linda r greene rochester general hospital rochester, ny linda.greene@rochestergeneral.org

Linda R GreeneRochester General Hospital

Rochester, NY

linda.greene@rochestergeneral.org

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 mortalitYKlompas M, Platt R. Ventilator-associated pneumonia – the wrong quality measure for benchmarking. Ann Intern Med. 2007;147:803-805

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 withPhysicians

Start with sputum specimen

Daily rounding

Daily review of CXR

Determination by ICUStaff

Differences in NYS among IPs collecting data

Prevention Strategies BundlesBurden 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

VAPsVAP

VACValori

Mechanical ventilation is primary risk Mechanical ventilation is primary risk factor:factor:

The endotrachel tube acts as a conduit from the upper respiratorytract 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 H2OSome controversy that cuff design may be more importantThan cuff pressure

Tube related issues primarily include aspiration of contaminated secretions from above the cuff

Location Defense Mechanism

Upper Airway

Nasopharynx Nasal Hairs

Turbinates

Upper airway anatomy

Mucociliary apparatus

IgA secretions

Oropharynx Saliva

Sloughing of epithelial cells

Bacterial Interference

Complement Production

Location Defense Mechanism

Conducting Airways

Trachea, Brochii Coughing, 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. 1348-1355, (2006)© 2006 American 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 epidemiologyfebruary 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

http://www.cdc.gov/hicpac/pdf/Nov12_13_HICPAC_web_slides.pdfhttp://www.cdc.gov/hicpac/pdf/Nov12_13_HICPAC_web_slides.pdf

Staff Education & Training!

staff feedback!

Sharing Data

Monthswithouta 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.

http://youtu.be/Pk7yqlTMvp8