Ventilator associated pneumonia

1. VentilatorVentilator
Associated PneumoniaAssociated Pneumonia
((VAP)VAP)
DR. PHILIP DR. PHILIP

2. Case-Case-
Mr. MIAH HASAN, 50yrs old man transferred from KKH on Mr. MIAH HASAN, 50yrs old man transferred from KKH on 26/12/1433 26/12/1433
as case of RTA-head injury with Cx spine # C4-C6(operated),Infected stage 4 sacral Bed Sore as case of RTA-head injury with Cx spine # C4-C6(operated),Infected stage 4 sacral Bed Sore
with respiratory failure (neural mediated RF).with respiratory failure (neural mediated RF).
DAY-148 in ICU/hospitalDAY-148 in ICU/hospital
DAY 1468 on ventilator(tracheostomy) SIMV mode Vt-500ml, RR-12/min, Fio2 45%, DAY 1468 on ventilator(tracheostomy) SIMV mode Vt-500ml, RR-12/min, Fio2 45%,
PEEP-3mbar, PS-16mbarPEEP-3mbar, PS-16mbar
Since five days Fio2- 65-75% ,PEEP -8, to maintainSpo2 above 95% and Since five days Fio2- 65-75% ,PEEP -8, to maintainSpo2 above 95% and
Pco2 -78mmHg ,Pco2 -78mmHg ,ABG-RES. ACIDOSIS WITH HYPOXIEMIAABG-RES. ACIDOSIS WITH HYPOXIEMIA
O/E- Temp38.9 degree celcius HR-102b/min ,BP-98/58mmHg ,RR-28breaths/min, O/E- Temp38.9 degree celcius HR-102b/min ,BP-98/58mmHg ,RR-28breaths/min,
pallor, emaciated, on noradrenaline & dopaminepallor, emaciated, on noradrenaline & dopamine
BED SORES partially clean with health granulation tissueBED SORES partially clean with health granulation tissue
Diarrhea since 10 days Diarrhea since 10 days
S/E -S/E -RS- mucopurulent resp secretion B/L crackles Rt>Lt RS- mucopurulent resp secretion B/L crackles Rt>Lt , ,
P/A and CVS-unremarkable CNS- conscious, vague response to vc, Quadriplegic P/A and CVS-unremarkable CNS- conscious, vague response to vc, Quadriplegic
LAB. R - Wbc-22,Hb-9.5g/dl , plt- 93 alb-2.46mg/dl TP-5.9mg/dl wbc-41(4/5)LAB. R - Wbc-22,Hb-9.5g/dl , plt- 93 alb-2.46mg/dl TP-5.9mg/dl wbc-41(4/5)
Sputum analysis- Candida, GPC-++ Pus cells-+++, Stool analysis –NBF Sputum analysis- Candida, GPC-++ Pus cells-+++, Stool analysis –NBF
Sputum-c/s(4/5/33)-pseu.auerginosa, klebsiella pneumonia. Sensitive to Ceftazidime, Sputum-c/s(4/5/33)-pseu.auerginosa, klebsiella pneumonia. Sensitive to Ceftazidime,
TienamTienam. CXR– will review. CXR– will review
TREATMENT- Antibiotics,zantac, iron folic acid, clexan and supportive treatment NGT TREATMENT- Antibiotics,zantac, iron folic acid, clexan and supportive treatment NGT
FEEDING partially supported by parenteral . FEEDING partially supported by parenteral . Antibiotic- tienam and ciproAntibiotic- tienam and cipro

3. 22/4/3322/4/33

4. 1/5/14331/5/1433

5. case--case--
Mrs. FARIYAL ABDUL BADER 55yrs lady transferred from KKH on Mrs. FARIYAL ABDUL BADER 55yrs lady transferred from KKH on
6/4/1433 as a case of POST-CPR, BRAIN ANOXIA ,DCM.6/4/1433 as a case of POST-CPR, BRAIN ANOXIA ,DCM.
DAY 29th in ICU and on VENTILATORDAY 29th in ICU and on VENTILATOR
SIMV mode(Tracheostomy) Vt- 500ml, RR-6/min, PS- 7mbar, Pinsp- 20, SIMV mode(Tracheostomy) Vt- 500ml, RR-6/min, PS- 7mbar, Pinsp- 20,
Fio2-30% consistent on same parameters with Sp02>97%Fio2-30% consistent on same parameters with Sp02>97%
O/E: O/E: Temp.38.5degree celciusTemp.38.5degree celcius, RR-14/min HR-70/min, , RR-14/min HR-70/min,
BP -98/60mmHg, Spo2 -99% BP -98/60mmHg, Spo2 -99%
S/E : RS- mucoid secretion, conducted soundsS/E : RS- mucoid secretion, conducted sounds
CVS/PER ABD- Unremarkable, CNS- unconscious GCS- 5T/15CVS/PER ABD- Unremarkable, CNS- unconscious GCS- 5T/15
Wbc-8, Hg-8.9,alb-3.4mg/dl , ABG- Met. Alkalosis, CXR-will review Wbc-8, Hg-8.9,alb-3.4mg/dl , ABG- Met. Alkalosis, CXR-will review
Blood c/s –CONS sen to vanco, Sputum c/s-NBG Urine c/s-NGBBlood c/s –CONS sen to vanco, Sputum c/s-NBG Urine c/s-NGB
Urine analysis(20/4/33)-pus cells-15-20/hpf, Rbcs 10-15/hpf, epith. Cells-Urine analysis(20/4/33)-pus cells-15-20/hpf, Rbcs 10-15/hpf, epith. Cells-
6-8 (11/4/33, 17/4/33—consistant pus cells and Rbcs)on 3/5- 2-3 pus cel6-8 (11/4/33, 17/4/33—consistant pus cells and Rbcs)on 3/5- 2-3 pus cel
TREATMENT-Aspirin, Plavix, Clexan, Captopril, Zocar, Amiodarone, TREATMENT-Aspirin, Plavix, Clexan, Captopril, Zocar, Amiodarone,
Depakin, Adol, Zantac, NGT feedingDepakin, Adol, Zantac, NGT feeding and supportive treatment. and supportive treatment.
Received Vancomycin.Received Vancomycin.

