ventilator Associated Pneumonia -By Dr.Tinku Joseph

VENTILATOR ASSOCIATED
PNEUMONIA (VAP)
Dr.Tinku Joseph
DM Resident
Department of Pulmonary Medicine
AIMS, Kochi
Email: tinkujoseph2010@gmail.com

 Ventilator-associated pneumonia (VAP) is a type of
HAP that develops more than 48 to 72 hours after
endotracheal intubation.
 Hospital-acquired (or nosocomial) pneumonia
(HAP) is pneumonia that occurs 48 hours or more
after admission and did not appear to be incubating
at the time of admission.
Definition- “Know the enemy”
(ATS/IDSA) guidelines 2005

 Healthcare-associated pneumonia (HCAP) is defined
as pneumonia that occurs in a nonhospitalized
patient with extensive healthcare contact, as defined
by one or more of the following:
 Intravenous therapy, wound care, or intravenous
chemotherapy within the prior 30 days
 Residence in a nursing home or other long-term care facility
 Hospitalization in an acute care hospital for two or more days
within the prior 90 days
 Attendance at a hospital or hemodialysis clinic within the
prior 30 days
(ATS/IDSA) guidelines 2005

 Typically in studies, patients are only included if
intubated greater than 48 hours
 Early onset= less than 4 days
 Late onset= greater than 4 days
 Endotracheal intubation increases risk of developing
pneumonia by 6 to 21 fold
 Accounts for 90% of infections in mechanically
ventilated patients
American Thoracic Society, Infectious Diseases Society of America.
Guidelines for the management of adults with hospital-acquired, ventilator-associated,
and healthcare-associated pneumonia.

VAP- Risk Factors
 Age >70 years
 Severe Illness
 Underlying Lung Disease
 Depressed Mental Status
 Immunocompromising conditions
 Viral Respiratory Tract Infection
 Treatments
 Agents that increase gastric pH (H2 blockers,
antacids, proton pump inhibitors)
 Previous antibiotic exposure, particularly to third-
generation cephalosporins.
 Paralytic agents
Host Factors

VAP- Risk Factors
 Intensive Care Setting
 Use of Antimicrobial Agents
 Contaminated hands
 Contaminated Equipment
Colonisation

VAP- Risk Factors
Colonisation

VAP- Risk Factors
 Mechanical ventilation
 Tracheostomy
 Use of a Nasogastric Tube
 Supine Position
Factors that facilitate reflux & aspiration into
the lower RT

VAP- Risk Factors
 Abdominal or thoracic
surgery
 Immobilisation
Factors that impede normal Pulmonary
Toilet

 VAP occurs in 10 - 65% of all ventilated patients
Crit Care Clin (2002)
 Incidence increases with duration of MV 3% /day for
first 5days, 2%/day for 6-10days and 1%/day after 10
days.
 Mortality rate is 27% &43%with antibiotic resistant
organism.
critical care societies collaborative(CCSCs)
 Mortality rate in VAP caused by Pseudomonas or
Acinetobacter is as high as 76%
Crit Care Med (2004)
Incidence

 Increases ventilatory support requirements and ICU
stay by 4.3 days
 Increases hospital LOS by 4 to 9 days
 Increases medical cost
Chest 2002;122:2115
Critical Care Medicine 2005;33:2184-93
Incidence

Pathogenesis
 Bacteria enter the lower respiratory tract via
following pathways:
– Aspiration of organisms from the oropharynx and
GI tract (most common cause)
– Direct inoculation
– Inhalation of bacteria
– Haematogeneous spread

ASPIRATION- primary route of bacterial entry into
LRT
ENDOTACHEAL TUBE
 Holds the vocal cords open-predispose to
micro & macro aspiration of colonized
bacteria from oropharynx to LRT.
Leakage of secretion containing bacteria
around the ETT cuff.

• NGT OR OROGASTRIC TUBE
• Interrupt gastro-esophageal sphincter leading
GI reflux and aspiration. Increase
oropharyngeal colonization, stagnation of
oropharyngeal and nasal secretion.
Pathogenesis

Inhalation of aerosols containing bacteria :
-Contaminated RT equipment
-From other patients/ healthcare personnel's
-Inadequate disinfection/sterilization technique
-Contaminated solutions/water
Direct contact:
-Cross Contamination (Hands)
Pathogenesis

MDR Pathogens
• Host risk factors for infection with MDR pathogens
include :
 Receipt of antibiotics within the preceding 90 days
 Current hospitalization of ≥5 days
 High frequency of antibiotic resistance in the
community or in the specific hospital unit.
 Immunosuppressive disease and/or therapy
 Severe septic shock.
 Patients with HCAP are at variable risk for infection due
to MDR pathogens.

