1. Ventilator Associated Pneumonia (VAP)
Author: Marianne Chulay, RN, DNSc, FAAN
Consultant, Clinical Research and Critical Care Nursing
Reviewers: Suzi Burns, Mary Jo Grap,
Judy Verger, and Lori Jackson
Issued 01/2008
Ventilator Associated Pneumonia (VAP) Practice Alert

2. Prevention of Ventilator Associated Pneumonia (VAP)
Ventilator Associated Pneumonia (VAP) Practice Alert

3. Lecture Content Epidemiology of VAP Prevention strategies
HOB elevation
Ventilator equipment changes
Continuous removal of subglottic secretions
Handwashing
Presentation relies on research based guidelines from national groups, governmental agencies or expert groups.
Ventilator Associated Pneumonia (VAP) Practice Alert

4. Epidemiology of Ventilator Associated Pneumonia (VAP)
Ventilator Associated Pneumonia (VAP) Practice Alert

5. Nosocomial Pneumonias
Account for 15% of all hospital associated infections
Account for 27% of all MICU acquired infections
Primary risk factor is mechanical ventilation (risk 6 to 21 times the rate for nonventilated patients)
Accounts for 15% of all hospital associated infections
Accounts for 27% of all MICU acquired infections
Primary risk factor is mechanical ventilation (risk 6 to 21 times the rate for nonventilated patients). Within 48 hours of intubation, the upper respiratory tract is colonized with bacteria, most commonly Gram negative bacilli.
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Craven, Chest 2000; 117:186S-187S.
Ventilator Associated Pneumonia (VAP) Practice Alert

6. Susceptibility to Nosocomial Pneumonias
A primary factor in the high incidence of nosocomial pneumonias in critically ill patients is probably related to the intubation of their respiratory tract for airway management and ventilatory support. This invasion, coupled with altered host defenses, is a treacherous combination. Many critically ill patients are immunocompromised due to their underlying problem, such as HIV disease, cancer or related to the stress of the critical illness. Quickly the trachea becomes colonized with a variety of organisms, most notably, Gram negative bacilli, leading to infection of the lower respiratory tract, pneumonia.
Increased
Nosocomial
Pneumonias
Altered
Host
Defenses
Tracheal
Colonization
Intubation
Ventilator Associated Pneumonia (VAP) Practice Alert

7. Primary Route of Bacterial Entry into Lower Respiratory Tract
Micro or macro aspiration of
oropharyngeal pathogens
Leakage of secretions
containing bacteria around
the ET cuff
Ventilator Associated Pneumonia (VAP) Practice Alert

8. VAP Etiology Staphlococcus aureus resistant organisms
Most are bacterial pathogens, with Gram negative bacilli common
Pseudomonas aeruginosa
Proteus spp
Acinetobacter spp
Staphlococcus aureus
Early VAP associated with non-multi-antibiotic-
resistant organisms
Late VAP associated with antibiotic-resistant organism
Early VAP (within 96 hours) is associated with non-multi-antibiotic-resistant organisms:
E coli
Klebsiella
Proteus
Streptococcus pneumoniae
Hemophylus influenza
Oxacillin sensitive Staphlococcus aureus
Late VAP associated with antibiotic-resistant organisms:
Pseudomonas aeruginosa
Oxacillin resistance Staphaerius and Acinetobacter
Ventilator Associated Pneumonia (VAP) Practice Alert

9. Significance of Nosocomial Pneumonias
Mortality ranges from 20 to 41%, depending on infecting organism, antecedent antimicrobial therapy, and underlying disease(s)
Leading cause of mortality from nosocomial infections in hospitals
Depending on the underlying illness, length of ICU stay and use and duration of mechanical ventilation, mortality can vary from 20 to 70%.
Nosocomial pneumonias are the leading cause of mortality related to nosocomial infections.
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Heyland et al, Am J Respir Crit Care Med 1999; 159:1249
Bercault et al, Crit Care Med 2001; 29:2303
Ventilator Associated Pneumonia (VAP) Practice Alert

