VAP Long Version

Ventilator Associated Pneumonia: 

Ventilator Associated Pneumonia Kathy Picard, RN, MS, CCRN Beth Israel Deaconess Medical Center

Objectives : 

Objectives State the definition for ventilator associated pneumonia (VAP) Define who is at greatest risk for the development of VAP Describe effective strategies for reducing the incidence of VAP

What is VAP?: 

What is VAP? A nosocomial pneumonia associated with mechanical ventilation that develops within 48 hours or more of hospital admission and which was not developing at the time of admission Crit Care Nurs Q (2004)

Causative Organisms: 

Causative Organisms Early onset: Hemophilus influenza Streptococcus pneumoniae Staphylococcus aureus (methicillin sensitive) Escherichia coli Klebsiella Late onset: Pseudomonas aeruginosa Acinetobacter Staphylococcus aureus (methicillin resistant) Most strains responsible for early onset VAP are antibiotic sensitive. Those responsible for late onset VAP are usually multiple antibiotic resistant Am J Resp Crit Care (1995)

Pathogenesis: 

Pathogenesis Bacteria enter the lower respiratory tract via three pathways: Aspiration of organisms from the oropharynx and GI tract (most common cause) Direct inoculation Inhalation of bacteria

Who is at Greatest Risk?: 

Who is at Greatest Risk? Reintubation Supine position Impaired cough/depressed LOC Oropharyngeal colonization Presence of NG/OG tubes and enteral feeding Cross contamination by staff

Why Do We Care?: 

Why Do We Care? Hospital acquired pneumonia (HAP) is the second most common hospital infection VAP is the most common intensive care unit (ICU) infection 90% of all nosocomial infections occurring in ventilated patients are pneumonias

Why Do We Care?: 

Why Do We Care? VAP occurs in 10 - 65% of all ventilated patients Crit Care Clin (2002) The incidence of VAP is highest in the following groups: Trauma Burns Neurosurgical population Surgery Mortality rate is 24 – 50% Am J Respir Crit Care (2002) Mortality rate in VAP caused by Pseudomonas or Acinetobacter is as high as 76% Crit Care Med (2004)

$$$$: 

$$$$ VAP increases: Medical costs Ventilator days ICU and hospital LOS Estimated direct cost of excess hospital stay due to VAP is $40,000 per patient Chest (2002)

What is Our Incidence?: 

What is Our Incidence? What are our rates? How do we collect data? What criteria do we use?

How Do We Diagnose? 2-1-2: 

How Do We Diagnose? 2-1-2 Radiographic evidence x 2 consecutive days New, progressive or persistent infiltrate Consolidation, opacity, or cavitation At least 1 of the following: Fever (> 38 degrees C) with no other recognized cause Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000 WBC/mm3) At least 2 of the following: New onset of purulent sputum or change in character of secretions New onset or worsening cough, dyspnea, or tachypnea Rales or bronchial breath sounds Worsening gas exchange ( ↓ sats, P:F ratio < 240, ↑ O 2 req.)

What Can We Do About It?: 

What Can We Do About It? 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)

Prevention: 

Prevention Handwashing Oral care HOB ↑ 30 degrees (in the absence of medical contraindications) Patient turning and rotational therapy GI/DVT prophylaxis Daily interruption of sedative infusions Airway/ventilator management

Handwashing: 

Handwashing Handwashing is the single most important (and easiest!!!) method for reducing the transmission of pathogens. Use of waterless antiseptic preparations is also acceptable and may increase compliance.

Handwashing: 

Handwashing Remember to wash your hands Before and after patient contact Beginning and end of work day Before and after using gloves After touching contaminated surfaces Go Ahead and Ask!

Publicity : 

Health care worker button Room poster Publicity

Oral Care: 

Oral Care Dental plaque contains multiple pathogens (may include s. aureus and p. aeruginosa) After 48 hours, normal oral flora of critically ill pts changes to more virulent gram (-) organisms Aspiration of oral secretions around the cuff and ETT occurs in all vented patients VAP rates are reduced when oral care measures are included in a comprehensive prevention program

Oral Care: 

Oral Care Why no consistency? Lack of placing high priority on oral care This is especially true in the first hours – days of critical illness, when colonization of pathogens occurs Anxiety regarding loss of ETT Inadequate or inconsistent supplies Optimal technique and frequency has not been determined

Oral Care : 