6. CXR-CXR-

7. INTRODUCTIONINTRODUCTION
Mechanical ventilator is one of the important life Mechanical ventilator is one of the important life
saving devices used in conditions like saving devices used in conditions like
Respiratory failure (main indication)Respiratory failure (main indication)
Protection of airwaysProtection of airways
Head injury Head injury
Post operativePost operative
ShockShock
However, as like any other devices/ medications However, as like any other devices/ medications
MV also associated with complications like MV also associated with complications like
Hemodynamic instability, Pneumothorax, VALI and Hemodynamic instability, Pneumothorax, VALI and
VENTILATOR ASSOCIATED PNEUMONIAVENTILATOR ASSOCIATED PNEUMONIA

8. What is VAP?What is VAP?
A Nosocomial pneumonia associated with A Nosocomial pneumonia associated with
mechanical ventilation (either by mechanical ventilation (either by
Endotracheal tube or Tracheostomy) that Endotracheal tube or Tracheostomy) that
develops within 48 hours or more of develops within 48 hours or more of
hospital admission and which was not hospital admission and which was not
present at the time of admission.present at the time of admission.
National institute of health excellence (NICE)-2007National institute of health excellence (NICE)-2007
center for disease control and preventioncenter for disease control and prevention

9. TYPES--TYPES--
EARLY ONSETEARLY ONSET::
--within 3-4days of MVwithin 3-4days of MV
less virulent, community acquired less virulent, community acquired
organism- organism- Str.pneumonia, H. influenzaeStr.pneumonia, H. influenzae
LATE ONSET:LATE ONSET:
--After 3-4 days of MVAfter 3-4 days of MV
More virulent, hospital acquired organism- More virulent, hospital acquired organism-
Pseudomonas, Acinetobacter, MRSA, Pseudomonas, Acinetobacter, MRSA, EnterobacteriaceaeEnterobacteriaceae

10. EPIDEMIOLOGYEPIDEMIOLOGY
• Hospital acquired pneumonia (HAP) is the Hospital acquired pneumonia (HAP) is the
second most common hospital infection.second most common hospital infection.
• VAP is the most common intensive care unit VAP is the most common intensive care unit
(ICU) infection.(ICU) infection.
• 90% of all nosocomial infections occurring 90% of all nosocomial infections occurring
in ventilated patients are pneumonias.in ventilated patients are pneumonias.

11. INCIDENCEINCIDENCE
VAP occurs in 10 - 65% of all ventilated VAP occurs in 10 - 65% of all ventilated
patients patients Crit Care Clin (2002Crit Care Clin (2002))
Incidence increases with duration of MVIncidence increases with duration of MV
3% /day for first 5days, 2%/day for 6-10days 3% /day for first 5days, 2%/day for 6-10days
and 1%/day after 10 days.and 1%/day after 10 days.
The incidence of VAP is highest in the The incidence of VAP is highest in the
following groups:following groups:
Trauma, Burns, Neurosurgical pts. Postop. Trauma, Burns, Neurosurgical pts. Postop.
Mortality rate is 27% &43%with antibiotic Mortality rate is 27% &43%with antibiotic
resistant organism. resistant organism.
critical care societies collaborative(CCSCscritical care societies collaborative(CCSCs) )
Mortality rate in VAP caused by Pseudomonas Mortality rate in VAP caused by Pseudomonas
or Acinetobacter is as high as 76% or Acinetobacter is as high as 76%
Crit Care Med (2004)Crit Care Med (2004)

12. Cont…Cont…
VAP VAP
Increases ventilatory support requirements Increases ventilatory support requirements
and ICU stay by 4.3 daysand ICU stay by 4.3 days
Increases hospital LOS by 4 to 9 daysIncreases hospital LOS by 4 to 9 days
Increases medical costIncreases medical cost
Chest 2002;122:2115Chest 2002;122:2115
Critical Care Medicine 2005;33:2184-93Critical Care Medicine 2005;33:2184-93

13. Causative OrganismsCausative Organisms
Early onset:Early onset:
Hemophilus influenzaHemophilus influenza
Streptococcus pneumoniaeStreptococcus pneumoniae
Staphylococcus aureus (methicillin sensitive)Staphylococcus aureus (methicillin sensitive)
Escherichia coliEscherichia coli
KlebsiellaKlebsiella
Late onset:Late onset:
Pseudomonas aeruginosaPseudomonas aeruginosa
AcinetobacterAcinetobacter
Staphylococcus aureus (methicillin resistant)Staphylococcus aureus (methicillin resistant)
Most strains responsible for early onset VAP are Most strains responsible for early onset VAP are
antibiotic sensitive. Those responsible for late onset antibiotic sensitive. Those responsible for late onset
VAP are usually multiple antibiotic resistantVAP are usually multiple antibiotic resistant
Am J Resp Crit Care (1995Am J Resp Crit Care (1995))

