1. Ventillator Associated Pneumonia
DR. MAHMOUD IBRAHIM

2. Ventilator Associated Pneumonia (VAP)
VAP is pneumonia that occurs in patients intubated and on mechanical ventilation for at least 48 hours.
•15% - 50% patients with VAP die
•varies with patient population and organism type
•Highest VAP mortality occurs inpatients with
-severe illness
-infection with non-fermentative Gram negative bacilli
e.g. Acinetobacter sp., etc.
•Increases length of stay >6 ICU days
•Cost $10,000 - $40,000

3. Etiology of VAP Early onset Late onset
•Occurs in first 4 days of hospitalization
•More likely to be caused by Moraxella catarrhalis, H. influenzae, or Strept. pneumoniae
Late onset
•Occurs 5 or more days into hospitalization
•Often caused by Gram-negative bacilli, or S. aureus (including MRSA), yeasts, fungi, legionellae and Pneumocystis carnii

4. Pathogenesis of VAP Results from - Aspiration of secretions (Micro aspirate) - Colonization of aero-digestive tract - Contaminated respiratory or other medical equipment

5. VAP Pathogens •Staphylococcus aureus - 24
VAP Pathogens •Staphylococcus aureus % •Pseudomonas aeruginosa % •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%

6. RISK FACTORS Pre-existing conditions •Head trauma •Coma
•Nutritional deficiencies
•Immunocompromised
•Multi organ system failure
•Acidosis
•Co-morbidities
•History of smoking or pulmonary disease

7. Diagnosis of VAP: These are non specific:
VAP has been diagnosed by clinical criteria.
These are non specific:
*Fever drug reaction, extrapulmonary
infection, blood transfusion .
*Pulmonary infiltrates Pulmonary
haemorrhage, chemical aspiration, pleural
effusion, congestive heart failure, tumor .
Fever and pulmonary infiltrates fibroproliferation of late acute respiratory distress
syndrome, atelectasis, pulmonary embolism.

8. Decisions based on clinical criteria resulted in inappropriate ttt of many patients without pneumonia
(Fagon et al., Chest 1993).

9. Previously Specific Standard Criteria for Diagnosis of VAP
Culture of tracheal aspirates are not very useful in establishing the VAP, although such cultures are highly sensitive, their specificity is low even when they are cultured quantitatively.

10. Specific Standard Criteria for Diagnosis of VAP (cont.)
*Histopathologic examination of lung tissue lung biopsy.
*positive pleural fluid culture.
*lung autopsy.

11. Recently Bronchoscopic Diagnostic Technique:
Two Bronchoscopic techniques are used: 1-Protected specimen brush(PSB) 2-Bronchoalveolar lavage examination (BAL). Both techniques are effective in diagnosis of VAP as the standard specific criteria

14. Direct Non-Bronchoscopic (Blind)Technique:
This involve passage of a catheter or a telescopic catheter through the endotracheal tube with advancement to a wedge position in the lung

15. Paradigm for Diagnosis of VAP
New or Persistent Infiltrates
Pathogenic Bacteria

16. NHSN(National Health Safety Network) surveillance definition for VAP Paient must fulfill each of the three categories below:

17. VAP Surveillance •Follow NHSN protocols
•Work with ICU and respiratory therapy staff to develop alerting process
•Monitor ventilated patient for
Positive cultures
Temperature chart/log
Pharmacy reports of antimicrobial use
Change in respiratory secretions

18. Referred to as “Ventilator-associated events” (VAE)
Surveillance Changes, }{ New approach: a surveillance definition algorithm that detects a broad range of conditions/complications that occur in mechanically ventilated patients
Referred to as “Ventilator-associated events” (VAE)
Includes criteria for
•Ventilator-associated conditions (VAC)
•Infection-related ventilator-associated conditions (IVAC)
•Possible VAP
•Probable VAP

19. VAE/VAP Surveillance Definition
Patient must be ventilated more than 2 calendar days
Patient must have >2 calendar days of stability or improvement of oxygenation followed by >2 calendar days of worsening oxygenation.
Earliest date of event for VAE is mechanical ventilation day 3 (first day of worsening oxygenation).
First possible day that VAC criteria can be fulfilled is mechanical ventilation day 4

20. Pneumonia Surveillance Definition
Surveillance definition can be met by 3 different criteria
Clinically defined pneumonia (PNU1)
Pneumonia with specific laboratory findings (PNU2)
Pneumonia in immuno-compromised patients (PNU3)