Diagnosis
NO UNVERSALLY
ACCEPTED GOLD
STANDARD
DIAGNOSTIC
CRITERIA!!!!!

DIAGNOSIS
CLINICAL
MICROBIOLOGICAL
RADIOLOGICAL

Clinical Pulmonary Infection Score
(CPIS)

Microbiological diagnosis
ATS/IDSA
QUALITATIVE
CLINICAL
CRITERIA
QUANTITATIVE
ENDOTRACHEAL
ASPIRATE
-BAL
-MINI BAL
- PROTEECTED
SPECIMEN
BRUSH

Respiratory secretion sampling

Bronchoscopic V/S Blind techniques

Difference between VAP and VAT

Role of biomarkers as diagnostic and
prognostic markers of VAP

RADIOLOGIC DIAGNOSIS
INFILTRATES
SOLITARY DIFFUSE
NEW
INFILTRATES

Radiological evidence of pneumonia
THINK
BEFORE
LABELLING
IT AS VAP!!

Radiological mimics of pneumonia in ICU
patients
 Chemical/Aspiration pneumonitis
 Atlectasis/lung collapse
 LVF
 ARDS
 Pleural effusion
 Pulmonary embolism
 Pulmonary hemorrhage
 Lung contusion
 Infiltrative tumor
 Radiation Pneumonitis
 Drug reaction
 Cryptogenic organizing pneumonia

How will u treat VAP?
BEFORE CHOOSING ANTIBIOTIC,
keep in mind on the following
issues:
 Risk factors of the patient
 Was it early or late onset
 Virulence of organism
 Antibiotic resistance
 Cost

TREATMENT PROTOCAL
 Initial therapy is empiric
 Start when VAP is suspected, Don’t delay
 Individualize to institution-
Hospital epidemiologic data
Drug cost and availability
 Individualize to patient-
-Early onset versus Late onset of VAP
-Prior antibiotic use
-Underlying disease Renal, liver disease etc
-Surveillance cultures
-Use gram stain results if possible

Specific anti microbial considerations
(MRSA)
 Linezolid or Vancomycin is a necessary first choice
for antistaphylococcal coverage .
 Should be discontinued if MRSA is not isolated.
 Linezolid – 600 mg twice daily intravenously (IV; or
orally if or when the patient is able to receive oral
medications)
 Vancomycin – 15 to 20 mg/kg (based on actual body
weight) IV every 8 to 12 hours for patients with
normal renal function,

 Alternative to Linezolid and vancomycin -:
Clindamycin (600mg IV TID)
 Telavancin: activity against MRSA. 10mg/kg IV OD.
 Other agents-: Daptomycin, Ceftaroline.
 Tigecycline-: It has been approved by the FDA for
skin and skin structure infections and intraabdominal
infections caused by MRSA
(MRSA)

(MSSA)
 If a sputum culture reveals MSSA empiric therapy for
MRSA should be replaced with nafcillin (2 g IV every
four hours) or oxacillin (2 g IV every four hours).

 Monotherapy/ Combination therapy
 Avoid cephalosporins monotherapy in ICU settings -:
Presence of ESBL producing Enterobacteriaceae.
Resistant organism.
 Carbapenams-: Most reliable agent.Eg: meropneam,
imipenam- cilastin, Ertapenam.
 Doripenam-: Not much preferred.
(Gram negative pathogens)

(Legionella)
 Patients who have diabetes mellitus, renal disease,
structural lung disease, or have been recently treated
with glucocorticoids may require coverage
for Legionella spp (azithromycin or a
fluoroquinolone).

(Anaerobes)
 Patients who have aspirated or had recent abdominal
surgery may warrant coverage for anaerobes
(clindamycin, beta-lactam-beta-lactamase inhibitor,
or a carbapenem).

 Antiinflammatory effects of macrolides
 Studies have shown good results in VAP (faster
resolution)
 Extended infusions: can potentially provide effective
therapy for pathogens with higher minimum
inhibitory concentrations (MICs), may impede the
emergence of resistance, and potentially provide a
pharmacoeconomic benefit.

Aerosolized antibiotics
 Aerosolized colistin, polymyxin, or aminoglycosides
may be considered as potential additional antibiotics
in patients with multidrug-resistant gram-negative
bacilli.
 Aerosolization may increase antibiotic concentrations
at the site of infection and may be particularly useful
for treatment of organisms that have high MICs to
systemic antimicrobial agents.