14. RISK FACTORSRISK FACTORS

15. RISK FACTORS FOR VAPRISK FACTORS FOR VAP
Host related:Host related:
-Underlying medical conditions- -Underlying medical conditions-
COPD, obesity, ARDS, gastro esophageal disease, COPD, obesity, ARDS, gastro esophageal disease,
burn, trauma, MODS etc--burn, trauma, MODS etc--
-Immunosuppression, Malnutrition(S.Albumin<2.2g/dl)-Immunosuppression, Malnutrition(S.Albumin<2.2g/dl)
-Advanced age-Advanced age
-Patients’ body position-Patients’ body position
-Level of consciousness- impaired LOC, delirium, -Level of consciousness- impaired LOC, delirium,
coma. coma.
-Number of intubations- Reintubations-Number of intubations- Reintubations
-Medications (Antibiotics, sedation, NM blockers)-Medications (Antibiotics, sedation, NM blockers)

16. Cont..Cont..
• Device related:Device related:
- - MV with Endotracheal tube, trcheostomy MV with Endotracheal tube, trcheostomy
-Prolonged MV-Prolonged MV
-Number of intubations- reintubation-Number of intubations- reintubation
-Use of humidifier-Use of humidifier
-Nasogastric or orogastric tubes-Nasogastric or orogastric tubes
• Personnel related:Personnel related:
-Improper hand washing-Improper hand washing
-Failure to change gloves between contacts with pts -Failure to change gloves between contacts with pts

-Not wearing personal protective equipment when -Not wearing personal protective equipment when
antibiotic resistant bacteria have been identified.antibiotic resistant bacteria have been identified.
BJMP jun2009: vol.2,nub.2, 16-19. & Am.jour of Criti care nurse 2007; 27:32-39 BJMP jun2009: vol.2,nub.2, 16-19. & Am.jour of Criti care nurse 2007; 27:32-39

17. PATHOGENESISPATHOGENESIS
Bacteria enter the lower respiratory tract via Bacteria enter the lower respiratory tract via
following pathways:following pathways:
Aspiration of organisms from the oropharynx Aspiration of organisms from the oropharynx
and GI tract (most common cause)and GI tract (most common cause)
Direct inoculationDirect inoculation
Inhalation of bacteriaInhalation of bacteria
Haematogeneous spreadHaematogeneous spread

18. ASPIRATION- Primary Route of ASPIRATION- Primary Route of
Bacterial Entry into LRT Bacterial Entry into LRT
ENDOTACHEAL TUBE ENDOTACHEAL TUBE
Holds the vocal cords Holds the vocal cords
open-predispose to micro & macro aspiration open-predispose to micro & macro aspiration
of colonized bacteria from oropharynx to LRT.of colonized bacteria from oropharynx to LRT.
Leakage of secretion containing bacteria Leakage of secretion containing bacteria
around the ETT cuff.around the ETT cuff.
NGT OR OROGASTRIC TUBE NGT OR OROGASTRIC TUBE
Interrupt gastro-esophageal sphincter Interrupt gastro-esophageal sphincter
leading GI reflux and aspiration. leading GI reflux and aspiration.
Increase oropharyngeal colonization, stagnation Increase oropharyngeal colonization, stagnation
of oropharyngeal and nasal secretion.of oropharyngeal and nasal secretion.

19. Cont..Cont..
Inhalation of aerosols containing bacteria :Inhalation of aerosols containing bacteria :
-Contaminated RT equipment -Contaminated RT equipment
-from other patients/ healthcare personnel's-from other patients/ healthcare personnel's
-Inadequate disinfection/sterilization technique -Inadequate disinfection/sterilization technique
-Contaminated solutions/water-Contaminated solutions/water
Direct contact:Direct contact:
-Cross Contamination (Hands)-Cross Contamination (Hands)

20. HOW DO WE DIAGNOSE? 2-1-2HOW DO WE DIAGNOSE? 2-1-2
Radiographic evidence x Radiographic evidence x 22 consecutive days consecutive days
New, progressive or persistent infiltrateNew, progressive or persistent infiltrate
Consolidation, opacity, or cavitationConsolidation, opacity, or cavitation
Clinical singsClinical sings
At least At least 11 of the following: of the following:
Fever (> 38 degrees C) with no other recognized causeFever (> 38 degrees C) with no other recognized cause
Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000 Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000
WBC/mm3)WBC/mm3)
At least At least 22 of the following: of the following:
New onset of purulent sputum or change in character of New onset of purulent sputum or change in character of
secretionssecretions
New onset or worsening cough, dyspnea, or tachypneaNew onset or worsening cough, dyspnea, or tachypnea
Rales or bronchial breath soundsRales or bronchial breath sounds
Worsening of gas exchange (Worsening of gas exchange (↓ sats, P:F ratio < 240, ↑ O↓ sats, P:F ratio < 240, ↑ O
22 req.) req.)

