1

Transition from VAP to VAE.

CORNELIAAKUHN

2

3

OBJECTIVES

• Review history of VAP monitoring• Definition of VAE.• Why VAE.• Review important changes made to VAE

surveillance.• Describe the use of VAE in the Critical Care

unit

4

DEFINITION

• VAE{Ventilator associated events} deterioration in respiratory status AFTER A PERIOD OF STABILITY OR IMPROVEMENT ON THE VENTILATOR, evidence of infection or inflammation, and laboratory evidence of respiratory infection.

5

History of VAP.

1970 •CDC starts surveillance on health care associated pneumoniae

2002 •New surveillance criteria implemented.•VAP defined as pneumonia event occurring within 48hours of mechanical ventilation.

2011 •Leaders from critical care societies collaborative convene to identify objective approach to surveillance/reporting in mechanical ventilated patients.

2013 •VAE surveillance new approach finalized by the working group and implemented in NHSN/CDC.

6

WHY VAE

• Ventilator associates pneumonia{VAP} is an important complication of mechanical ventilation but not the only one.

• Vap determined by ;o Subjective clinical signs/symptoms o Radiological evidenceo Laboratory data.

• Lack of specificity for

VAP.• Inter observer

variability.

• Lack of specificity and sensitivity

• Documentation varies.

• Lack of specificity.• Practices vary among providers

• Controversy about best practices

7

Cont:

• Consequences-hospitals employed divergent and non comparable approaches to Vap surveillance and reporting[gaming]lack of accurate data.

• No minimum required amount of time that the ETT/ventilator must have been in place for a Pneumonia to count as a VAP

8

Who is eligible for surveillance

Inclusion• Inpatients of acutecare hospitals,long term acute

care hospitals ,inpatient rehabilitaion facilities.• Mechanically ventilated patients >18 years old.Exclusion• Patients ventilated for less than 3 days.• Patients on high frequency ventilation or

extracorporeal life support.• Patients in outside the care areas stated above.

9

Hierarchial Tiers of VAE

1. Ventilator-associated conditions (VAC) e.g pneumonia, acute respiratory distress

syndrome, atelectasis and pulmonary edema2. Infection-related ventilator-associated

complication3. Possible/probable VAP

10

1.Ventilator Associated Conditions

• Patient has a baseline period of stability or improvement on the ventilator, defined by ≥ 2 calendar days of stable or decreasing DAILY MINIMUM FiO2 or PEEP values

• The baseline period is defined as the 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2

11

1st Example

• The baseline period is defined by mechanical ventilation (MV) days 1 through 4 and the period of worsening oxygenation by MV days 5 and 6 where the daily minimum PEEP is ≥ 3 cmH2O greater than the daily minimum PEEP during the baseline period. Note that there is no VAC on MV day 3, because PEEP values 0-5 cmH2O are considered equivalent for the purposes of this surveillance.

12

Example

MV day Daily minimum peep (cmh2o)

Daily minimum fio2(%)

VAE

1 0 100%

2 3 50%

3 5 50%

4 5 50%

5 8 50% VAC6 8 50%

13

2nd Example

• The baseline period is defined by mechanical ventilation (MV) days 3 and 4 (shaded in light gray), and the period of worsening oxygenation by MV days 5 and 6 (shaded in darker gray), where the daily minimum FiO2 is ≥ 0.20 (20 points) over the daily minimum FiO2 during the baseline period.

14

Example

MV day Daily minimum peep (cmh2o)

Daily minimum fio2(%)

VAE

1 8 100%

2 6 50%

3 5 40%

4 5 40%

5 6 70% VAC6 6 70%

15

2. Infection Related Ventilator Associated Complications (IVAC)

• Patient meets criteria for VAC and On or after calendar day 3 of mechanical ventilation and

within 2 calendar days before or after the onset of worsening oxygenation, the patient meets both of the following criteria:

1) Temperature > 38 °C or < 36°C, OR white blood cell count ≥ 12,000 cells/mm3 or ≤ 4,000 cells/mm3.

AND 2) A new antimicrobial agent(s) is started, and is continued

for ≥ 4 calendar days

16

3. Possible Ventilator-Associated Pneumonia (PVAP)

• Patient meets criteria for VAC and IVAC ANDOn or after calendar day 3 of mechanical

ventilation and within 2 calendar days before or after the onset of worsening oxygenation, ONE of the following criteria is met

17

Criterion 1

• Positive culture of one of the following specimens, meeting quantitative or semi-quantitative thresholds as outlined in protocol, without requirement for purulent respiratory secretions:

Endotracheal aspirate, ≥ 105 CFU/ml or corresponding semi-quantitative result

Bronchoalveolar lavage, ≥ 104 CFU/ml or corresponding semi-quantitative result

Lung tissue, ≥ 104 CFU/g or corresponding semi-quantitative result

Protected specimen brush, ≥ 103 CFU/ml or corresponding semi-quantitative result

18

Criterion 2

• Purulent respiratory secretions (defined as secretions from the lungs, bronchi, or trachea that contain >25 neutrophils and

19

Criterion 3

• One of the following positive tests: Pleural fluid culture (where specimen was obtained

during thoracentesis or initial placement of chest tube and NOT from an indwelling chest tube)

Lung histopathology Diagnostic test for Legionella species Diagnostic test on respiratory secretions for influenza

virus, respiratory syncytial virus, adenovirus, parainfluenza virus, rhinovirus, human metapneumovirus, coronavirus

20

NOTE

• VAEs are defined by a 14-day period, starting on the day of onset of worsening oxygenation (the event date, day 1). A new VAE cannot be identified or reported until this 14-day period has elapsed

21

IN SUMMARY

• Surveillance of VAE for ventilated patients is key in patients care.

• Overall it improves overall practice and care• Helps clinicians have a clear direction on

infection prevention.

22

REFERENCES

• www.cdc.org/nhsn.{Jan 2015 revision}

• International JCIA manual 5th edition.

http://www.cdc.org/nhsn.%7BJan

24

THANK YOU

Slide 1Slide 2OBJECTIVESDEFINITIONHistory of VAP.WHY VAECont:Who is eligible for surveillanceHierarchial Tiers of VAE1.Ventilator Associated Conditions1st ExampleExample2nd ExampleExample2. Infection Related Ventilator Associated Complications (IVAC)3. Possible Ventilator-Associated Pneumonia (PVAP)Criterion 1Criterion 2Criterion 3NOTEIN SUMMARYSlide 22REFERENCESSlide 24