PREVENTION OF VAP: BUNDLE CARE

MRS. ANGELINE JEYA RANI. K

LECTURER

COLLEGE OF NURSING

CMC,VELLORE.
 INTRODUCTION

Ventilation associated pneumonia (VAP)

is the most common nosocomial
infection in Intensive Care Units (ICUs).

Its risk is increasing at a rate of 1-3%

per day of intubation.

Signifies 6-20 fold higher risk of

developing pneumonia compared to
nonventilated ICU patients.

Aspiration of oral colonization has been

identified as one of the common causes
of VAP.
AJRCCM 2002; 165:867-903
 WHAT IS VAP ?

• Ventilator Associated Pneumonia (VAP) is a subtype

of hospital acquired pneumonia which occurs in
people who are on mechanical ventilation
through an endotracheal or tracheostomy tube
for at least 48hours.
Oropharynx is inhabited by
anaerobic bacteria.

Within 48 hours in ICU, oral cavity

undergoes a transformation to
predominantly gram negative microbes
- more virulent.
Secretions around the cuff,
colonization of gastric tubes
transfers microbes through
microaspiration.

Entry of pathogen causing

pneumonia
 HISTORY OF THE VAP GUIDELINES

1997 2003
1983 Revised guidelines Guidelines updated and
Measures to decrease expanded
Fundamental infection
aspiration, Focused on-preventing
control measures.
Prevent cross especially VAP (bacterial)
Routine infection
contamination , or Orotracheal intubation
control measures.
colonization of health Vs nasotracheal
Perioperative
care workers hands intubation
prevention measures,
hand washing, and Appropriate Noninvasive ventilation
handling of respiratory disinfection of Vs Invasive
fluids, medications, and respiratory equipment
Reduce the duration and
equipment. Vaccines need for mechanical
Staff education. ventilation
 VAP BUNDLE CARE

• Safety !!
• Highest priority
• Everyone’s expectation
 BUNDLE

• A “bundle” is a group of interventions

related to disease process that, when
executed together result in better
outcomes, than when implemented
individually.
 VAP BUNDLE

The VAP bundle was proposed in 2005

• Is a package of evidence-based interventions

that, when implemented together for all patients
on mechanical ventilation, has resulted in dramatic
reductions in the incidence of VAP.
 Prevent
colonization

General Prevent
measures aspiration

ET Suction Minimizing
and duration of
humidification ventilation

At every step, NURSES form an important link in

infection control
 The Bundle Components

1. Elevation of Head of the bed (HOB)

2. Daily oral care with Chlorhexidine
3. Peptic ulcer disease prophylaxis
4. Deep vein thrombosis (DVT)
prophylaxis
5. Daily sedation vacations and
assessment of readiness to extubate
1. ELEVATION OF HEAD OF THE BED (HOB)

• Nursing standard
• Suggested elevation is 30-45o
• Elevation of HOB prevents aspiration
• Potential to improve ventilation
1. ELEVATION OF HEAD OF BED CONT’D…

• Semi recumbent position (45o) than supine

reduces VAP from 34%- 8%

Wang L, Li X, Yang Z, 2016

 2. Oral Hygiene Care

• Mouth washes, gel, toothbrush, or combination

techniques may be used
• Chlorohexidine (CHX) - 0.2%
• HOW TO USE ? 10ml of 0.2% CHX in 1:1 dilution
in water thrice daily minimum
ORAL CARE INTERVENTION RATIONALE

Assessment of Conduct an initial admission as Assessment allows

oral cavity well as daily assessment of the
lips, oral tissue, tongue teeth,
and saliva of each patient on a
mechanical ventilator.
for initial and early
identification of oral
hygiene problems and
for continued
observation of oral
health.

Maintain saliva Unit specific protocols should Saliva provides both

be implemented that assist mechanical and
patients at risk of VAP in immunological
maintaining saliva production, effects which act to
oral tissue health, and remove pathogens
minimizing the development of colonizing the
mucositis. oropharynx.
ORAL CARE INTERVENTION RATIONALE

Elevate head Keep the head of the bed Elevation aids in

elevated at at least 30 (unless preventing reflux and
medically contraindicated) and aspiration of gastric
position patient so that oral contents; oral
secretion pool into buccal secretions may drain
pocket; especially important into a subglottic area
during such activities as where they become
feeding and brushing teeth. rapidly colonized with
pathogenic bacteria.
Subglottic Patients oral and subglottic Minimize aspiration of
suctioning secretions should be suctioned contaminated secretion
continuously or into lung.
intermittently/routinely with
the frequency dependent upon
secretion production.
3. PEPTIC ULCER PROPHYLAXIS

• Stress ulcer prophylaxis: May /may

not have a direct impact on VAP
rates.
• Impact associated risk factors that
are related to patients being
treated with mechanical ventilation
in the ICU.
 3. PEPTIC ULCER PROPHYLAXIS
CONT’D…