21. CONT…CONT…
Microbiological criteria (optionalMicrobiological criteria (optional))
At least one of the followingAt least one of the following::
• Positive growth in blood culture not related to another Positive growth in blood culture not related to another
source of infection.source of infection.
• Positive growth culture pleural fluid.Positive growth culture pleural fluid.
• Bronchoaleveolar lavage Bronchoaleveolar lavage
> 105colony forming units/ml. > 105colony forming units/ml.
sensivity &specificity 42-93% &45-100% sensivity &specificity 42-93% &45-100%
Protected Protected
specimen brushing >103cfu/mlspecimen brushing >103cfu/ml (33-100% & 50- (33-100% & 50-
100%) 100%) chest.Apr2000;117(4suppl2):198-2002)chest.Apr2000;117(4suppl2):198-2002)
•Histopathological evidence of pneumoniaHistopathological evidence of pneumonia

22. Cont--Cont--
• RADIOLOGICAL FINDING AND 2 CLINICAL RADIOLOGICAL FINDING AND 2 CLINICAL
CRITERIA SENCIVITY OF DIAGNOSING VAP CRITERIA SENCIVITY OF DIAGNOSING VAP
IS 69% AND THE SPECIFICITY IS 75%IS 69% AND THE SPECIFICITY IS 75%
• SAMPLING OF RESPIRATORY SECREATIONSAMPLING OF RESPIRATORY SECREATION
can be obtained from distal or proximal airway however can be obtained from distal or proximal airway however
the sensivity and specificity is more with distal airway the sensivity and specificity is more with distal airway
sample(Bronchoalveolar lavage(BAL) , Protected specimen sample(Bronchoalveolar lavage(BAL) , Protected specimen
brush sampling(PABbrush sampling(PAB).).
• ABSENCE OF RADIOLOGICAL FINDING ABSENCE OF RADIOLOGICAL FINDING
HELPFUL FOR EXCLUDING THE DIAGNOSIS HELPFUL FOR EXCLUDING THE DIAGNOSIS
OF VAPOF VAP

23. A new streamlined surveillance defintion for A new streamlined surveillance defintion for
ventilator-associated pneumoniaventilator-associated pneumonia
Any one of the followingAny one of the following
1. Opacity, infiltrate, or consolidation that appears, evolves, or persists over 72 hrs1. Opacity, infiltrate, or consolidation that appears, evolves, or persists over 72 hrs
2. Cavitation2. Cavitation
Any one of the followingAny one of the following
1. Temperature 100.4°F within past 24 hrs1. Temperature 100.4°F within past 24 hrs
2. White blood cell 4,000 or 12,000 white blood cells/mm3 within past 24 hrs2. White blood cell 4,000 or 12,000 white blood cells/mm3 within past 24 hrs
Both of the followingBoth of the following
1. Two days of stable or decreasing daily minimum FIO2 followed by increase in 1. Two days of stable or decreasing daily minimum FIO2 followed by increase in
daily minimum FIO2 15 points sustained for 2 calendar days OR 2 days of stable or daily minimum FIO2 15 points sustained for 2 calendar days OR 2 days of stable or
decreasing daily minimum positive end-expiratory pressure followed by increase in decreasing daily minimum positive end-expiratory pressure followed by increase in
daily minimum positive end-expiratory pressure by 2.5 cm H2O sustained for 2 daily minimum positive end-expiratory pressure by 2.5 cm H2O sustained for 2
calendar dayscalendar days
2. Gram-negative stain of respiratory secretions with moderate (2+) or more 2. Gram-negative stain of respiratory secretions with moderate (2+) or more
neutrophils per low power field within 72 hrs. neutrophils per low power field within 72 hrs.
Critical care med 2012 vol.40,no.1Critical care med 2012 vol.40,no.1

24. TREATMENT PROTOCALTREATMENT PROTOCAL
• Initial therapy is empiric Initial therapy is empiric
• Start when VAP is suspected, Don’t delay Start when VAP is suspected, Don’t delay
• Individualize to institution- Individualize to institution-
-Hospital epidemiologic data -Hospital epidemiologic data
-Drug cost and availability -Drug cost and availability
• Individualize to patient- Individualize to patient-
-Early onset versus Late onset of VAP -Early onset versus Late onset of VAP
-Prior antibiotic use -Prior antibiotic use
-Underlying disease Renal, liver disease etc -Underlying disease Renal, liver disease etc
-Surveillance cultures -Surveillance cultures
-Use gram stain results if possible-Use gram stain results if possible

25. TREATMENTTREATMENT
• GENERAL APPROACH FOR INFECTION CONTROLGENERAL APPROACH FOR INFECTION CONTROL
• ANTIBIOTICS-ANTIBIOTICS-
Selection of antibiotics:Selection of antibiotics:
Early onset of VAP and no risk for MDR -Early onset of VAP and no risk for MDR -
Cefrioxone, fluroquinolones, ampicillin-sublactumCefrioxone, fluroquinolones, ampicillin-sublactum
Late onset of VAP and risk for MDR-Late onset of VAP and risk for MDR-
Antipseudomonal cephalosporin(cfepime,ceftazidime)Antipseudomonal cephalosporin(cfepime,ceftazidime)
Carbapenems(imipenem,meronem), Carbapenems(imipenem,meronem),
Beta lactam/betalactamase inhibitors- Beta lactam/betalactamase inhibitors-
piperacillin-tazobactampiperacillin-tazobactam
Amonoglycocides with vancomycine,linezoidAmonoglycocides with vancomycine,linezoid
ANTIBIOTCS TO BE ADJUSTED FURTHER ON THE ANTIBIOTCS TO BE ADJUSTED FURTHER ON THE
BASIS OF CULTURE REPORTBASIS OF CULTURE REPORT

