Ventilator associated pneumonia

Ventilator-Associated Pneumonia Josh Solomon, MD VAP • difficult to diagnose • expensive to treat • increased patient mortality and hospital stay • MANY CASES PREVENTABLE Definition • hospital acquired pneumonia after 48h on ventilator (endotracheal or tracheotomy) • EARLY ONSET - 96 hours on ventilator Incidence • Difficult to determine due to definition • Intubated patients have 21 times the risk to develop pneumonia • Estimate that 28% of ventilated patients will get VAP – out of every 4! Outcome • Mortality increased but % unknown (15-50%) • Increased ICU stay by an average of days Heyland AJRCCM 1999, 159, 1249-56 • 28% patients x days in ICU =$$$$ Pathogenesis Gram(–) and staph colonize oropharynx *Colonized tubing/humidifier/neb *From the sinuses and teeth *Biofilm on ETT Secretions pool above ET cuff Mucociliary clearance impaired No cough reflex Edema/hemorrhage good environment Isakov Seminars RCCM 1999, 27, 5-17 Pathogenesis Gram(–) and staph colonize oropharynx *Colonized tubing/humidifier/neb *From the sinuses and teeth *Biofilm on ETT Secretions pool above ET cuff Mucociliary clearance impaired No cough reflex Edema/hemorrhage good environment Isakov Seminars RCCM 1999, 27, 5-17 Pathogenesis Gram(–) and staph colonize oropharynx *Colonized tubing/humidifier/neb *From the sinuses and teeth *Biofilm on ETT Secretions pool above ET cuff Mucociliary clearance impaired No cough reflex Edema/hemorrhage good environment Isakov Seminars RCCM 1999, 27, 5-17 Aspiration Prevention Use of NIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports •3% per day for 1st week, 2% per day for 2nd week •Shorter ventilation equals less VAP •protocols for weaning and minimizing sedation Aspiration Prevention Use of NIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •supine position causes aspiration (especially during tube feeds) •3 fold reduction in VAP when patients kept at 45° •need trained nursing staff Aspiration Prevention Use of NIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •reintubation carries significant increase in VAP risk •VAP in 30% patients with unexpected extubation vs 13.8% in controls de Lassence Anesthesiology 2002, 97, 148-56 Aspiration Prevention Use of NIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •maintain at > 20 cm H2O to prevent drainage Aspiration Prevention Use of NIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation check residuals minimize narcotics use prokinetic agents like metoclopramide small bore feeding tubes post pyloric reduces VAP ?delay feeds in high risk patients Aspiration Prevention Use of NIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •circuit changes DO NOT prevent VAP •condensate in tubing leads to VAP if it goes down the ETT tube •drain condensate •change circuit only for emesis, blood or purulence Aspiration Prevention Use of NIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •Allows patients cough reflex to assist in secretion clearance Other Prevention Steps • Minimize blood transfusions – associated with increased risk VAP Shorr, Crit Care Med 2004, 32, 666-674 • Tight control of blood glucose – reduces mortality, sepsis, ICU stay – no data in VAP but suspected effect van den Berghe NEJM 2001, 345, 1359-67 Concusions • MANY CASES OF VAP ARE PREVENTABLE! • Simple techniques – hand washing, elevated head of bed, attention to tube feed residuals, bld glc control • Minimizing interventions – transfusions, abx courses, tubing changes, duration of ventilation Implementation Strict monitoring of monthly cases of VAP Staff education (doctors, nurses, technicians) Protocols for all patients on ventilators that address patient and ventilator management Documentation of success in decreasing incidence of VAP Conclusion • • • • VAP is pneumonia after 48 hours on a vent It is difficult to diagnose and treat It prolongs stay and increases mortality It results from aspiration of contaminated secretions • Simple measures decrease the incidence • Appropriate treatment improves outcome Future • Vaccines – investigating vaccine against S.aureus • Nebulized Antibiotics – shown to reduce colonization with gram negatives Colonization Prevention Hand Washing Appropriate Nurse:Pt Ratio Avoid Unnecessary Antibiotics Avoid Unnecessary Ulcer Proph Sucralafate for Ulcer Prophylaxis Oral Intubation Short Course Antibiotics Digestive Decontam/Oral Chlorhex Staff Education •higher acidity favors microbial growth •H2 blockers and antacids associated with increased VAP •unclear what to given benefits of stress ulcer proph •sucralafate better for VAP prevention but conflicting studies Aspiration Prevention Use of NIPPV when possible Shorten Duration of Ventilation Subglottic Suctioning Semi-erect Position Prevent Self-Extubation Maintain adequate cuff pressure Avoid gastric overdistention Avoid Vent Circuit changes Drain Vent Condensate Avoid pt Transports Minimize Sedation •specialized ET tubes that allow suctioning of secretions •cost 25% more than normal tubes [...]... – Staphylococcus, Strep pneumonia, Haemophilus influenza • LATE – (>96 hours, resistant organisms) – Pseudomonas, MRSA, Klebsiella, Acinetobacter Treatment • start early and before microbiological data is back – delay is associated with increased mortality (69.7 vs 28.4 with 16h delay) Iregui Chest 2002, 122, 262-8 • start with appropriate regimen – inappropriate initial abx associated with increased