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OBJECTIVES

To highlight the definition of VAP

To shed light on pathophysiology and the
potential risk factors of VAP
To shed light on diagnostic criteria and
prevention of VAP
To underline the usefulness of Bundles of care,
especially in VAP
Vague concept on antibiotic therapy
VAP

A health Care related nosocomial chest infection

in a ventilated patient which is very difficult
to diagnose
Early onset VAP occurs within 2 to 4 days of
intubation. Responsive to usual antibiotics.
Late onset occurs after day 4. These pathogens
are usually resistant to routine treatment.
MDR specimens may be involved
BACTERIA ASSOCIATED WITH VAP

Early onset – staphylococcus aureus,

stretptococcus pneumoniae, Haemophilus
influenzae, proteus species, serratia
marcescens, klebsiealla pneumoniae, and
Esscherichia Coli.
Late onset – Pseudomonas Aeruginosa,
Methillin Resistant Staphyloccus Aureus,
Acinetobacter species and Enterobacter
Species
PATHOPHYSIOLOGY OF VAP
INCIDENCE AND IMPACT ON HEALTH CARE

Incidence is quoted up to 22.8%

Increased mortality between 27% - 43%
Increased length of stay in ITU by 5-7 days and
increased length of hospital stay by 2-3 folds
Obviously added cost of care
 RISK FACTORS
1.Host related – Immune-compromised, chronic obstructive
pulmonary disease, acute respiratory distress syndrome,
body position of patient, conscious level, repeat
intubations, prior exposure to antibiotics, heavy sedation
2.Device related – Endotracheal tube, Ventilator circuit,
presence of nasogastric tube/OG tube
3.Personnel related – Poor Hand hygiene, failure to change
gloves between contacts with patients, Not following
protocols of barrier nursing when dealing with antibiotic
resistant bacteria
DIAGNOSIS BASED ON CLINICAL GROUNDS. SEE CPIS
Radiological infiltrates ( DD – atelectasis,
oedema, infarction, ARDS, embolism,
haemorrhage, aspiration)
Clinical deteriorations
Microbiological test to confirm the nature and
sensitivity of bacteria- specimen taken non
invasively via a protected suction catheter is
equally good
DIAGNOSTIC CRITERIA FROM CHFT
• The diagnosis can be made on clinical suspicion +/- microbiological evidence
using the Johanson criteria,
• Radiological evidence of new or progressive infiltrates on chest xray
• Plus two out of
• Abnormal white cell count (WCC <4 or WCC >11)
• Abnormal temperature (temp <36 or >38)
• Purulent secretions
• A deterioration in gas exchange has been proposed (i.e over 48 hours) as a
sustained increase in PEEP by ≥ 3cmH2O from prior 2 days minimum PEEP
and/or increase in FiO2 by ≥ 0.2 from prior 2 days minimum FiO2
• Diagnosis should primarily be made on clinical criteria. The use of microbiology
evidence is not diagnostic but confirms likely pathogens to target
General Precautions
Universal infection control
precautions
Hygiene
Multi-disciplinary
Staff:Patient ratios
Prevention of aspiration
Elevation of head of the bed
Endotracheal cuff pressure
Avoiding circuit manipulation
Drainage of subglottic
secretions

Prevention
measures for
VAP
Decontamination Early extubation
Oral decontamination Early weaning protocol
Selective gastrointestinal Daily sedation breaks
decontamination
Silver endotracheal tube
 VENTILATOR CARE BUNDLE

The ventilator care bundle is

1. Elevation of the head of the bed to 30 degrees or greater
2. Daily sedation holding
3. Deep vein thrombosis prophylaxis
4. Gastric ulcer prophylaxis (ventilation is a risk factor for ulceration
on ICU and hence benefits outweigh the risk of increased VAP)
5. Normalise blood glucose (currently aim for BG <10 mmol/L
although network care bundle outlines target 4.4-6.1)
6. Normalise haemoglobin (use a transfusion trigger of 7g/dL)
TAKE HOME MESSAGE
VAP is a health care related chest infection which affects mechanically
ventilated patient
Caused by colonisation with bacterial particles and micro aspiration
Contributed by host related, staffs related and equipment's related
factors
Diagnosis is mostly based on clinical suspicion which takes into
account of new and progressive pulmonary infiltrates, raised
inflammatory markers and a positive sputum culture
Ventilation care bundle is aimed to prevent VAP
Treatment involves a MD approach to care