26. Risk Factors for drug resistance Risk Factors for drug resistance
ABX in last 14 days ABX in last 14 days
Prior culture with MRO Prior culture with MRO
Immunocompromised Immunocompromised
Chronic primary lung pathology Chronic primary lung pathology
Acute or long term care hospitalization within Acute or long term care hospitalization within
14 days 14 days
Tracheostomy for > 5 day Tracheostomy for > 5 day

27. DURATION OF TREATMENTDURATION OF TREATMENT
- - Depends on severity,Depends on severity,
- Time to clinical response and micro organism response- Time to clinical response and micro organism response
- Isolation of microorganism- Isolation of microorganism
- Longer duration >14-21days risk of toxicity and resistance - Longer duration >14-21days risk of toxicity and resistance
- Shorter duration<7days- risk of recurrence- Shorter duration<7days- risk of recurrence
--standard duration of treatment 7-14 daysstandard duration of treatment 7-14 days
- Longer durtion 14-21 days may be indicated in- Longer durtion 14-21 days may be indicated in
Multilobular involvement, cavitation, gram-ve Multilobular involvement, cavitation, gram-ve
necrotising necrotising pneumonia, isolation of Pseudomonas, pneumonia, isolation of Pseudomonas,
AcnetobacterAcnetobacter

28. Further inpatient careFurther inpatient care
About 30% of pts. Fail to respond-About 30% of pts. Fail to respond-

29. PREVENTIONPREVENTION
Specific practices have been shown to decrease Specific practices have been shown to decrease
VAPVAP
Strong evidence that a collaborative, Strong evidence that a collaborative,
multidisciplinary approach incorporating many multidisciplinary approach incorporating many
interventions is paramountinterventions is paramount
Intensive education directed at nurses and Intensive education directed at nurses and
respiratory care practitioners resulted in a 57% respiratory care practitioners resulted in a 57%
decrease in VAPdecrease in VAP
Crit Care Med (2002)Crit Care Med (2002)

30. PREVENTIONPREVENTION
ConventionalConventional Infection control Aproach Infection control Aproach
•DESIGN OF ICU- DESIGN OF ICU-
Adequate space, lighting, proper function of ventilatory Adequate space, lighting, proper function of ventilatory
system, facilities for hand washing, Isolation room.system, facilities for hand washing, Isolation room.
•STAFFING-STAFFING-
Education, Adequate number, quality, importance of personal Education, Adequate number, quality, importance of personal
cleanliness and attention to asceptic procedures.cleanliness and attention to asceptic procedures.
•Hand washing and Hand rubbing with alcohol based solution.Hand washing and Hand rubbing with alcohol based solution.
•PERIODICAL BACTERIAL MONITORING POLICY.PERIODICAL BACTERIAL MONITORING POLICY.
• SPECIFIC SPECIFIC PROPHYLAXIS- Use Gloves, Gown, Mask. PROPHYLAXIS- Use Gloves, Gown, Mask.
Use of NIPPV Use of NIPPV
Minimize duration of MV, checking daily for readiness to Minimize duration of MV, checking daily for readiness to
weaning/extubationweaning/extubation ( (Text book of criti care med. 5 the Edit. Text book of criti care med. 5 the Edit.
MitchellP.FinkSHOEMAKER) MitchellP.FinkSHOEMAKER)

31. EFFECTEFFECT OF VAP BUNDLE CARE OF VAP BUNDLE CARE

32. VAP BUNDLE VAP BUNDLE (VAP reduction rate(VAP reduction rate44.5%44.5%) )
VAP bundle(4) originated in 2005 from INSTITUTE VAP bundle(4) originated in 2005 from INSTITUTE
OF HEALTH CARE IMPROVEMENT(IHI) & CDCOF HEALTH CARE IMPROVEMENT(IHI) & CDC
1.1. Elevation of the head of the bed (HOB) to between 30 and Elevation of the head of the bed (HOB) to between 30 and
45 degrees.45 degrees.
2.2. Daily sedative interruptional and daily assessment of Daily sedative interruptional and daily assessment of
readiness to extubate.readiness to extubate.
3.3. Stress ulcer disease prophylaxis.Stress ulcer disease prophylaxis.
4.4. Deep venous thrombosis (DVT) prophylaxis (unless Deep venous thrombosis (DVT) prophylaxis (unless
contraindicated)contraindicated)
5.5.IN 2010 FIFTH COMPONENT DAILY ORAL CARE IN 2010 FIFTH COMPONENT DAILY ORAL CARE
WITH CHLORHEXIDINE IS ADDED. WITH CHLORHEXIDINE IS ADDED.
((criti. care 2012 vol. 40,no.1)criti. care 2012 vol. 40,no.1)