21. An alternative paradigm for surveillance:
Ventilator Associate Conditions (VAC) Definition:
≥2 days of stable or decreasing daily minimum PEEP or FiO2
followed by
Rise in daily minimum PEEP ≥3 cm H2O sustained ≥2 days or
Rise in daily minimum FiO2 ≥20 points sustained ≥2 days

22. Infection Related Ventilator Associate Conditions (IVAC)
Definition:
VAC associated with alterations in WBC (<to 4 or ≥ 12) or temperature (< 36 or ≥ 38oC) within 2 days
and
Prescription of antibiotics continued ≥ 4 days

33. MANAGEMENT OF VAP
PREVENTION
TREATMENT

34. VAP Prevention Strategies (Modifiable Risk Factors)
1.Prevent aspiration of secretions
•Maintain elevation of head of bed (HOB) (30-45 degrees)
•Avoid gastric over-distention
•Avoid unplanned extubation and re-intubation
•Use cuffed endotracheal tube with in-line or subglottic suctioning
•Encourage early mobilization of patients with physical/occupational therapy
2.Reduce duration of ventilation
•Conduct “sedation vacations”
•Assess readiness to wean from vent daily
•Conduct spontaneous breathing trials

35. VAP Prevention Strategies - continued
3.Reduce colonization of aero-digestive tract •Use non-invasive ventilation methods when possible - i.e. CPAP, BiPap •Use oro-tracheal over naso-tracheal intubation, Naso-tracheal may cause sinusitis, which increases VAP risk •Use cuffed Endotracheal Tube(ETT) with inline or subglottic suctioning -Minimizes secretions above cuff; prevents contamination of lower airway •Avoid acid suppressive therapy for patients not at high risk for stress ulcer or stress gastritis - Increases colonization of the digestive tract

36. VAP Prevention Strategies - continued •Perform regular oral care with an antiseptic agent •Reduce the opportunities to introduce pathogens into the airway ‒Good hand hygiene ‒Glove use for contact with respiratory secretions or contaminated objects; follow with hand hygiene ‒Educate staff to avoid contaminating the ETT from patient’s mouth, introducing pathogens from patient’s other body sites or the environment

37. VAP Prevention Strategies - continued
4.Prevent exposure to contaminated equipment
•Use sterile H20 to rinse reusable respiratory equipment
•Remove condensate from ventilatory circuits
•Change ventilatory circuit only when malfunctioning or visibly soiled
•Store and disinfect respiratory equipment effectively

38. Interventions Implemented were as per the Canadian VAP Guidelines
Prevention Recommendations
ETT with subglottic secretion drainage
Semi-recumbent positioning (≥45°)
Oral care with Chlorhexidine
Oral route of intubation
Closed suctioning system
New ventilator circuit for each patient
Ventilator circuit changes only if soiled or damaged
Heated humidifier changes every 5-7 days
Change suctioning system only if blocked or damaged 
Muscedere et al, JCC 2008

39. Daily assessment of readiness to extubate &”sedation vacation”
VAP BUNDLE ELEMENTS
Head of bed˃ 300
Daily assessment of readiness
to extubate &”sedation vacation”
Peptic ulcer disease prophylaxsis
DVT prophylaxsis

40. Elevation of The Head of Bed (HOB):
* Please remember to elevate the HOB>30 degree , and raise knees for all ventilated patients unless contraindicated . *Elevation of HOB has been correlated with reduction in the rate of the ventilator associated pneumonia. (Drakulovic Lancet, 1999)

41. The pathogenesis of VAP:
Bacterial colonization of the stomach and oropharynx
Subsequent pulmonary aspiration of contaminated secretion

42. Elevation of The Head of Bed (HOB)(cont.):
*Drakulovic et al., conducted a randomized controlled trial in 85 mechanically ventilated patients assigned to semi-recumbent or supine position.
*Supine patients had an incidence of suspected VAP of 34 percent , while the semi-recumbent patients has an incidence of 8 percent (p=0.003).
(Drakulovic Lancet, 1999)

43. DVT Prophylaxis:
*As elevation of head of bed may contribute to venous stasis and DVT. *The risk of venous thromboembolism is reduced if prophylaxis is consistently applied. *A clinical practice guideline recommends DVT prophylaxis for patients admitted to the ICU. (Geerts , Chest,2004)

44. PUD (Peptic Ulcer Disease)
Prophylactic:
*Stress ulceration are the most common cause of gastrointestinal bleeding in intensive care unit patients . *This predisposed to aspiration and VAP . * Thus applying PUD prophylaxis is a necessary intervention.

