1. Rev: 17 January 2019

2. Ventilator Associated Pneumonia
Diagnosis of VAP was covered in the previous discussion
Rev: 17 January 2019

3. Adult Ventilator Bundle
VAP prevention measures
Handwashing
Patient positioning
Oral care
Management of oropharyngeal and tracheal secretions
Daily “Sedation Vacation” and daily assessment of readiness to extubate
General measures to improve care
Peptic ulcer disease prophylaxis
Deep vein thrombosis (DVT) prophylaxis
Rev: 17 January 2019

4. Handwashing
Strict handwashing before and after handling patient or patient’s equipment or supplies
Rev: 17 January 2019

5. Patient Positioning
Elevate the Head of the Bed 30-45o by flexing bed or reverse Trendelenberg
Reduces chance of gastric reflux and aspiration of gastric contents
Proper position in bed
keep joints in neutral, semi-flexed position
minimize abdominal compression
Rev: 17 January 2019
Drakulovic MB. Lancet.1999;354:

6. Evidence for Elevating Head of Bed
Elevate the Head of the Bed 30-45o by flexing bed or reverse Trendelenberg
Randomized controlled trial: 86 adult intubated patients on mechanical ventilation assigned to semi-recumbent (45o) or supine position
Semi-recumbent: Supine:
Suspected VAP: 8% %
(CI for difference 10-42%: p=0.003)
Confirmed VAP: % %
(CI for difference 4-32%: p=0.018)
Rev: 17 January 2019
Drakulovic MB. Lancet.1999;354:

7. Patient Positioning Precautions
Head elevation in patient with hypovolemia - possible significant hypotension
Transporting patients on ventilatory support
Spine precautions
May need to use Reverse Trendelenberg
Rev: 17 January 2019
Drakulovic MB. Lancet.1999;354:

8. Positioning DO’s and DON’Ts
Maintain HOB > 30 degrees unless contraindicated.
Leave patient in supine position for prolonged periods
Forget to turn tube feedings off prior to placing patient in supine position
Continue Q 2 hour turning schedule. 
Rev: 17 January 2019

9. Rev: 17 January 2019
Picture from Sage

10. Oral care Colonization of oropharynx -
Normal flora includes both Gram-positive and anaerobic bacteria.
When normal flora compromised, more susceptible to colonization by microorganisms (e.g., Gram-negative bacilli), not normally found in oropharyngeal secretions.
Migration to lower airway can lead to VAP
Pfeifer, LT; Orser, L.; Gefer, C.; McGuinness, R.; and Hannon, CV (2001). Preventing ventilator-associated pneumonia. American Journal of Nursing, 101(8), 24AA-24GG.
Rev: 17 January 2019

11. Oral care Colonization of Oropharynx - Dental Plaque
Colonization of dental plaque is either present on admission or acquired in 40% of ICU patients.
Positive dental plaque culture significantly associated with subsequent nosocomial infections – particularly aerobic pathogens.
ICU patients at risk due to:
Difficulties performing adequate oral hygiene
Changes in properties of saliva
Reduction of anaerobic flora secondary to antibiotics
Fourrier, F.; Buvivier, B.; Boutigny, H.; Roussel-Delvallez, M, and Chopin, C. (1998) Colonization of dental plaque: A source of nosocomial infections in intensive care unit patients. Critical Care Medicine 26:
Rev: 17 January 2019

12. Oral care Protocol Assess oral cavity at least every shift
Brush teeth each shift with suction oral brush and 1.5% hydrogen peroxide solution
Oral care every 2 hours with suction oral swabs and 1.5% hydrogen peroxide solution
Hypopharyngeal/subglottic suctioning at least q6h and as necessary
Apply mouth moisturizer as needed
Sage oral care kit can make compliance easier
Rev: 17 January 2019

13. Management of Oral and Tracheal Secretions
Proper care of oral and tracheal secretions is essential to minimize risk of aspiration
To prevent aspiration of pooled secretions hypopharyngeal suctioning should be performed before
suctioning the ETT
repositioning the ETT
deflating the cuff
repositioning your patient
Rev: 17 January 2019

14. Management of Oral and Tracheal Secretions (3a)
Care of Equipment:
Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O)
Rev: 17 January 2019

15. Management of Oral and Tracheal Secretions (3b)
Care of Equipment:
Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O)
Use Ballard system or use 2 people to assist
Rev: 17 January 2019

16. Management of Oral and Tracheal Secretions (3c)
Care of Equipment:
Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O)
Use Ballard system or use 2 people to assist
Keep end of vent circuit, suction catheter or Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper or towel.
Rev: 17 January 2019

17. Management of Oral and Tracheal Secretions (3d)
Care of Equipment:
Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O)
Use Ballard system or use 2 people to assist
Keep end of vent circuit, suction catheter or Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper or towel.
Help keep the vent circuit free from accumulated water. Drain water away from the patient.
Rev: 17 January 2019

18. Management of Oral and Tracheal Secretions (3e)
Care of Equipment:
Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O)
Use Ballard system or use 2 people to assist
Keep end of vent circuit, suction catheter or Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper (from gloves or gauze).
Help keep the vent circuit free from accumulated water. Draining water away from the patient.
Change the suction canister and mouth care kit every 24 hours.
Rev: 17 January 2019

19. Management of Oral and Tracheal Secretions (3f)
Care of Equipment:
Maintain endotracheal tube cuff pressure at desired level (usually ~20 cmH2O)
Use Ballard system or use 2 people to assist
Keep end of vent circuit, suction catheter or Yankauer tip and patient’s manual ventilation bag off the bed. Hang them up or place them on a sterile paper (from gloves or gauze).
Help keep the vent circuit free from accumulated water by draining water away from the patient.
Change the suction canister and mouth care kit every 24 hours.
Rev: 17 January 2019

