INFECTION PREVENTION

CONTROL
Ventilator Associated
Pneumonia
 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?
■ 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
 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 multi antibiotic resistant
 Pathogenesis
■ Bacteria enter the lower respiratory tract by this
pathways:
■ Aspiration of organisms from the oropharynx
and GI tract (most common cause)
■ Inhalation of bacteria
 VAP Pathogens

■ •Staphylococcus aureus - 24.4%

■ •Pseudomonas aeruginosa - 16.3%
■ •Enterobacter spp - 8.4%
■ •Acinetobacter baumannii - 8.4%
■ •Klebsiella pneumoniae - 7.5%
■ •Escherichia coli - 4.6%
■ •Candida spp - 2.7%
■ •Klebsiella oxytoca - 2.2%
■ •Coagulase-negative staphylococci - 1.3%
 Challenges in VAP Prevention

Pre-existing conditions (Non-modifiable risk factors)

■ •Head trauma
■ •Coma
■ •Nutritional deficiencies
■ •Immunocompromised
■ •Multi organ system failure
■ •Acidosis
■ •History of smoking or pulmonary disease
 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?
■ Hospital acquired pneumonia (HAP) is the
second most common hospital infection
■ VAP is the most common intensive care
unit (ICU) infection
 Why Do We Care?
■ VAP occurs in 10 - 65% of all ventilated patients

■ The incidence of VAP is highest in the following

groups:
■ Trauma
■ Burns
■ Neurosurgical population
■ Surgery
■ Mortality rate is 24 – 50%
■ Mortality rate in VAP caused by Pseudomonas or
Acinetobacter is as high as 76%
 $$$$
■ 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
 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
■ 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, ↑ O2 req.)
 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
 Prevention
■ Hand washing
■ Oral care
■ HOB ↑ 30 degrees (in the absence of medical
contraindications)
■ Patient turning and rotational therapy
■ DVT prophylaxis
■ Daily interruption of sedative infusions
■ Airway/ventilator management
 Hand washing
■ Hand washing is the single most important (and
easiest!!!) method for reducing the transmission of
pathogens.
 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
Publicity

Health care worker button

Room poster
 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 ventilated patients
■ VAP rates are reduced when oral care measures are
included in a comprehensive prevention program
 Oral Care
■ Oral decontamination – application of an antibiotic
solution
 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
 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
 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
HOB Elevation > 30 Degrees on all
Mechanically Ventilated Patients
Contraindications
■ Hypotension MAP <70
■ Tachycardia >150
■ Central line procedure
■ Posterior circulation strokes
■ Cervical spine instability
■ Some femoral lines no higher
than 30 degrees use reverse
trendelenburg
■ Increased ICP, No higher than
30 degrees avoid hip flexion
 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…
■ Rotational therapy is beneficial for patients at high
risk for 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
 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
 Oversedation
■ Predisposes patients to:
■ Thromboemboli
■ Pressure ulcers
■ Gastric aspiration
■ VAP
■ Sepsis
■ Consequences include:
■ Difficulty in monitoring neuro status
■ Increased use of diagnostic procedures
■ Increase ventilator days
■ Prolonged ICU and hospital stay
 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!
 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
 Airway Management
■ Mechanical ventilation
■ 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 H2O
 Airway Management
■ Suctioning
■ In-line suctioning using closed technique
■ Normal saline
■ Should not be routinely used to suction pts
■ Causes desaturation
■ Can potentially dislodge bacteria
■ Should be used to rinse the suction catheter after
suctioning
 Subglottal Suctioning
■ Should be done using a 14 Fr sterile suction catheter:
■ 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 Circuits
Humidification Systems
■ Heat and Humidity Exchangers (HMEs) should not be
routinely changed unless:
■ Visibly soiled
■ Use Heated Humidification (HH) if:
■ Ventilated longer than 96 hours
■ Thick/bloody secretions
■ Resp. Acidosis
■ Air leak from chest tube or around airway
 Gastric Alkalinization
■ H2 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
 Enteral Feedings
■ Elevate HOB 30 - 45 degrees
■ Routinely verify tube placement
 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