33. HANDWASHINGHANDWASHING
Hand washing is the single most important Hand washing is the single most important
(and easiest!!!) method for reducing the (and easiest!!!) method for reducing the
transmission of pathogenstransmission of pathogens
Use of waterless antiseptic preparations is also Use of waterless antiseptic preparations is also
acceptable and may increase compliance.acceptable and may increase compliance.
Remember to wash your handsRemember to wash your hands
Before and after patient contactBefore and after patient contact
Beginning and end of work dayBeginning and end of work day
Before and after using glovesBefore and after using gloves
After touching contaminated surfaceAfter touching contaminated surface

34. HOB 30 - 45 DegreesHOB 30 - 45 Degrees
The supine position is an independent risk The supine position is an independent risk
factor for death in all ICU patientsfactor for death in all ICU patients
HOB elevation to 30-45 degree especially during HOB elevation to 30-45 degree especially during
feeding prevent aspiration and 34% reduction feeding prevent aspiration and 34% reduction
in VAP in VAP ((Lancet.nov.1999;354,1851-1858)Lancet.nov.1999;354,1851-1858)
CDC recommends HOB 30-45CDC recommends HOB 30-45°° unless unless
contraindicatedcontraindicated

35. ContraindicationsContraindications
- Hypotension MAP <70- Hypotension MAP <70
-Tachycardia >150-Tachycardia >150
-CI <2.0-CI <2.0
-Central line procedure -Central line procedure
-Posterior circulation strokes -Posterior circulation strokes
-Cervical spine instability use reverse trendelenburg-Cervical spine instability use reverse trendelenburg
-Some femoral lines i.e.: IABP no higher than 30 -Some femoral lines i.e.: IABP no higher than 30
degrees use reverse trendelenburgdegrees use reverse trendelenburg
-Increased ICP, No higher than 30 degrees avoid -Increased ICP, No higher than 30 degrees avoid
hip flexion hip flexion
-Proning -Proning

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

37. Daily Sedative Interruption and Daily Daily Sedative Interruption and Daily
Assessment of Readiness to Extubate Assessment of Readiness to Extubate
OVERSEDATIONOVERSEDATION
Predisposes patients to:Predisposes patients to:
ThromboemboliThromboemboli
Pressure ulcersPressure ulcers
Gastric regurgitation and aspirationGastric regurgitation and aspiration
VAPVAP
SepsisSepsis
Consequences include:Consequences include:
Difficulty in monitoring neuro statusDifficulty in monitoring neuro status
Increased use of diagnostic proceduresIncreased use of diagnostic procedures
Increase ventilator daysIncrease ventilator days
Prolonged ICU and hospital stayProlonged ICU and hospital stay

38. Daily Wake UpDaily Wake Up
Every patient must be awakened Every patient must be awakened daily daily unless unless
contraindicated!contraindicated!
Daily weaning assessments reduce the duration of Daily weaning assessments reduce the duration of
mechanical ventilation.mechanical ventilation.
Wean infusion to off in increments of 10-25% daily in Wean infusion to off in increments of 10-25% daily in
order to perform a clinical assessmentorder to perform a clinical assessment
Rebolus and restart infusion if the patient becomes Rebolus and restart infusion if the patient becomes
symptomatic. Your new continuous IV dose should be symptomatic. Your new continuous IV dose should be
lower than what you began withlower than what you began with
Consider implementation of a sedation scale such as the Consider implementation of a sedation scale such as the
Richmond Agitation Sedation Scale (RASS) scale to avoid Richmond Agitation Sedation Scale (RASS) scale to avoid
over sedation.over sedation.
Goal is to decrease sedationGoal is to decrease sedation

39. STRESS ULCER PROPHYLAXISSTRESS ULCER PROPHYLAXIS
SUCRALFATE, H2 RECEPTOR BLOCKER, SUCRALFATE, H2 RECEPTOR BLOCKER,
PROTON PUMP INHIBITORPROTON PUMP INHIBITOR
Increases gastric ph and minimize bacterial colonization that Increases gastric ph and minimize bacterial colonization that
reduces the risk of VAP and GI bleedingreduces the risk of VAP and GI bleeding
SUCRALFATE-SUCRALFATE-
Decreases the VAP rate but increases the risk of GI bleeding by 4%.Decreases the VAP rate but increases the risk of GI bleeding by 4%.
H2 receptor blockers/PP inhibitors- H2 receptor blockers/PP inhibitors-
Increase rate of VAP by increasing gastric Ph leading to colonization of Increase rate of VAP by increasing gastric Ph leading to colonization of
bacteria and decreases the risk of GI bacteria and decreases the risk of GI bleeding.bleeding.
H2 receptor blocker, PP inhibitor preferred over sucralfateH2 receptor blocker, PP inhibitor preferred over sucralfate
Am J Respir Crit Care Med. 2005;171(4):388-416Am J Respir Crit Care Med. 2005;171(4):388-416..

40. Deep Venous Thrombosis Deep Venous Thrombosis
(DVT) Prophylaxis(DVT) Prophylaxis
There is increase risk of thomboembolism in There is increase risk of thomboembolism in
mechanically ventilated patient.mechanically ventilated patient.
There is no any data association between DVT There is no any data association between DVT
prophylaxis and decreasing rates of VAP.prophylaxis and decreasing rates of VAP.
VAP rates decreased most dramatically in hospitals VAP rates decreased most dramatically in hospitals
where all elements of the Ventilator Bundle were where all elements of the Ventilator Bundle were
implemented, including this one.implemented, including this one.
Chest. 2004;126(3 Suppl):338S-400SChest. 2004;126(3 Suppl):338S-400S..