10. Significance of Nosocomial Pneumonias
Increases ventilatory support requirements and ICU stay by 4.3 days
Increases hospital LOS by 4 to 9 days
Increases cost - > $11,000 per episode
Estimates of VAP cost / year for nation > $ 1.2 billion
The occurrence of nosocomial pneumonia in critically ill patients:
increases their requirements for mechanical ventilatory support, both the length of ventilatory support and the amount of supplemental oxygen and minute ventilation required.
and the length of stay is also increased, which also means,
an increased cost. In the US, a nosocomial pneumonia typically increases costs by > 11,000 dollars per episode, with an estimate of > 1.2 billion dollars /year cost for the USA.
Heyland et al, Am J Respir Crit Care Med 1999;159:1249
Craven, Chest 2000;117: S
Rello et al, Chest 2002;122:2115
Safdar et al, Critical Care Medicine 2005;33:
Ventilator Associated Pneumonia (VAP) Practice Alert

11. VAP Prevention
Ventilator Associated Pneumonia (VAP) Practice Alert

12. Continuous Removal of Subglottic Secretions
Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation.
ET tubes with an additional lumen for the removal of subglottic secretions have been found to decrease VAP in some studies by as much as 20 to 40%
Extra cost of the tubes will more than be paid for by the decrease in VAP costs.
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005
Ventilator Associated Pneumonia (VAP) Practice Alert

13. Continuous Removal of Subglottic Secretions
Mahul et al. Int Care Med 1992;18:20-25
Valles et al. Ann Int Med 1995;122:
Kollef et al. Chest 1999;116:
Smulders et al. Chest 2002;121:
Dezfulian et al. Am J Med 2005;118:11-18 (meta-analysis)
Studies to support HOB elevation:
Two studies have found that when radioactively labeled enteral feeding was given to patients, higher counts of radioactive material were found in ET tube secretions when patients were in the supine position as compared to a position with the HOB elevated
Ventilator Associated Pneumonia (VAP) Practice Alert

14. VAP Reduction with ET Suction Above the Cuff
This data are from the most recent study by Smulders et al. They studied 150 general ICU patients who had an expected duration of mechanical ventilation of > 72 hours. Patients were randomly assigned to one of two groups: one received a conventional oral ET and the other group received an oral ET with a dorsal suction lumen. Suction was applied in an intermittent fashion.
VAP rates were significantly lower in the suction group, with only 4% of the patients being dx with VAP, whereas 16% of the group without suction experienced VAP.
Results all of the other studies demonstrate a reduction in VAP when suction is applied above the ET cuff site.
Smulders et al. Chest;121:
Ventilator Associated Pneumonia (VAP) Practice Alert

15. HOB Elevation
HOB at 30-45º
Positioning HOB in an elevated angle, if not medically contraindicated, is very important.
Studies have shown, though, that even when no contraindication to HOB elevation is present, the rate of backrest elevation is low.
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005
Ventilator Associated Pneumonia (VAP) Practice Alert

16. HOB Elevation
Torres et al, Annals of Int Med 1992;116:
Ibanez et al. JPEN 1992;16:
Orozco-Levi et al. Am J Respir Crit Care Med 1995;152:
Drakulovic et al. Lancet 1999;354:
Davis et al. Crit Care 2001;5:81-87
Grap et al. Am J of Crit Care :
Studies to support HOB elevation:
Two studies (Torres and Orozco-Levi) have found that when radioactively labeled enteral feeding was given to patients, higher counts of radioactive material were found in ET tube secretions when patients were in the supine position with no HOB elevation as compared to a position with the HOB elevated.
Some of these studies have shown a strong association of supine positioning, enteral feeding, and the occurrence of VAP.
Gastric reflux is presumed to be the underlying cause of the higher radioactive counts and higher incidence of VAP in patients with no HOB elevation.
HOB at 30-45º
Ventilator Associated Pneumonia (VAP) Practice Alert

17. HOB Elevation Leads to Significant Deduction in VAP
Studies have also shown a dramatic decrease in VAP when a simple HOB elevation is done.
These data are from a study by Drakulovic et al in 86 intubated and mechically ventilated patients in a medical and respiratory ICU.
Subjects were randomly assigned to either 0 degrees or 45 degree HOB elevation.
VAP was detected in 2 of 39 patients (5%) in the HOB elevation to 45 degree group and 11 of 47 patients (23%) of the 0 degree HOB elevation.
The risk reduction was 78% for patients placed in the HOB elevation to 45 degrees.
Dravulovic et al. Lancet
1999;354:
Ventilator Associated Pneumonia (VAP) Practice Alert