Oral Care Research has shown that oral care for intubated patients is usually provided using foam swabs (91% of the time) and the focus is on patient comfort Foam swabs do not reduce dental plaque Am J Crit Care (2002) Oral decontamination – application of an antibiotic solution several times q day Not a CDC recommendation – may cause overgrowth of resistant bacteria

Oral Care: 

Oral Care Chlorhexidine oral rinse Antiseptic agent active against both gram (-) and (+) organisms Allergies are rare May discolor teeth When used prior to intubation has been shown to ↓ respiratory tract infections CDC does not recommend routine use

Oral Care: 

Oral Care Best Practice?? Daily assessment to determine oral health Brush q 12 hours to prevent plaque Oral cleansing q 2-4 hours to promote healing and maintain integrity of oral tissues Use of an alcohol-free, antiseptic oral rinse to prevent or reduce bacterial load of oropharynx Routine suctioning of mouth to manage oral secretions and minimize risk of aspiration Use of a moisturizer Am J Crit Care (2005)

HOB 30 - 45 Degrees: 

HOB 30 - 45 Degrees The supine position is an independent risk factor for death in all ICU patients Major benefit is prevention of aspiration CDC recommends HOB 30-45 ° unless contraindicated

Stryker beds display Fowler angle at foot of bed Keep patient at 30-45 degrees while intubated : 

Stryker beds display Fowler angle at foot of bed Keep patient at 30-45 degrees while intubated

HOB 30 - 45 Degrees: 

HOB 30 - 45 Degrees What are we doing? Fowler angle displayed Frame to frame signage Signs at HOB Documentation reminders Audits

HOB Elevation > 30 Degrees on all Mechanically Ventilated Patients : 

HOB Elevation > 30 Degrees on all Mechanically Ventilated Patients Contraindications Hypotension MAP <70 Tachycardia >150 CI <2.0 Central line procedure Posterior circulation strokes Cervical spine instability use reverse trendelenburg Some femoral lines ie: IABP no higher than 30 degrees use reverse trendelenburg Increased ICP, No higher than 30 degrees avoid hip flexion Proning

Reverse Trendelenburg : 

Reverse Trendelenburg In full reverse Trendelenburg the foot of bed will read -12 degrees Angle of head elevation is approximately 20 degrees (not 30 degrees) when at -12 Evaluate the individual clinical situation to assess if the patient can tolerate the addition of a small amount of Fowlers angle which may flex the hip

Patient Turning and Rotational Therapy: 

Patient Turning and Rotational Therapy Kinetic therapy (KT) – continuous turning through bedframe rotation at least 62 ° on each side Continuous lateral rotation therapy (CLRT) - similar to KT, but degree of turn < 40 ° Advantages include more even distribution of transpulmonary pressures and tidal volume and increased mobilization of secretions.

Patient Turning…: 

Patient Turning… Review of 11 randomized, controlled studies (1073 patients) All rotational therapies included 48% reduction in risk of developing pneumonia Shorter ICU stay (decrease of 2.1 days) No difference in mortality Kinetic therapy more effective than CLRT Crit Care Med (2002) CDC does not have a current recommendation for routine use of kinetic therapy for prevention of pneumonia CDC (2003)

Patient Turning…: 

Patient Turning… Rotational therapy is beneficial for patients at high risk for atelectasis and pneumonia, including patients who are: sedated and ventilated > 3 – 4 days difficult to turn have head injury in traction When rotational beds are not used, turn at least q 2 hours

Oversedation: 

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

Nurse-Driven Sedation Weaning Protocols: 

Nurse-Driven Sedation Weaning Protocols Multiple research studies have shown that nurse driven sedation protocols improve patient outcomes Routine assessments and response to therapy should be incorporated in the protocol A sedation goal should be defined for each individual patient Without a goal, adequate levels of sedation will not be achieved

Continuous Infusions: Daily Wake Up: 

Continuous Infusions: Daily Wake Up All infusions should be at the lowest rate to achieve effect IV bolus therapy should be used to supplement infusion when necessary Every patient must be awakened daily unless contraindicated!