• Reduces acid production in stomach and the

consequent risk of bleeding from gastric
erosions and peptic ulcers
• Tube position to be checked before feeding
• Head end elevation 30-45o
• Volume of feeds to be titrated
4. DEEP VEIN THROMBOSIS (DVT)
PROPHYLAXIS

• Reduces potential for clot formation

• Reduces potential for pulmonary emboli

• May be a complication of mechanical
ventilation due to increased venous stasis in the
lower extremities.
4. DVT PROPHYLAXIS CONT’D…

• Complication of sepsis, cancer, trauma,

postoperative course, peripheral vascular
disease, and immobility.
• Prophylaxis for DVT - reduce the incidence of
venous thromboembolism.
4. DVT prophylaxis cont’d…

• Use of anticoagulant
(or) TED stockings
• Apply appropriately
• Change every 12 hrs
• Observe for any skin
changes
5. ‘DAILY SEDATION VACATION’ AND
ASSESSMENT OF READINESS TO
EXTUBATE

• Stop sedation at 8 am every morning

to allow patients to wake up.
• Provide simple commands to follow such as
rolling eyes, squeezing fingers and moving
their tongue.
5. SEDATION VACATION CONT’D…

• Exceptions: head injury, severe sepsis, ARDS,

tetanus, asthma, ACS
• Withhold narcotics (e.g. Morphine or Fentanyl)
unless indicated for pain
5. ‘DAILY SEDATION VACATION’
CONT’D…

• Lighten sedation daily at an appropriate time

to assess for neurological readiness to
extubate.
• Include precautions to prevent self-extubation
such as increased monitoring and vigilance
during the trial.
 OTHER STRATEGIES :
A. BREATHING EXERCISES

• Early post operative chest

physiotherapy, incentive spirometry
• Ambulation if indicated
 B. SUCTION

• Microorganisms attach to synthetic surfaces,

multiply and develop biofilms.
• Biofilm : is a thin, but robust layer of
secretions adhering to a solid surface and
containing a community of bacteria and other
organisms.
 Suction CONT’D…

• ETT impairs mucociliary clearance and disrupts

the cough reflex
• Accumulation of tracheobronchial secretions
increase the incidence of VAP
• ETT produces injury to oropharynx causing
bacteria to enter in the lower airway tract
• Finally, formation of biofilm on the surface of ETT
occurs leading to pathogenesis of VAP
 SUCTION CONT’D…

PREVENTIVE MEASURES
• Open system suction Vs closed suction
• Sterile catheter should be used only once
• Only sterile fluid for suctioning
• Subglottic secretion drainage is useful in
prevention of VAP
 PREVENTIVE MEASURES CONT’D…
VAP Preventive Recommendation Practice points
strategies
Head end elevation 30 to 45 YES 1. Simple and inexpensive
degrees 2. Must regularly monitor
elevation of the head end

Sub glottic secretion drainage YES 1. Ensure tubes available

wherever emergency
intubation is done
2. Aspirate abovee cuff q4h

Maintain endotracheal cuff YES 1. Must monitor cuff pressures

pressure between 20 and 30 6-8hourly
cm water 2. Avoid high cuff pressures-
can damage tracheal
mucosa/cause
tracheomalacia
 • Hand washing is effective
C. HAND HYGIENE
• Use of Hand rub
F1000Research 2017, 6(F1000 Faculty Rev):2061 Last updated: 15 DEC 2017
ARTICLE : UPDATE ON VENTILATOR ASSOCIATED PNEUMONIA
 Case Scenario 1
A 35 year old gentleman got admitted in MICU
following organophosphorous poisoning. He is on
endotracheal tube connected to ventilator. Today is his 4th
day and feeds have been initiated.
He is on the following list of medications
 Atropine infusion

 Heparin

 Pantoprazole

 The medical team wants early tracheostomy

What are the possible risk factors for VAP in this case?
 Risk factors for the occurrence of VAP

 Prolonged intubation  Tracheostomy

 Enteral feeding  Neurosurgery

 Supine position  Acute respiratory

 Low endotracheal tube

distress syndrome
pressure  Multiorgan failure

 Ventilator circuit  Coma

contamination  Re-intubation
 Male sex

 Age more than 60 years

 CHOOSE NO VAP “S”
• C-Cuff pressure between • N – No Saline lavage
20 and 30 cm water • O- Oral intubation if
• H-Head end elevation possible
30-45 deg
• V- No indication for
• O-Oral care
Chlorhexidine regular Ventilator
circuits
• O- Order enteral feeds
• S- Suction when • A- Ambu bag
indicated • P-Please wash hands
• E-ET tube for subglottic • S- Titrate sedation and
suction analgesia
 Take home message

• Nurses play very important link in VAP

control
• Prevent colonization
• Prevent aspiration
• Minimize duration of ventilation
• ET suction/humidification
• General measures
• CHOOSE ZERO VAPS
 Take home message

PREVENT VAP-WHAP
The application of VAP BUNDLE is very challenging
• Early Weaning
• Hand Hygiene
• Aspiration precautions
• Prevention of contamination