VENTILATOR ASSOCIATED PNEUMONIA.ppt

VENTILATOR ASSOCIATED PNEUMONIA.ppt

1. VENTILATOR
ASSOCIATED
PNEUMONIA
Monday, March
13, 2023
1
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

2. VAP(VENTILATOR ASSOCIATED PNEUMONIA)
ANosocomialpneumonia associatedwithmechanical
ventilation(eitherbyEndotrachealtubeorTracheostomy)that
developswithin48hoursormoreofhospitaladmissionand
whichwasnotpresentatthetimeofadmission.
Monday, March 13, 20232
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

3. Epidemiology
Hospitalacquiredpneumonia(HAP)isthesecondmost
commonhospitalinfection.
VAPisthemostcommonintensivecareunit(ICU)infection.
90%ofallnosocomialinfectionsoccurringinventilated
patientsarepneumonias.
Monday, March 13, 20233
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

4. VAP…….
Monday, March 13, 2023
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.
4
TYPES
Early–Onset(<96hoursofintubationor
ICUadmission)
•Community-acquired
•Pathogens:Streptococcus pneumoniae,
Haemophilus influenzae,Staphylococcus
aureus
•Antibiotic-sensitive
Late-Onset(>96hoursofintubationorICU
admission)
•Hospital-acquired
•Pathogens: Pseudomonas
aeruginosa,MRSA, Acinetobacter
Enterobacter.
•Antibiotic-resistant

5. INCIDENCE
VAPoccursin10-65%ofallventilatedpatients.
IncidenceincreaseswithdurationofMV3%/dayforfirst
5days,2%/dayfor6-10daysand1%/dayafter10days.
Mortalityrateis27%&43%withantibioticresistantorganism.
MortalityrateinVAPcausedbyPseudomonas and
Acinetobacterisashighas76%
Increasesventilatorysupportrequirements,LOS,MEDICAL
COST
Monday, March 13, 20235
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

6. HOST RELATED:-Medical /surgical disease, Immunosuprssion,
Malnutrition (Alb<2.2g/dl ), Advanced age, Supine position,Level
of conciousness, Medication-NMB, sedation, steroids, Previous
antibiotic use.
HEALTHCARE PERSONNEL RELATED: -Improper hand
washing, Failure to change gloves and mask gown when ever
required.
DEVICE RELATED:-MV with ETT or TRACHEOSTOMY TUBE,
MV>48 hrs, Reintubations, NGT or Oro-gastric tube,Use of
Humidifier.
RISK FACTORS
Monday, March 13, 20236
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

7. PATHOGENESIS
Bacteria enter the lower respiratory tract via following pathways:
Aspiration of organisms from the oropharynx and GI
tract (most common cause)
Direct inoculation (through improper suctioning)
Inhalation of bacteria
Haematogeneous spread
Monday, March 13, 20237
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

8. HOW DO WE DIAGNOSE? 2 -1-2
Radiographic evidence x 2 consecutive days
New, progressive or persistent infiltrate
Consolidation, opacity, or cavitation
Clinical sings 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 of gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)
Monday, March 13, 20238
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

9. Ventilator Associated Pneumonia Care
Bundle -Evidence Based Practices
HeadOfBedelevatedto30˚-45˚
Dailysedationvacation&dailyassessmentofreadinessto
weanoff.
DVTProphylaxis
StressUlcerProphylaxis
Subglotticsecretiondrainage
Dailymouthcarewithchlorhexidine
Monday, March 13, 20239
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

10. HOB UP 30 DEGREES OR
HIGHER
Recommended elevation is 30-45 degrees,
If semi-recumbent or supine ↑34% incidence VAP,
↑HOB → ↓risk of aspiration of gastrointestinal contents,
↓risk of aspiration of oropharyngeal secretions,
↓risk of aspiration of
↑HOB improves patients’ ventilation,
↑HOB may aid ventilatory efforts and minimize atelectasis
unless contraindiacated,
Monday, March 13, 202310
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

11. Sedationvacationresultsinsignificantreductionintimeon
mechanicalventilation.
Ifthepatientisco-operativeandabletounderstand
commandsleavethesedationoff.Distressedoragitated
patientsrequirere-sedating.
Administerbolusesasappropriatetoachievesafety.
Monday, March 13, 202311
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

12. 3. Peptic Ulcer Disease (PUD) Prophylaxis
Criticallyillintubatedpatientslacktheabilitytodefendtheir
airway.
DecreasingpHofgastriccontentsmayprotectagainst
greaterpulmonaryinflammatoryresponsetoaspirationof
gastrointestinalcontents.
Monday, March 13, 202312
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

13. 4.Deep Vein Thrombosis (DVT) Prophylaxis
Mechanically-ventilatedpatientsareathighriskforVTE.Riskfactorsinclude
immobilityandastressinflammatoryresponseresultinginhypercoagulation.
AlthoughthereisnoevidencetosuggestVTEprophylaxisreducesVAPrisk,it
isappropriatetoincludeVTEprophylaxisinabundlethatpromotesimproved
careofmechanically-ventilatedpatientsduetotheirhighriskforVTE.
Monday, March 13, 202313
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

14. 5.Subglottal Suctioning
Should be done using a 14 Fr sterile suction catheter:
Prior to ETT rotation
Prior to lying patient supine
Prior to extubation
Monday, March 13, 202314
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

15. 6. mouth care with chlorhexidine
Most bacterial nosocomial pneumonias are caused by aspiration
OF bacteria colonizing the oropharynx and upper GI tract of the
patient.
Gram-positivebacteriaoftenconstitutetheoralmicrofloraofhealthyindividuals.
However,thebalanceoforalmicrofloraofpatientshospitalizedinICUsformorethan
48htendstochange.ThesechangesleadtoaprevalenceofGram-negative
bacteriasuchasStaphylococcusaureus,Streptococcuspneumoniae,
Acinetobacterbaumanii,Haemophilus influenzae,andPseudomonas
aeruginosa.Thesebacteriahaveallbeenassociatedwithnosocomialpneumonia
Mouthcareshouldbegivenineveryshiftorevery6hrs.
Monday, March 13, 202315
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.

16. GENERAL INSTRUCTIONS
HAND WASHING
STERILE SUCTIONING (DO NOT REUSE SUCTION
CATHETER)
2 ND HOURLY POSITIONING.
ENTERAL FEEDING
USE OF PPE
Monday, March 13, 202316
Mr. Sandeep Kumar M, ANS, AIIMS BHOAPL.