20. Sedation Vacation
Sedation vacation: discontinuation of sedation until patient is responsive (awake)
128 adults on mechanical ventilation randomized to sedation vacation group or control sedation group.
Duration of ventilation:
sedation vacation group 4.9 days
control sedation group 7.3 days
(p=0.004)
Rev: 17 January 2019
Kress JP. N Engl J Med. 2000; 342:

21. PUD Prophylaxis
Why?
Reduces acid production in stomach and the consequent risk of bleeding from gastric erosions and peptic ulcers
Identified Issues and Concerns
Some studies have shown increased rates of ventilator associated pneumonia in patients on prophylactic treatments, e.g. sucralfate
Anecdotal Experience
None significant
Rev: 17 January 2019

22. PUD Prophylaxis Surviving Sepsis Campaign Guidelines:
“Stress ulcer prophylaxis should be given to all patients with severe sepsis. H2 receptor inhibitors are more efficacious than sucralfate and are the preferred agents. Proton pump inhibitors have not been assessed in a direct comparison with H2 receptor antagonists and, therefore, their relative efficacy is unknown. They do demonstrate equivalency in ability to increase gastric pH.”
Dellinger RP. Crit Care Med. 2004; 32:
Rev: 17 January 2019

23. DVT Prophylaxis
Systematic review of risks of venous thromboembolism and its prevention:
“We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).”
Geerts WH. Chest. 2004; 126: 338S-400S.
Rev: 17 January 2019

24. Deep vein thrombosis (DVT) prophylaxis
Atlas Toolkit: keyword search DVT
Educational Materials
Risk Assessment and Order sets
Utilization Monitoring/Evaluation Strategies
HCA Facility Examples
Healthstream Education Module
1. Log into Healthstream
2. Select the Find tab at the top of the screen
3. Select the category Patient Safety
4. Select the sub-category Medication Safety
5. Click the course name: Venous Thromboembolism Risk Screening and Prophylaxis
Rev: 17 January 2019

25. Pediatric Ventilator Bundle Applies to patients of ages 1month- 13 years
Same as Adult
VAP prevention measures
Handwashing
Patient positioning
Oral Care
Management of oral and tracheal secretions
Daily assessment of readiness to extubate
General measures to improve Critical Care
Peptic ulcer disease prophylaxis
Different from Adult
VAP prevention measures: Sedation Vacation
Deep vein thrombosis prophylaxis
Rev: 17 January 2019

26. Neonatal Ventilator Bundle (0-28 days of age)
No clear data on proven measures to reduce VAP in neonates. Recommendations based on “common sense” best practice.
Same as Adult
VAP prevention measures
Handwashing
Management of oral and tracheal secretions
Daily assessment of readiness to extubate
Different from Adult
Patient positioning
Oral Care
Daily “Sedation Vacation”
General measures to improve Critical Care
Peptic ulcer disease prophylaxis
Deep vein thrombosis (DVT) prophylaxis
Rev: 17 January 2019

27. Summary: Consider these Components for your Interventions and Checklists
Handwashing
Before entering patient room
On exiting patient room
Patient Position
Bed elevated degrees
Patient properly positioned in bed
Proper Oral Care every 2 hours
Rev: 17 January 2019

28. Summary: Consider these Components for your Interventions and Checklists
Secretion Management
Check and maintain proper ETT cuff pressure
Use inline (Ballard) ETT suction
Suction hypopharyngeal secretions as needed
Keep end-of-circuit suction catheter clean and off patient bed
Rev: 17 January 2019

29. Summary: Consider these Components for your Interventions and Checklists
Care of Ventilator Equipment
Circuit drained of accumulated condensed water
Change suction canister and oral care kit daily
Sedation Vacation
Discontinue sedation daily
Rev: 17 January 2019

30. For a Successful Strategy to Reduce VAP
Set an Aim: “Improve the health and well-being of ventilated patients by reducing the VAP rate.”
Set goals: for example: “Reduce VAP rate by 50% by April 2006.” “Implement use of ventilator bundle with greater than 95% reliability.”
Plan Well: Adopt a change methodology that
accelerates improvement such as The Model for Improvement.
Benchmark: use national benchmark (e.g., National Healthcare Safety Network - NHSN)
Rev: 17 January 2019

31. Selected references
Drakulovic MB, Torres A, et al. Supine body position as a risk factor for noscomila pneumonia in mechanically ventilated patients: a randomized trial. Lancet.1999;354:
Pfeifer LT, Orser L, Gefer C, McGuinness R, Hannon CV. Preventing ventilator-associated pneumonia. American Journal of Nursing. 2001; 101(8), 24AA-24GG
Fourrier F, Buvivier B, Boutigny H, Roussel-Delvallez M, Chopin C. Colonization of dental plaque: A source of nosocomial infections in intensive care unit patients. Critical Care Medicine. 1998;26:
Kress JP, Pohlman AS, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000; 342:
Schweickert WD, Gehlbach BK, et al. Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Crit Care Med. 2004, 32(6):
Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53 (RR-3):1-36.
IHI.org: A resource from the Institute for Healthcare Improvement. Getting Started Kit: Prevent Ventilator-Associated Pneumonia, Bibliography. Accessed April
American Thoracic Society Documents. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:
Garcia R. Addressing JCAHO’s Patient Safety Goal #7: Focus on Key HICPAC Strategies for the Prevention of VAP. Brookdale University Medical Center, Brooklyn, NY:APIC Seminar; 2004
Rev: 17 January 2019