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Ventilator Associated Pneumonia

• Diagnosis of VAP was covered in the previous discussion

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Adult Ventilator Bundle

VAP prevention measures1. Handwashing 2. Patient positioning3. Oral care 4. Management of oropharyngeal and tracheal

secretions5. Daily “Sedation Vacation” and daily assessment of

readiness to extubate

General measures to improve care1. Peptic ulcer disease prophylaxis2. Deep vein thrombosis (DVT) prophylaxis

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Handwashing

• Strict handwashing before and after handling patient or patient’s equipment or supplies

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Patient Positioning

• Elevate the Head of the Bed 30-45o by flexing bed or reverse Trendelenberg

–Reduces chance of gastric reflux and aspiration of gastric contents

• Proper position in bed –keep joints in neutral, semi-flexed position–minimize abdominal compression

Drakulovic MB. Lancet.1999;354:1851-1858.

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Evidence for Elevating Head of Bed

• Elevate the Head of the Bed 30-45o by flexing bed or reverse Trendelenberg

– Randomized controlled trial: 86 adult intubated patients on mechanical ventilation assigned to semi-recumbent (45o) or supine position

Semi-recumbent: Supine:Suspected VAP: 8% 34%

(CI for difference 10-42%: p=0.003)

Confirmed VAP: 5% 23%(CI for difference 4-32%: p=0.018)Drakulovic MB. Lancet.1999;354:1851-1858.

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Patient Positioning

• Precautions– Head elevation in patient with

hypovolemia - possible significant hypotension

– Transporting patients on ventilatory support

– Spine precautions• May need to use Reverse Trendelenberg

Drakulovic MB. Lancet.1999;354:1851-1858.

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Do:

http://www.tccd.edu/neutral/DivisionDepartmentPage.asp?pagekey=191&menu=1

http://www.engin.umich.edu/alumni/engineer/03SS/protective/

http://www.rtmagazine.com/Articles.ASP?articleid=r0202F03

Positioning DO’s and DON’Ts

• Leave patient in supine position for prolonged periods

• Continue Q 2 hour turning schedule. 

• Maintain HOB > 30 degrees unless contraindicated.

Don’t:

• Forget to turn tube feedings off prior to placing patient in supine position

Rev: April 11, 2023 9Picture from Sage

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Oral care

• Colonization of oropharynx - – Normal flora includes both Gram-positive and

anaerobic bacteria.– When normal flora compromised, more

susceptible to colonization by microorganisms (e.g., Gram-negative bacilli), not normally found in oropharyngeal secretions.

– Migration to lower airway can lead to VAPPfeifer, LT; Orser, L.; Gefer, C.; McGuinness, R.; and Hannon, CV (2001). Preventing

ventilator-associated pneumonia. American Journal of Nursing, 101(8), 24AA-24GG.

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Oral care

• Colonization of Oropharynx - Dental Plaque– Colonization of dental plaque is either present on

admission or acquired in 40% of ICU patients.– Positive dental plaque culture significantly associated

with subsequent nosocomial infections – particularly aerobic pathogens.

– ICU patients at risk due to:• Difficulties performing adequate oral hygiene• Changes in properties of saliva• Reduction of anaerobic flora secondary to

antibiotics Fourrier, F.; Buvivier, B.; Boutigny, H.; Roussel-Delvallez, M, and Chopin, C. (1998)

Colonization of dental plaque: A source of nosocomial infections in intensive care unit patients. Critical Care Medicine 26:301-308.

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Oral care Protocol

• Assess oral cavity at least every shift• Brush teeth each shift with suction oral brush

and 1.5% hydrogen peroxide solution• Oral care every 2 hours with suction oral swabs

and 1.5% hydrogen peroxide solution• Hypopharyngeal/subglottic suctioning at least

q6h and as necessary• Apply mouth moisturizer as needed• Sage oral care kit can make compliance easier

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Management ofOral and Tracheal Secretions

• Proper care of oral and tracheal secretions is essential to minimize risk of aspiration

• To prevent aspiration of pooled secretions hypopharyngeal suctioning should be performed before – suctioning the ETT– repositioning the ETT– deflating the cuff– repositioning your patient

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Management ofOral and Tracheal Secretions (3a)

• Care of Equipment:– Maintain endotracheal tube cuff pressure at

desired level (usually ~20 cmH2O)

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Management ofOral and Tracheal Secretions (3b)

• Care of Equipment:– Maintain endotracheal tube cuff pressure at

desired level (usually ~20 cmH2O)– Use Ballard system or use 2 people to assist

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• Care of Equipment:– Maintain endotracheal tube cuff pressure at

desired level (usually ~20 cmH2O)– Use Ballard system or use 2 people to assist– Keep end of vent circuit, suction catheter or

Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper or towel.

Management ofOral and Tracheal Secretions (3c)

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• Care of Equipment:– Maintain endotracheal tube cuff pressure at

desired level (usually ~20 cmH2O)– Use Ballard system or use 2 people to assist– Keep end of vent circuit, suction catheter or

Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper or towel.

– Help keep the vent circuit free from accumulated water. Drain water away from the patient.

Management ofOral and Tracheal Secretions (3d)

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Management ofOral and Tracheal Secretions (3e)

• Care of Equipment:– Maintain endotracheal tube cuff pressure at desired

level (usually ~20 cmH2O)– Use Ballard system or use 2 people to assist– Keep end of vent circuit, suction catheter or Yankauer

tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper (from gloves or gauze).

– Help keep the vent circuit free from accumulated water. Draining water away from the patient.

– Change the suction canister and mouth care kit every 24 hours.

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Management of Oral and Tracheal Secretions (3f)

• Care of Equipment:– Maintain endotracheal tube cuff pressure at desired

level (usually ~20 cmH2O)– Use Ballard system or use 2 people to assist– Keep end of vent circuit, suction catheter or Yankauer

tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper (from gloves or gauze).

