ความหมายความหมายAs Pneumonia in patient who have As Pneumonia in patient who have

been on mechanical ventilation been on mechanical ventilation for greater than 48 hrsfor greater than 48 hrs

Traditional signs and symptom Traditional signs and symptom of VAPof VAP

CXR showing new or progressive CXR showing new or progressive diffuse infiltrate which is not diffuse infiltrate which is not attributable to any other causeattributable to any other cause

Onset of purulent sputumOnset of purulent sputumFever greater than 38.5 CFever greater than 38.5 CLeukocytosisLeukocytosisPositive sputum or blood culturePositive sputum or blood culture

Risk factor for VAPRisk factor for VAPEndotracheal intubationEndotracheal intubationNasogastric tubeNasogastric tubeSupine positionSupine positionImpair mental statusImpair mental statusLength of mechanical ventilationLength of mechanical ventilationInvasive procedureInvasive procedureContinue or over sedativeContinue or over sedativeTreatment regimen-gastric alkalinizationTreatment regimen-gastric alkalinizationProlong ATB useProlong ATB useIneffective hand washingIneffective hand washingHospital environment and equipmentHospital environment and equipmentContact with other patients/hospital staffContact with other patients/hospital staff

The endotracheal tube increase the risk for The endotracheal tube increase the risk for VAP byVAP by

-preventing cough-preventing cough

-preventing upper airway filtering-preventing upper airway filtering

- preventing upper airway humidification- preventing upper airway humidification

-inhibit epiglosttic and upper airway reflexs-inhibit epiglosttic and upper airway reflexs

-inhibit cilliary transport by the epithelium-inhibit cilliary transport by the epithelium

-acting as a direct conduit into the lung for -acting as a direct conduit into the lung for airborne pathogenairborne pathogen

Risk factor for VAPRisk factor for VAP

Host or patient risk factor includeHost or patient risk factor include -age of 65 or more-age of 65 or more -underlying chronic disease -underlying chronic disease

((CODP,Asthma,EmphysemaCODP,Asthma,Emphysema)) -immunosuppression-immunosuppression -depress conciousness-depress conciousness -thoracic or abdominal surgery-thoracic or abdominal surgery -previous pneumonia-previous pneumonia

Risk factor for VAPRisk factor for VAP

Evidencd base practice Evidencd base practice guideline to reduce VAPguideline to reduce VAP

Staff educationStaff education Colonization reductionColonization reduction -Hand washing-Hand washing -Oral hygiene-Oral hygiene -Standard suction protocol-Standard suction protocol -Avoid saline lavage-Avoid saline lavage -Close suction system-Close suction system -Maintain close circuit-Maintain close circuit -Stress ulcer prophylaxis-Stress ulcer prophylaxis

Aspiration reduction/preventionAspiration reduction/prevention -Regular oral and subglottic suction-Regular oral and subglottic suction -Elevation of head -Elevation of head ≥ ≥ 30 degree30 degree -Maintain pressure cuff=20 mmHg-Maintain pressure cuff=20 mmHg -Post –pyloric feeding: continue -Post –pyloric feeding: continue

better than bolus feedingbetter than bolus feeding -Early extubation-Early extubation -Weaning protocol-Weaning protocol -Daily assessment of extubation -Daily assessment of extubation

readinessreadiness -Daily interruption of Sedation-Daily interruption of Sedation

VAP BundleVAP Bundle

Elevate the head of the bed at least 30 Elevate the head of the bed at least 30 degreedegree

Perform daily sedation interruption and Perform daily sedation interruption and daily assessment of readiness to extubatedaily assessment of readiness to extubate

Perform peptic ulcer disease prophylaxisPerform peptic ulcer disease prophylaxis Perform deep vein thrombosis prophylaxisPerform deep vein thrombosis prophylaxis Perform oral care with chlohexidinePerform oral care with chlohexidine

Post pyloric gastric enteral feedingPrevent

gastric distension and reflux

Reduce Aspiration

Reduced Oropharynge

al Colonization

Stress ulcer Prophylaxis

Use standard suction protocol

Sub-glottic suction

NO VAP

Adequate and regular oral hygiene protocolAvoid inadvertant extubation with reintubationHead up position

Maintain cuff properly,

extubate early

Avoid contaminate

d respiratory suctioning equipment

Avoid colonization and direct to

bacterial delivery into

the lung

Use standard suction protocol

Use close suction

Wash hand, use universal

precautionEnsure adequate disinfectio

n or sterilizatio

nKeep

circuit closedAvoid

saline lavage

“Idea best practice” for the reduction of colonization and aspiration is kep in VAP

prevention

(Based on the model proposed by the Center for Disease Control and Prevention )