41. DAILY ORAL CAREDAILY ORAL CARE
Dental plaque- due to absence of mechanical chewing Dental plaque- due to absence of mechanical chewing
and the saliva and they are reservoir for potential and the saliva and they are reservoir for potential
pathogens that causes VAP.pathogens that causes VAP.
MECHANICAL INTERVENTIONMECHANICAL INTERVENTION
Tooth brushing , Rinsing of oral cavity to remove dental plaqueTooth brushing , Rinsing of oral cavity to remove dental plaque
PHARMACOLOGICAL INTERVENTIONPHARMACOLOGICAL INTERVENTION
0.12% CHLORHEXIDINE ORAL RINSE0.12% CHLORHEXIDINE ORAL RINSE
Am J Crit Care. 2009 Am J Crit Care. 2009 Sep;18(5):428-437 Sep;18(5):428-437
Oral decontaminationOral decontamination- 2%genta+2%Collistin+2%Vanco paste QID - 2%genta+2%Collistin+2%Vanco paste QID
Selective decontamination of digestive tract(SDDSelective decontamination of digestive tract(SDD)- )-
2%polymyxin+tobra+Amphotericine paste oral application QID.2%polymyxin+tobra+Amphotericine paste oral application QID.
SolutionSolution 100mg poly+80mg tobra+500mg ampho QID throu NG.100mg poly+80mg tobra+500mg ampho QID throu NG.
I/V Cefuroxime 1.5g TID first 4days.I/V Cefuroxime 1.5g TID first 4days.

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

43. PREVENTIONPREVENTION
 NIPPV NIPPV
 Subglottic suctionSubglottic suction
Maintaining ETT/TT cuff pressure 20- 30cmH20Maintaining ETT/TT cuff pressure 20- 30cmH20
Orotracheal rather than nasotracheal intubationOrotracheal rather than nasotracheal intubation
Avoid unnecessary disconnection of MV circuit.Avoid unnecessary disconnection of MV circuit.
 Closed inline suctioning.Closed inline suctioning.
 Avoid saline instillation for suctioning thick secretion.Avoid saline instillation for suctioning thick secretion.
Appropriate Humidification of inspired air.Appropriate Humidification of inspired air.
Early Enteral feedingEarly Enteral feeding
Turning patient every 2 hrly.Turning patient every 2 hrly.

44. Airway ManagementAirway Management
Mechanical ventilationMechanical ventilation
Avoidance of Endotracheal intubation Avoidance of Endotracheal intubation
Mask ventilation trials Mask ventilation trials , NIPPV, NIPPV
Minimize duration on MVMinimize duration on MV
Orotracheal intubation Orotracheal intubation
Nasotracheal intubation slightly increase the risk for VAPNasotracheal intubation slightly increase the risk for VAP
Avoid Reintubations- increases risk of VAP 6 fold Avoid Reintubations- increases risk of VAP 6 fold
(Am resp.criti car med.1995;152(1):137-141)(Am resp.criti car med.1995;152(1):137-141)
Cuff managementCuff management
HVLP ETT cuff VAP rate 20% , LVHP ETT cuff VAP rate HVLP ETT cuff VAP rate 20% , LVHP ETT cuff VAP rate 20% 20%
(Text book of criti. Care. 5 th Edit. Mitchell P.Fink SHOEMAKER)(Text book of criti. Care. 5 th Edit. Mitchell P.Fink SHOEMAKER)
Maintain at 25-30 cm HMaintain at 25-30 cm H
22OO

45. Airway ManagementAirway Management
SuctioningSuctioning
In-line suctioning using closed technique than open In-line suctioning using closed technique than open
techniquetechnique
Normal salineNormal saline
Should not be routinely used to suction ptsShould not be routinely used to suction pts
Causes desaturationCauses desaturation
Does not increase removal of secretionsDoes not increase removal of secretions
Can potentially dislodge bacteria from ETT to LRTCan potentially dislodge bacteria from ETT to LRT
ShouldShould be used to rinse the suction catheter after suctioning be used to rinse the suction catheter after suctioning
Maintaining adequate hydration, proper humidification of Maintaining adequate hydration, proper humidification of
ventilatory circuit, nebulizer, mucolytic agent can help to ventilatory circuit, nebulizer, mucolytic agent can help to
decrease the viscosity and eliminate the need for saline lavage decrease the viscosity and eliminate the need for saline lavage
((Am. jour.crical care Am. jour.crical care
nurse 2007 vol. 27; 32-36:)nurse 2007 vol. 27; 32-36:)

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

47. SUBGLOTTAL SUCTIONINGSUBGLOTTAL SUCTIONING
Should be done using a 14 Fr sterile suction catheter:Should be done using a 14 Fr sterile suction catheter:
Prior to ETT rotationPrior to ETT rotation
Prior to lying patient supinePrior to lying patient supine
Prior to ExtubationPrior to Extubation
Continuous subglottic suctioningContinuous subglottic suctioning
ETT with dedicated lumen to ETT with dedicated lumen to
continuously or intermittently suction above continuously or intermittently suction above
suction above the cuff may suction above the cuff may
reduce the risk of VAP. reduce the risk of VAP.
Am J Respire cri car Med Oct.. 2010 Am J Respire cri car Med Oct.. 2010