– Help keep the vent circuit free from accumulated water by draining water away from the patient.

– Change the suction canister and mouth care kit every 24 hours.

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Sedation Vacation

• Sedation vacation: discontinuation of sedation until patient is responsive (awake)

• 128 adults on mechanical ventilation randomized to sedation vacation group or control sedation group.

• Duration of ventilation:• sedation vacation group 4.9 days • control sedation group 7.3 days

(p=0.004)

Kress JP. N Engl J Med. 2000; 342: 1471-1477.

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PUD Prophylaxis

Why?

• Reduces acid production in stomach and the consequent risk of bleeding from gastric erosions and peptic ulcers

Identified Issues and Concerns

• Some studies have shown increasedincreased rates of ventilator associated pneumonia in patients on prophylactic treatments, e.g. sucralfate

Anecdotal Experience

• None significant

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PUD Prophylaxis

Surviving Sepsis Campaign Guidelines:Surviving Sepsis Campaign Guidelines:

“Stress ulcer prophylaxis should be given to all patients with severe sepsis. H2 receptor inhibitors are more efficacious than sucralfate and are the preferred agents. Proton pump inhibitors have not been assessed in a direct comparison with H2 receptor antagonists and, therefore, their relative efficacy is unknown. They do demonstrate equivalency in ability to increase gastric pH.”

Dellinger RP. Crit Care Med. 2004; 32: 858-873.

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DVT Prophylaxis

Systematic review of risks of venous Systematic review of risks of venous thromboembolism and its prevention:thromboembolism and its prevention:

“We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).”

Geerts WH. Chest. 2004; 126: 338S-400S.

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Deep vein thrombosis (DVT) prophylaxis

• Atlas Toolkit: keyword search DVT– Educational Materials – Risk Assessment and Order sets – Utilization Monitoring/Evaluation Strategies – HCA Facility Examples

• Healthstream Education Module– 1. Log into Healthstream – 2. Select the Find tab at the top of the screen– 3. Select the category Patient Safety– 4. Select the sub-category Medication Safety– 5. Click the course name: Venous Thromboembolism Risk

Screening and Prophylaxis

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Pediatric Ventilator Bundle Applies to patients of ages 1month- 13 years Same as Adult

VAP prevention measuresHandwashing Patient positioningOral Care Management of oral and tracheal secretionsDaily assessment of readiness to extubate

General measures to improve Critical CarePeptic ulcer disease prophylaxis

Different from AdultVAP prevention measures: Sedation Vacation

Deep vein thrombosis prophylaxis

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Neonatal Ventilator Bundle(0-28 days of age)

No clear data on proven measures to reduce VAP in neonates. Recommendations based on “common sense” best practice.

Same as AdultVAP prevention measures

Handwashing Management of oral and tracheal secretionsDaily assessment of readiness to extubate

Different from AdultVAP prevention measures

Patient positioningOral Care Daily “Sedation Vacation”

General measures to improve Critical CarePeptic ulcer disease prophylaxisDeep vein thrombosis (DVT) prophylaxis

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Summary:Consider these Components

for your Interventions and Checklists

• Handwashing– Before entering patient room– On exiting patient room

• Patient Position– Bed elevated 30-45 degrees– Patient properly positioned in bed

• Proper Oral Care every 2 hours

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Summary:Consider these Components

for your Interventions and Checklists

• Secretion Management– Check and maintain proper ETT cuff pressure– Use inline (Ballard) ETT suction– Suction hypopharyngeal secretions as

needed– Keep end-of-circuit suction catheter clean and

off patient bed

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Summary:Consider these Components

for your Interventions and Checklists

• Care of Ventilator Equipment– Circuit drained of accumulated condensed

water– Change suction canister and oral care kit daily

• Sedation Vacation– Discontinue sedation daily

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For a Successful Strategy to Reduce VAP

• Set an Aim: “Improve the health and well-being of ventilated patients by reducing the VAP rate.”

• Set goals: for example: “Reduce VAP rate by 50% by April 2006.” “Implement use of ventilator bundle with greater than 95% reliability.”

• Plan Well: Adopt a change methodology that• accelerates improvement such as The Model

for Improvement.• Benchmark: use national benchmark (e.g.,

National Healthcare Safety Network - NHSN)

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Selected references1. Drakulovic MB, Torres A, et al. Supine body position as a risk factor for noscomila

pneumonia in mechanically ventilated patients: a randomized trial. Lancet.1999;354:1851-1858

2. Pfeifer LT, Orser L, Gefer C, McGuinness R, Hannon CV. Preventing ventilator-associated pneumonia. American Journal of Nursing. 2001; 101(8), 24AA-24GG

3. Fourrier F, Buvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: A source of nosocomial infections in intensive care unit patients. Critical Care Medicine. 1998;26:301-308.

4. Kress JP, Pohlman AS, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000; 342: 1471-1477

5. Schweickert WD, Gehlbach BK, et al. Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Crit Care Med. 2004, 32(6):1272-1276.

6. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53 (RR-3):1-36.

7. IHI.org: A resource from the Institute for Healthcare Improvement. Getting Started Kit: Prevent Ventilator-Associated Pneumonia, Bibliography. Accessed April 2006. http://www.ihi.org/NR/rdonlyres/FD28C31B-5E93-448D-B5DC-9941ACB6C150/0/VAPBibliographyFINAL.pdf

8. American Thoracic Society Documents. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388-416.

9. Garcia R. Addressing JCAHO’s Patient Safety Goal #7: Focus on Key HICPAC Strategies for the Prevention of VAP. Brookdale University Medical Center, Brooklyn, NY:APIC Seminar; 2004