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Ventilator Associated Pneumonia (VAP)

Ventilator Associated Pneumonia (VAP). Issued 01/2008. Author: Marianne Chulay, RN, DNSc, FAAN Consultant, Clinical Research and Critical Care Nursing Reviewers: Suzi Burns, Mary Jo Grap, Judy Verger, and Lori Jackson. Prevention of Ventilator Associated Pneumonia (VAP).

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Ventilator Associated Pneumonia (VAP)

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  1. Ventilator Associated Pneumonia (VAP) Issued 01/2008 Author: Marianne Chulay, RN, DNSc, FAAN Consultant, Clinical Research and Critical Care Nursing Reviewers: Suzi Burns, Mary Jo Grap, Judy Verger, and Lori Jackson Ventilator Associated Pneumonia (VAP) Practice Alert

  2. Prevention of Ventilator Associated Pneumonia (VAP) Ventilator Associated Pneumonia (VAP) Practice Alert

  3. Lecture Content • Epidemiology of VAP • Prevention strategies • HOB elevation • Ventilator equipment changes • Continuous removal of subglottic secretions • Handwashing Ventilator Associated Pneumonia (VAP) Practice Alert

  4. Epidemiology of Ventilator Associated Pneumonia (VAP) Ventilator Associated Pneumonia (VAP) Practice Alert

  5. Nosocomial Pneumonias • Account for 15% of all hospital associated infections • Account for 27% of all MICU acquired infections • Primary risk factor is mechanical ventilation (risk 6 to 21 times the rate for nonventilated patients) CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 Craven, Chest 2000; 117:186S-187S. Ventilator Associated Pneumonia (VAP) Practice Alert

  6. Susceptibility to Nosocomial Pneumonias Increased Nosocomial Pneumonias Altered Host Defenses Tracheal Colonization Intubation Ventilator Associated Pneumonia (VAP) Practice Alert

  7. Primary Route of Bacterial Entry into Lower Respiratory Tract • Micro or macro aspiration of oropharyngeal pathogens • Leakage of secretions containing bacteria around the ET cuff Ventilator Associated Pneumonia (VAP) Practice Alert

  8. VAP Etiology • Most are bacterial pathogens, with Gram negative bacilli common • Pseudomonas aeruginosa • Proteus spp • Acinetobacter spp • Staphlococcus aureus • Early VAP associated with non-multi-antibiotic- resistant organisms • Late VAP associated with antibiotic-resistant organism Ventilator Associated Pneumonia (VAP) Practice Alert

  9. Significance of Nosocomial Pneumonias • Mortality ranges from 20 to 41%, depending on infecting organism, antecedent antimicrobial therapy, and underlying disease(s) • Leading cause of mortality from nosocomial infections in hospitals CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 Heyland et al, Am J Respir Crit Care Med 1999; 159:1249 Bercault et al, Crit Care Med 2001; 29:2303 Ventilator Associated Pneumonia (VAP) Practice Alert

  10. Significance of Nosocomial Pneumonias • Increases ventilatory support requirements and ICU stay by 4.3 days • Increases hospital LOS by 4 to 9 days • Increases cost - > $11,000 per episode • Estimates of VAP cost / year for nation > $ 1.2 billion Heyland et al, Am J Respir Crit Care Med 1999;159:1249 Craven, Chest 2000;117:186-187S Rello et al, Chest 2002;122:2115 Safdar et al, Critical Care Medicine 2005;33:2184-93 Ventilator Associated Pneumonia (VAP) Practice Alert

  11. VAP Prevention Ventilator Associated Pneumonia (VAP) Practice Alert

  12. Continuous Removal of Subglottic Secretions Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation. CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005 Ventilator Associated Pneumonia (VAP) Practice Alert

  13. Continuous Removal of Subglottic Secretions • Mahul et al. Int Care Med 1992;18:20-25 • Valles et al. Ann Int Med 1995;122:179-186 • Kollef et al. Chest 1999;116:1339-1346 • Smulders et al. Chest 2002;121:858-862 • Dezfulian et al. Am J Med 2005;118:11-18 (meta-analysis) Ventilator Associated Pneumonia (VAP) Practice Alert

  14. VAP Reduction with ET Suction Above the Cuff Smulders et al. Chest;121:858-862 Ventilator Associated Pneumonia (VAP) Practice Alert

  15. HOB at 30-45º CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005 HOB Elevation Ventilator Associated Pneumonia (VAP) Practice Alert

  16. HOB at 30-45º Torres et al, Annals of Int Med 1992;116:540-543 Ibanez et al. JPEN 1992;16:419-422 Orozco-Levi et al. Am J Respir Crit Care Med 1995;152:1387-1390 Drakulovic et al. Lancet 1999;354:1851-1858 Davis et al. Crit Care 2001;5:81-87 Grap et al. Am J of Crit Care 2005 14:325-332 HOB Elevation Ventilator Associated Pneumonia (VAP) Practice Alert

  17. Dravulovic et al. Lancet 1999;354:1851-1858 HOB Elevation Leads to Significant Deduction in VAP Ventilator Associated Pneumonia (VAP) Practice Alert

  18. Is HOB Elevation Done? Despite effectiveness of HOB elevation, compliance is poor. • Grap et al. Am J Crit Care 1999;8:475-480 • Grap et al. Am J Crit Care 2005;14:325-332 Degrees of HOB Elevation Ventilator Associated Pneumonia (VAP) Practice Alert

  19. Frequency of Equipment Changes No Routine Changes Ventilator Tubing Between Patients Not Enough Data Inner Cannulas of Trachs Ambu Bags CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 Ventilator Associated Pneumonia (VAP) Practice Alert

  20. Handwashing What role does handwashing play in nosocomial pneumonias? Albert, NEJM 1981; Preston, AJM 1981; CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 Ventilator Associated Pneumonia (VAP) Practice Alert

  21. VAP Prevention Wash hands or use an alcohol-based waterless antiseptic agent before and after suctioning, touching ventilator equipment, and/or coming into contact with respiratory secretions. CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 AACN Practice Alert for VAP, 2007 Ventilator Associated Pneumonia (VAP) Practice Alert

  22. VAP Protection • Use a continuous subglottic suction ET tube for intubations expected to be > 24 hours • Keep the HOB elevated to at least 30 degrees unless medically contraindicated CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 AACN Practice Alert for VAP, 2007 Ventilator Associated Pneumonia (VAP) Practice Alert

  23. No Data to Support These Strategies • Use of small bore versus large bore gastric tubes • Continuous versus bolus feeding • Gastric versus small intestine tubes • Closed versus open suctioning methods • Kinetic beds CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 Ventilator Associated Pneumonia (VAP) Practice Alert

  24. Oral Care • Role of oral care, colonization of the oropharynx, and VAP unclear – dental plaque may be involved as a reservoir • Limited research on impact of rigorous oral care to alter VAP rates • Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 Grap M. Amer J of Critical Care 2003;12:113-119. Ventilator Associated Pneumonia (VAP) Practice Alert

  25. Need Further Assistance? For more information or further assistance, please contact a clinical practice specialist with the AACN Practice Resource Network. Email: practice@aacn.org Phone: (800) 394-5995, x217 Ventilator Associated Pneumonia (VAP) Practice Alert

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