Linda R Greene Rochester General Hospital Rochester, NY

Nothing to Declare

 Describe the epidemiology and pathogenesis of ventilator associated pneumonia  Compare and contrast the current definition of ventilator associated pneumonia with the proposed revised definition  List at least 3 evidence based practices to prevent ventilator associated pneumonia.  Discuss future trends and strategies in prevention  ventilator associated pneumonia

Early Work On VAP Prevention

GAO Report on HAIs in hospitals April 2008

 Leadership needed from HHS to prioritize preventive practices  Improve central coordination  Identify priorities  Increase reliable estimates of HAIs

The literature supporting high-profile measures to reduce ventilator-associated pneumonia (VAP): Many studies show significant reductions in VAP rates but almost none show any impact on patients' duration of mechanical ventilation, length of stay in the intensive care unit and hospital, or mortalitY Klompas M, Platt R. Ventilator-associated pneumonia – the wrong quality measure for benchmarking. Ann Intern Med. 2007;147:

 Lack of specificity in the VAP definition  Array of events from critical to benign  Benign events may actually capture colonization

Pleural effusion or atelectasis however, pneumonia cannot be rule out Opacities in lower lobe may be atalectasis, pneumonia or emphysematous changes Bibasilar changes which may represent atelectasis, pneumonia or edema

Must be vetted with Physicians Start with sputum specimen Daily rounding Daily review of CXR Determination by ICU Staff Differences in NYS among IPs collecting data

Prevention Strategies Bundles Burden on IP – less time for surveillance

 Pressure to have a VAP outcome measure for public reporting

 Stakeholder meetings  VAP working group  Objective Definition  Clinically relevant

 Representation from all major stakeholder groups: CDC IDSA CSTE APIC SHEA ATS Critical Care Society

VAP sVAP VAC Valor i

Mechanical ventilation is primary risk factor: The endotrachel tube acts as a conduit from the upper respiratory tract to the lower respiratory tract Secretions collect on and around the cuff causing leakage of fluids into the lower respiratory tract Sedation inhibits the natural ability to clear secretions Patients undergoing mechanical ventilation are frequently fed via nasogastric tubes contributing to aspiration Critically ill patients are often maintained in a supine position Activity is limited

Cuffs: current recommendation is that cuff pressure should be maintained at no less than 20 cm H2O Some controversy that cuff design may be more important Than cuff pressure Tube related issues primarily include aspiration of contaminated secretions from above the cuff

LocationDefense Mechanism Upper Airway NasopharynxNasal Hairs Turbinates Upper airway anatomy Mucociliary apparatus IgA secretions OropharynxSaliva Sloughing of epithelial cells Bacterial Interference Complement Production

LocationDefense Mechanism Conducting Airways Trachea, BrochiiCoughing, epiglottic reflexes Airway branching Mucocillary apparatus Immunoglobulin production Airway Surface Liquid Lower Airways Terminal airways Alveoli Alveolar lining fluid Cytokines Alveolar Macrophages Polymorohonuclear Leukocytes Cell- mediated Immunity

What about Prevention Efforts?

If unable to bend at the hip - use Reverse Trendelenberg

 Head of bed elevation: controversial, hard to maintain, but still recommended by most authors.  Must be at least 30 degrees, and must measure, not estimate

Reduced VAP incidence in some studies but not others, does not hold up in metanalysis Probably good for reducing length of ventilation and ICU stay though

 Not part of original bundle  Chlorohexidine recommended in increasing number of studies: Oral Decontamination with Chlorhexidine Reduces the Incidence of Ventilator-associated Pneumonia Koehman et alAmerican Journal of Respiratory and Critical Care Medicine Vol 173. pp , (2006) © 2006 American Thoracic SocietyAmerican Thoracic Society

Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. Chan et. Al BMJ 2007, 334:889. Randomized Controlled Trial and Meta-analysis of Oral Decontamination with 2% Chlorhexidine Solution for the Prevention of Ventilator-Associated Pneumonia Tantipong et L infection control and hospital epidemiology february 2008, vol. 29, no. 2

 Effect of oral hygiene with o.12% chlorohexidine gluconate on the Incidence of Nosocomial Pneumonia in children undergoing cardiac surgery Jacomo et al. ICHE et al. June 2011 vol 3 no 6

The Basic Bundle HOB Monitoring Sedation Vacation PUD Prophylaxis DVT prophylaxis Enhanced Bundle Mouth Care- consider chlorohexidine Education and Training Program New Generation ET tubes Oral gastric tubes Ambulation

Antimicrobial coating of ET tubes e.g., silver coating, silver-sulfadiazene, chlorhexidine- recommended by some BIOFILM - Once microorganisms have made contact and formed an attachment with a living host or non-living surface or object, development of a biofilm can take place. Bacteria living in a biofilm can have significantly different properties from free-floating bacteria, as the dense extracellular matrix of biofilm and the outer layer of cells may protect the bacteria from antibiotics and normal host defense mechanisms of the white blood cells, such as phagocytosis Rationale

 Avoid Intubation if possible -Non-invasive ventilation: avoiding intubation will avoid VAP, so use NIV whenever possible  Weaning: the longer you are on the ventilator, the more likely you are to get VAP. Weaning protocols have been conclusively shown to improve the rate of weaning from the ventilator

Implementation Science – How do we get evidence to the bedside ? We have to take a closer look at processes

EngageEducateExecuteEvaluate

Staff Education & Training!

staff feedback!

Months without a VAP 10 mo 1 mo

 Look at other outcomes  Mortality, readmission rates, length of stay  Use data to continually evaluate effectiveness of interventions

 Communicate consistently: disseminate results of process and outcome measures.  Connect to purpose: help staff understand how simple actions connect to outcomes.  Review Deviations: review all cases to identify opportunities and system issues.