2. ความหมาย As Pneumonia in patient who have been on mechanical ventilation for greater than 48 hrs

3. Traditional signs and symptom of VAP CXR showing new or progressive diffuse infiltrate which is not attributable to any other cause CXR showing new or progressive diffuse infiltrate which is not attributable to any other cause Onset of purulent sputum Onset of purulent sputum Fever greater than 38.5 C Fever greater than 38.5 C Leukocytosis Leukocytosis Positive sputum or blood culture Positive sputum or blood culture

4. Risk factor for VAP Endotracheal intubation Nasogastric tube Supine position Impair mental status Length of mechanical ventilation Invasive procedure Continue or over sedative Treatment regimen-gastric alkalinization Prolong ATB use Ineffective hand washing Hospital environment and equipment Contact with other patients/hospital staff

5. The endotracheal tube increase the risk for VAP by The endotracheal tube increase the risk for VAP by -preventing cough -preventing cough -preventing upper airway filtering -preventing upper airway filtering - preventing upper airway humidification - preventing upper airway humidification -inhibit epiglosttic and upper airway reflexs -inhibit epiglosttic and upper airway reflexs -inhibit cilliary transport by the epithelium -inhibit cilliary transport by the epithelium -acting as a direct conduit into the lung for airborne pathogen -acting as a direct conduit into the lung for airborne pathogen Risk factor for VAP

6. Host or patient risk factor include Host or patient risk factor include -age of 65 or more -age of 65 or more -underlying chronic disease (CODP,Asthma,Emphysema) -underlying chronic disease (CODP,Asthma,Emphysema) -immunosuppression -immunosuppression -depress conciousness -depress conciousness -thoracic or abdominal surgery -thoracic or abdominal surgery -previous pneumonia -previous pneumonia Risk factor for VAP

7. Evidencd base practice guideline to reduce VAP Staff education Staff education Colonization reduction Colonization reduction -Hand washing -Hand washing -Oral hygiene -Oral hygiene -Standard suction protocol -Standard suction protocol -Avoid saline lavage -Avoid saline lavage -Close suction system -Close suction system -Maintain close circuit -Maintain close circuit -Stress ulcer prophylaxis -Stress ulcer prophylaxis

8. Aspiration reduction/prevention Aspiration reduction/prevention -Regular oral and subglottic suction -Regular oral and subglottic suction -Elevation of head ≥ 30 degree -Elevation of head ≥ 30 degree -Maintain pressure cuff=20 mmHg -Maintain pressure cuff=20 mmHg -Post –pyloric feeding: continue better than bolus feeding -Post –pyloric feeding: continue better than bolus feeding -Early extubation -Early extubation -Weaning protocol -Weaning protocol -Daily assessment of extubation readiness -Daily assessment of extubation readiness -Daily interruption of Sedation -Daily interruption of Sedation

9. VAP Bundle Elevate the head of the bed at least 30 degree Elevate the head of the bed at least 30 degree Perform daily sedation interruption and daily assessment of readiness to extubate Perform daily sedation interruption and daily assessment of readiness to extubate Perform peptic ulcer disease prophylaxis Perform peptic ulcer disease prophylaxis Perform deep vein thrombosis prophylaxis Perform deep vein thrombosis prophylaxis Perform oral care with chlohexidine Perform oral care with chlohexidine

10. Post pyloric gastric enteral feeding Prevent gastric distension and reflux Reduce Aspiration Reduced Oropharyngeal Colonization Stress ulcer Prophylaxis Use standard suction protocol Sub-glottic suction NO VAP Adequate and regular oral hygiene protocol Avoid inadvertant extubation with reintubation Head up position Maintain cuff properly, extubate early Avoid contaminated respiratory suctioning equipment Avoid colonization and direct to bacterial delivery into the lung Use standard suction protocol Use close suction Wash hand, use universal precaution Ensure adequate disinfection or sterilization Keep circuit closed Avoid saline lavage “Idea best practice” for the reduction of colonization and aspiration is kep in VAP prevention (Based on the model proposed by the Center for Disease Control and Prevention )