18. Is HOB Elevation Done? Despite effectiveness of HOB elevation,
compliance is poor.
Grap et al. Am J Crit Care 1999;8:
Grap et al. Am J Crit Care 2005;14:
Degrees of
HOB Elevation
Despite the overwhelming nature of the findings of HOB elevation, observational studies have found that only a minority of critically ill patients (30%) have HOB elevation in the recommended range.
Mary Jo Grap and colleagues in 99 found that on average, backrest elevation in 347 measurements of 52 critically ill patients were only 23 degrees, with less than 30% of the patients achieving the recommended > 30 degree elevation recommendation.
In 2005, Mary Jo Grap found that mean HOB elevation was 21.7° in 66 ICU patient and that the patients were < 30° 72% of the time and < 10° 39% of the time. Combination of time spent in low backrest on day 1 and higher Apache II scores were significantly associated with VAP
It was for this very reason that AACN decided to include HOB elevation in the VAP Practice Alert statement. This simple nursing intervention can have very dramatic improvements in VAP rates.
Ventilator Associated Pneumonia (VAP) Practice Alert

19. Frequency of Equipment Changes
No Routine Changes
Ventilator
Tubing
Between
Patients
Not Enough
Data
Inner Cannulas of Trachs
Ambu
Bags
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Ventilator Associated Pneumonia (VAP) Practice Alert

20. Handwashing What role does handwashing play in nosocomial pneumonias?
cross colonization plays a major role in the spread of nosocomial pathogens.
Gram negative bacilli are ubiquitous and often present in high concentrations in critically ill patients, the hospital environment and on the hands of hospital personnel. Especially problematic in the intubated patient is the ventilator tubing - high colony counts exist near the mouth piece.
Washing hands before and after every patient contact is a very effective strategy to prevent cross contamination. Gloves should be worn by person’s with open lesions or dermatitis.
Despite the Center for Disease Control in Atlanta’s recommendation to wash hands after every patient contact, most studies on hand washing find that <50% of the time that HCW follow this recommendation.
Albert, NEJM 1981; Preston, AJM 1981;
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Ventilator Associated Pneumonia (VAP) Practice Alert

21. VAP Prevention
Wash hands or use an alcohol-based waterless antiseptic agent before and after suctioning, touching ventilator equipment, and/or coming into contact with respiratory secretions.
The CDC recommends that hand washing occur before and after suctioning, whenever ventilator equipment is touched and/or if staff come in contact with respiratory secretions.
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP, 2007
Ventilator Associated Pneumonia (VAP) Practice Alert

22. VAP Protection
Use a continuous subglottic suction ET tube for intubations expected to be > 24 hours
Keep the HOB elevated to at least 30 degrees unless medically contraindicated
All these CDC recommendations are at level IA:
Use a continuous subglottic suction ET tube for all intubations expected to be > 24 hours.
Keep the HOB elevated to at least 30 degrees unless medically contraindicated.
Vent circuit - do not change routinely; change when visibly soiled / malfunctioning. Periodically drain / discard condensate in tubing – away from patient
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
AACN Practice Alert for VAP, 2007
Ventilator Associated Pneumonia (VAP) Practice Alert

23. 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
Research on the following strategies have not shown any difference in VAP rates:
Small bore versus large bore gastric tubes
Continuous versus bolus feeding
Closed versus open suctioning methods
Use of special beds (lateral rotational therapy, kinetic beds)
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Ventilator Associated Pneumonia (VAP) Practice Alert

24. Oral Care
Role of oral care, colonization of the oropharynx, and VAP unclear – dental plaque may be involved as a reservoir
Limited research on impact of rigorous oral care to alter VAP rates
Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
Role of oral care, colonization of the oropharynx, and VAP unclear – dental plaque may be involved as a reservoir
Limited research on impact of rigorous oral care to impact VAP rates.
Only 1 study has shown a decrease in VAP with the use of an oral chlorhexadine rinse, and that was done in preop CS patients. Too early to know if similar results will be obtained in other patients.
Surveys indicate most nurses use foam swabs rather than toothbrushes in intubated patients
CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004
Grap M. Amer J of Critical Care 2003;12:
Ventilator Associated Pneumonia (VAP) Practice Alert

25. Need Further Assistance?
For more information or further assistance, please contact a clinical practice specialist with the AACN Practice Resource Network.
Phone:
(800)
Ventilator Associated Pneumonia (VAP) Practice Alert