48. Ventilator Circuit-ManagementVentilator Circuit-Management
Vent circuit should not be routinely opened Vent circuit should not be routinely opened
once ventilation is initiatedonce ventilation is initiated
Disconnection of ventilation tubing can lead to Disconnection of ventilation tubing can lead to
loss of PEEP and alveolar de-recruitmentloss of PEEP and alveolar de-recruitment
If circuit must be disconnected, clamp ETT If circuit must be disconnected, clamp ETT
with padded Kelly forceps to avoid PEEP losswith padded Kelly forceps to avoid PEEP loss
Expiratory condensation should be removed via Expiratory condensation should be removed via
the trap in the tubingthe trap in the tubing
Inspiratory condensation – if clean, may be Inspiratory condensation – if clean, may be
drained back into the water reservoirdrained back into the water reservoir
Ventilator circuit can be changed weekly, unless Ventilator circuit can be changed weekly, unless
it is soiled with blood or vomitusit is soiled with blood or vomitus

49. Ventilator Circuits Humidification SystemsVentilator Circuits Humidification Systems
Appropriate Humidification of inspired airAppropriate Humidification of inspired air
Active Humidification or Passive HumidificationActive Humidification or Passive Humidification
Heat and Humidity Exchangers (HMEs) should Heat and Humidity Exchangers (HMEs) should notnot be be
routinely changed unless:routinely changed unless:
Visibly soiledVisibly soiled
> 5 cm H> 5 cm H
22O auto-PEEPO auto-PEEP
Convert to Heated Humidification (HH) if:Convert to Heated Humidification (HH) if:
Ventilated longer than 96 hoursVentilated longer than 96 hours
Thick/bloody secretionsThick/bloody secretions
Resp. AcidosisResp. Acidosis
Air leak from chest tube or around airwayAir leak from chest tube or around airway
VT < 300 cc or > 750 ccVT < 300 cc or > 750 cc

51. Enteral FeedingsEnteral Feedings
Early enternal feeding decrease bacterial Early enternal feeding decrease bacterial
colonization and rate of VAPcolonization and rate of VAP
Bolus feeding should be avoided to minimize Bolus feeding should be avoided to minimize
the risk of aspiration the risk of aspiration
Elevate HOB 30 - 45 degreesElevate HOB 30 - 45 degrees
Routinely verify tube placementRoutinely verify tube placement
No CDC recommendations for:No CDC recommendations for:
Preferential use of small bore tubesPreferential use of small bore tubes
Continuous versus intermittent feedingContinuous versus intermittent feeding
Post pyloric placementPost pyloric placement CDC (2003)CDC (2003)

52. PATIENT TURNING-PATIENT TURNING-
Routine turning of patient for every 2 hrs Routine turning of patient for every 2 hrs
increase pulmonary drainage and decrease the increase pulmonary drainage and decrease the
risk of VAP.risk of VAP.
Use of beds with continues lateral rotation can Use of beds with continues lateral rotation can
decrease the incidence of pneumonia but do not decrease the incidence of pneumonia but do not
decreases mortality or duration of MV decreases mortality or duration of MV
(critical care 2002;30(9):1983-1986)(critical care 2002;30(9):1983-1986)

53. No Data
to Support These Strategies
• Use of small bore versus large bore gastric
tubes
• Continuous versus bolus feeding
• Gastric versus small intestine tubes.
• Closed versus open suctioning methods.
• Kinetic beds.

54. NEW DEVELOPMENTNEW DEVELOPMENT
• National healthcare safety(NHSN) and CDC proposed- National healthcare safety(NHSN) and CDC proposed-
VAP terminology changed to VAC (ventilated associated VAP terminology changed to VAC (ventilated associated
conditions and complications) not necessarily limited VAP.conditions and complications) not necessarily limited VAP.
• VAP Surveillance definination algorithm. VAP Surveillance definination algorithm.
Chest x ray is not included ,Chest x ray is not included ,
And diagnosis is mainly depend on worsening of gas exchange, And diagnosis is mainly depend on worsening of gas exchange,
clinical features, isolation of microorganism in resp.secreationclinical features, isolation of microorganism in resp.secreation..
• ETT-ETT-- - with continuous subglottic suction, ployurethrene cuff,Sponge with continuous subglottic suction, ployurethrene cuff,Sponge
cuff , Silver nitrate and antibiotic coated ETTscuff , Silver nitrate and antibiotic coated ETTs. .
• VAP industrial complex- VAP industrial complex- kinetic beds, inlines suction catheters kinetic beds, inlines suction catheters
• VAP bunddle with 7 components –VAP bunddle with 7 components – 5+ 5+ Replacing NGT to Replacing NGT to
Orogastric tube and Hand washing by health care personnel.Orogastric tube and Hand washing by health care personnel.
IMPLEMENTATION and ENFORCEMENT of VAP bundle IMPLEMENTATION and ENFORCEMENT of VAP bundle

56. SUMMARY
Nosocomial pneumonia and especially VAP are the
most frequent infectious complications in the ICU, and
they significantly contribute to morbidity and mortality.

VAP is an important determinant of ICU and hospital
lengths of stay and healthcare costs.
No standard to diagnose.
Several simple preventive measures(VAP bundle) and
timely initiation of appropriate antibiotics ensure better
outcomes in patients with VAP.