Daily Wake Up: 

Daily Wake Up Wean infusion to off in increments of 10-25% daily in order to perform a clinical assessment Rebolus and restart infusion if the patient becomes symptomatic. Your new continuous IV dose should be lower than what you began with Goal is to decrease sedation

Endotracheal Intubation: 

Endotracheal Intubation Contributes to the development of VAP: Causes mucosal injury, producing decreased mucociliary clearance Decreases effectiveness of cough Increases binding sites for bacteria Increases mucus secretion Provides a reservoir for bacteria Reintubation is a significant risk factor for VAP Crit Care Nurs Clin N Am (2004)

Airway Management: 

Airway Management Mechanical ventilation Avoidance Mask ventilation trials Orotracheal intubation Nasotracheal intubation may slightly increase the risk for VAP Ventilator circuitry changes Change only when soiled or malfunctioning Cuff management Maintain at 25-30 cm H 2 O

Airway Management: 

Airway Management Suctioning In-line suctioning using closed technique Normal saline Should not be routinely used to suction pts Causes desaturation Does not increase removal of secretions Can potentially dislodge bacteria Should be used to rinse the suction catheter after suctioning

Suctioning: 

Suctioning Oral suction devices (Yankauer) Policies for use and storage not written Harbor potentially pathogenic bacteria within 24 hours 71% of nurses store the device in its packaging (STAMP) Best practice??? Change q day Rinse with sterile water or NS Allow to air dry

Subglottal Suctioning: 

Subglottal Suctioning Should 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 to continuously or intermittently suction above the cuff may reduce the risk of VAP

Ventilator Circuit: 

Ventilator Circuit Vent circuit should not be routinely opened once ventilation is initiated Disconnection of ventilation tubing can lead to loss of PEEP and alveolar de-recruitment If circuit must be disconnected, clamp ETT with padded Kelly forceps to avoid PEEP loss In the event of ineffective ventilation, manual ventilation with AMBU bag may be used Expiratory condensation should be removed via the trap in the tubing Inspiratory condensation – if clean, may be drained back into the water reservoir

Ventilator Circuits Humidification Systems: 

Ventilator Circuits Humidification Systems Heat and Humidity Exchangers (HMEs) should not be routinely changed unless: Visibly soiled > 5 cm H 2 O auto-PEEP Convert to Heated Humidification (HH) if: Ventilated longer than 96 hours Thick/bloody secretions Resp. Acidosis Air leak from chest tube or around airway VT < 300 cc or > 750 cc

Gastric Alkalinization: 

Gastric Alkalinization H 2 blockers and antacids ↓ incidence of stress ulcers Colonization of the GI tract occurs as the pH rises These organisms ascend the GI tract and gain access to the trachea Sucralfate protects the lining of the stomach without ↑ pH CDC does not make a recommendation for the choice of H 2 blockers vs Carafate for the prevention of stress ulcers CDC (2003)

Enteral Feedings: 

Enteral Feedings Elevate HOB 30 - 45 degrees Routinely verify tube placement No CDC recommendations for: Preferential use of small bore tubes Continuous versus intermittent feeding Post pyloric placement CDC (2003)

Tips To Get Started: 

Tips To Get Started Develop processes that enhance efficiency and communication to help move evidence into practice Implement interventional hygiene Measure the results using standard definitions to capture and compile data Compare against the benchmarks Celebrate and reward your successes and growth as a team Check on a quarterly basis continued compliance with the new program

Seize The Opportunity: 

Seize The Opportunity Be The Change Agent

References: 

References American Thoracic Society. HAP in adults: diagnosis, assessment of severity, initial antimicrobial therapy and preventive strategies. Am J Resp Crit Care 1995;153: 1711-1725. Chastre J. et al. Ventilator Assosciated Pneumonia. Am J Respir Crit Care Med 2002; 10:364-368. Cutler C> et al. Improving oral care in patients receiving mechanical ventilation. Am J Crit Care 2005; 14(5): 389-394. Grap M. et al. Preventing VAP: evidence-based care 2004; 16: 349-458. Keenan S. et al. VAP: prevention, diagnosis, and therapy. Crit Care Clin 2002; 18(1): 107-125. Kollef M. Prevention of hospital associated and ventilator associated pneumonia. Crit Care Med 2002; 32: 1396-1405. Marik, P. et al. One good turn deserves another. Crit Care Med 2002; 30(9): 2146-2148. Munro C. et al. Oral health status: effect on VAP. Am J Crit Care 2002; 11(3): 280. Myrianthefs P. et al. Nosocomial pneumonia. Crit Care Nurse Quarterly 2004; 27(3): 241-257. Rello J. et al. Epidemiology and outcomes of ventilator associated pneumonia in a large US database. Chest 2002; 122: 2115-2121. Zack JE. et al. Effect of an education program aimed at reducing the occurrence of VAP. Crit Care Med 2002; 30(11): 2407-2412.