted in a 57% decrease in VAP
Crit Care Med (2002)
Conventional Infection control Aproach
•DESIGN OF ICU-
Adequate space, lighting, proper function of ventilatory system, facilities
for hand washing, Isolation room.
•STAFFING-
Education, Adequate number, quality, importance of personal cleanliness and
attention to asceptic procedures.
•PERIODICAL BACTERIAL MONITORING POLICY.
• SPECIFIC PROPHYLAXIS- Use Gloves, Gown, Mask.
Use of NIPPV
Minimize duration of MV, checking daily for readiness to weaning/extubation
(Text book of criti care med. 5 the Edit. MitchellP.FinkSHOEMAKER)
Daily Sedative Interruption and Daily
Assessment of Readiness to Extubate OVERSEDATION
Predisposes patients to: Thromboemboli
Pressure ulcers
Gastric regurgitation and aspiration
VAP
Sepsis
Consequences include: Difficulty in monitoring neuro status
Increased use of diagnostic procedures
Increase ventilator days
Prolonged ICU and hospital stay
STRESS ULCER PROPHYLAXISIncreases gastric ph and minimize bacterial colonization that reduces
the risk of VAP and GI bleeding
SUCRALFATE- Decreases the VAP rate but increases the risk of GI
bleeding by 4%.
H2 receptor blockers/PP inhibitors- Increase rate of VAP by
increasing gastric Ph leading to colonization of bacteria and decreases
the risk of GI bleeding.
H2 receptor blocker, PP inhibitor preferred over
sucralfate
Am J Respir Crit Care Med. 2005;171(4):388-
416.
Airway Management
Mechanical ventilation
Avoidance of Endotracheal intubation
Mask ventilation trials , NIPPV
Minimize duration on MV
Orotracheal intubation
Nasotracheal intubation slightly increase the risk for VAP
Avoid Reintubations- increases risk of VAP 6 fold
(Am resp.criti car med.1995;152(1):137-141)
Maintain at 25-30 cm H2O
SUBGLOTTAL SUCTIONINGShould be done using a 14 Fr sterile suction
catheter: Prior to ETT rotation
Prior to lying patient supine
Prior to Extubation
Continuous subglottic suctioning
ETT WITH DEDICATED LUMEN IS USED FOR CONTINUOUS OR INTERMITTED
SUBGLOTTIC SUCTIONING
Enteral Feedings
Early enternal feeding decrease bacterial colonization and rate of VAP
Bolus feeding should be avoided to minimize the risk of aspiration
Elevate HOB 30 - 45 degrees
Routinely verify tube placement
PATIENT TURNING-
Routine turning of patient for every 2 hrs increase pulmonary
drainage and decrease the risk of VAP.
Use of beds with continues lateral rotation can decrease the
incidence of pneumonia but do not decreases mortality or duration
of MV (critical care 2002;30(9):1983-1986)
NEW DEVELOPMENT• National healthcare safety(NHSN) and CDC proposed-
VAP terminology changed to VAC (ventilated associated conditions and complications) not necessarily limited VAP.
• VAP Surveillance definination algorithm.
Chest x ray is not included ,
And diagnosis is mainly depend on worsening of gas exchange, clinical features, isolation of microorganism in resp.secreation.
• ETT-- with continuous subglottic suction, ployurethrenecuff,Sponge cuff , Silver nitrate and antibiotic coated ETTs.
• VAP industrial complex- kinetic beds, inlines suction catheters
• VAP bunddle with 7 components – 5+ Replacing NGT to Orogastric tube and Hand washing by health care personnel.
IMPLEMENTATION and ENFORCEMENT of VAP bundle
VAP TO VAC
NOVEL SURVEILLANCE CRITERIA BY CDC
- to include other complication in ventilated patients
WHAT IS VENTILATOR ASSOCIATED CONDITION
- defined by 2 days of stable or decreasing ventilators setting
- followed by consistently higher ventilator settings
VAP TO VAC
NOW IF IT IS ASSOCIATED BY SIGNS OF INFLAMMATION AND
INFECTION ----
“IVAC”
(INFECTION RELATED VENTILATOR
ASSOCIATED CONDITION)
POSSIBLE OR PROBABLE VAP
Based on presence of PURULENT SECRETION AND
PATHOGENIC CULTURE DATA
IVACPURULENT
SECRETION
PATH.
CULTUREPOSSIBLE
VAP
IVACPURULENT
SECRETIONPATH.
CULTURE PROBABLE
VAP
or
CONCLUSION
- SIGNIFICANT MORTALITY IN ICU PATIENTS
- NO GOLD STANDARD CRITERIA
- EARLY DIAGNOSIS AND USE OF ANTIBIOTICS
- PREVENTION IS THE CORNERSTONE OF DECREASING THE
INCIDENCE OF VAP
- APPLYING VAP BUNDLE PROTOCOL
- APPROPRIATE ANTIBIOTIC SELECTION
TAKE HOME MESSAGE
- DIAGNOSE VAP WHEN THERE IS SUSPICION
- CLASSIFY AND START EMPIRICAL ANTIBIOTIC AT THE EARLIEST
- DON’T FORGET TO SEND CULTURE SAMPLES
- PREVENTION IS THE KEY
- APPLY VAP BUNDLE PROTOCOL
- XRAYS ARE NOT DIAGNOSTIC ACCORDING TO NEW PROTOCOL
- WEAN THE PATIENT EARLY
- STOP ANTIBIOTIC RESISTANCE
- FINALLY PLS DO WASH UR HANDS ***- SIMPLE BUT EFFECTIVE