45. Sedation Interruption:
Sedation in ICU has the benefit of reducing psychological problems to the patients . However heavy sedation is harmful and predispose to VAP by : Inhibiting coughing Inhibiting mobilization Decreasing immune function Promoting aspiration Prolongs time on ventilator.

46. Optimal Sedation: 2-Cough , swallowing reflexes intact.
1-Awake and cooperative patient.
2-Cough , swallowing reflexes intact.
3-Add analgesia to the protocol .
4- Titration to a sedation score to avoid
oversedating the patient .
5-Intermittent rather than continuous sedation.
6-Sedation vacation (sedation interruption).

47. Sedation Vacation: Application: commands at least once a day.
*Hold sedation until patient is alert or can follow
commands at least once a day.
*After sedation interruption restart sedation at a
fraction of the prior dose (1/2 or 3/4). *Kress et al .,conducted a randomized controlled
trial in 128 adults mechanically ventilated
patients receiving continuous infusion of sedative
agents in a medical ICU, daily interruption of sedation
resulted in a highly significant reduction in time spent
on mechanical ventilation ,from 7.3 days to 4.9 days
(p=0.004).
(Kress, N Engl J Med,2000)

48. Mechanical Ventilation Weaning Protocol:
*Non-physician driven weaning protocol (by nurses or respiratory therapists). *Daily assessment of readiness to wean from ventilator: -keep Vt and pressure low. -preextubation assessment and worksheet . -ETT cuff inflation via minimal leak technique to 20-25cmH2O(minimal occlusive pressure). *This reduce mechanical ventilation days and ventilation associated pneumonia . (Dries JTrauma,2006)

49. Oral Care:
Designed for patients who are intubated or tracheostomized *Mouth care protocol. *Brush twice . *Swab every two hours. *Chlorhexidine rinse. *Apply mouth moisturizer. *Replace suction line, tubing every 24hours (Chlebicki, Crit Care Med,2007)

50. Other Consideration:
*Proper hand washing technique. *Proper care of respiratory equipment. *Proper care of all ICU equipment (monitor, lines, syringes, pumps, ect....).

51. Non Invasive Ventilation (NIV):
*To reduce need and duration of intubation and mechanical ventilation. *Many studies show a decrease in pneumonia and mortality in NIV group patients compared to invasive mechanical ventilation (Girou etal,2000). *Patients population in whom NIV has been effective are:- COPD, pulmonary edema, hypoxemic respiratory failure.

52. Type of NIV: 1-Negative pressure ventilation
2-Positive pressure ventilation (BIPAP or CPAP).

53. Negative non invasive ventilation:
Ventilation by lowering the pressure surrounding the chest wall during inspiration and reversing the pressure to atmospheric level during expiration. The device augment the tidal volume by generating negative extra thoracic pressure.

55. Positive non invasive ventilation:
Technique supplying positive pressure ventilation support to the airways through masks attached to a patients nose or mouth.
CPAP......raise the functional residual capacity or open collapsing obstructed airways. BIPAP.....also reduce the inspiratory muscle load.

59. Patients in whom NIV is effective are :
1-Acute respiratory failure
~acute exacerbation of COPD.
~acute respiratory distress syndrom ARDS
~pneumonia.
2- Acute heart failure......decrease preload and afterload .....beneficial on cardiac output and blood pressure in addition to improved ventilation.
3-Weaning from mechanical ventilation.

60. Contra- indication to NIV:
~respiratory arrest
~inability to use mask because of trauma or surgery.
~excessive secretion
~hemodynamic instability
~impaired mental status

61. Antibiotics *The ATS (American thoracic society)
has focus on pseudomonas
aeruginosa as an important factor in
the ttt algorism of VAP.
*Patient with suspicious Pseudomonus aeruginosa combination therapy
with a beta lactam antibiotic (penicillin or
cephalosporin) plus quinolone or beta lactam with aminoglycoside .

62. Antibiotics (cont.)
*Patient without suspicious of Pseudomonus aeruginosa.....second or third generation cephalosporin plus macrolide or quinolone .
*Empiric initial therapy is started immediately upon presentation with VAP till cultures and gram stains of collected sputum is performed then therapy is tailored to these results.

63. Summary *VAP is an important cause of death in ICU.
*It is a presentable disease.
*VAP bundle may prevent the disease and enhance the outcome .
*In the past the specific diagnosis of VAP was difficult and need invasive procedures. (Lung biopsy).

64. Summary *Bronchoscopy …….specific and sensitive diagnosis.
*Antibiotics……. Should be started immediately then tailored according to culture and gram stains.

65. Thank You