VAP- Duration of treatment
 The duration of therapy should be based upon the
clinical response.
 The standard duration of therapy in the past was 14
to 21 days in part because of a concern for difficult to
treat pathogens (eg, Pseudomonas spp).

 Specific practices have been shown to decrease VAP
 Strong evidence that a collaborative,
multidisciplinary approach incorporating many
interventions is paramount
 Intensive education directed at nurses and
respiratory care practitioners resulted in a 57%
decrease in VAP
Crit Care Med (2002)
Prevention of VAP

Conventional Infection control Aproach
Design of ICU
Adequate space, lighting, proper function of ventilatory system, facilities
for hand washing, Isolation room.
Staffing
Education, Adequate number, quality, importance of personal
cleanliness and attention to asceptic procedures.
Hand washing and Hand rubbing with alcohol based
solution.
Prevention of VAP

Conventional Infection control Aproach
 Periodical bacterial monitoring policy.
 Specific prophylaxis-
• use gloves, gown, mask.
• Use of NIPPV
• Minimize duration of MV, checking daily for readiness
to weaning/extubation
• (Text book of criti care med. 5 the Edit.
MitchellP.FinkSHOEMAKER)
Prevention of VAP

VAP BUNDLE (VAP reduction rate44.5%)
VAP bundle(4) originated in 2005 from INSTITUTE
OF HEALTH CARE IMPROVEMENT(IHI) & CDC
IN 2010 FIFTH COMPONENT DAILY ORAL CARE WITH
CHLORHEXIDINE IS ADDED. 2011 -: Subglottic suction
(criti. care 2012 vol. 40,no.1)

Prevention of VAP
 Society of Healthcare Epidemiology (SHEA) and the
Infectious Diseases Society of America (IDSA) issued
updated practice recommendations to reduce the
risk of ventilator-associated pneumonia (VAP) 2014

Patient positioning
 The supine position is an
independent risk factor for
death in all ICU patients
 HOB elevation to 30-45 degree
especially during feeding
prevent aspiration and 34%
reduction in VAP
(Lancet.nov.1999;354,1851-1858)
 CDC recommends HOB 30-45°
unless contraindicated
Prevention of VAP

Contraindications
Hypotension MAP <70
Tachycardia >150
CI <2.0
Central line procedure
Posterior circulation strokes
Cervical spine instability use reverse trendelenburg
Some femoral lines i.e.: IABP no higher than 30
degrees use reverse trendelenburg
Increased ICP, No higher than 30 degrees avoid hip
flexion
Proning

Reverse Trendelenburg
 In full reverse Trendelenburg the foot of bed will read
-12 degrees
 Angle of head elevation is approximately 20 degrees
(not 30 degrees) when at -12
 Evaluate the individual clinical situation to assess if
the patient can tolerate the addition of a small
amount of Fowlers angle which may flex the hip

Daily Sedative Interruption and Daily
Assessment of Readiness to Extubate
OVERSEDATION
• Predisposes patients to:
– Thromboemboli
– Pressure ulcers
– Gastric regurgitation and aspiration
– VAP
– Sepsis
• Consequences include:
– Difficulty in monitoring neuro status
– Increased use of diagnostic procedures
– Increase ventilator days
– Prolonged ICU and hospital stay

Daily Wake Up
 Every patient must be awakened
daily unless contraindicated!
 Daily weaning assessments
reduce the duration of
mechanical ventilation.
 Wean infusion to off in
increments of 10-25% daily in
order to perform a clinical
assessment

 Rebolus and restart infusion if the patient becomes
symptomatic. Your new continuous IV dose should
be lower than what you began with
 Consider implementation of a sedation scale such as
the Richmond Agitation Sedation Scale (RASS) scale
to avoid over sedation.
 Goal is to decrease sedation
Daily Wake Up

Stress ulcer prophylaxis
Sucralfate, H2 receptor blocker, proton pump inhibitor
Increases gastric PH and minimize bacterial colonization that
reduces the risk of VAP and GI bleeding
Sucralfate
Decreases the VAP rate but increases the risk of GI bleeding by 4%.
H2 receptor blockers/PP inhibitors
Increase rate of VAP by increasing gastric PH leading to colonization
of bacteria and decreases the risk of GI bleeding.

H2 receptor blocker, PP inhibitor
preferred over sucralfate
Am J Respir Crit Care Med. 2005;171(4):388-416

Deep Venous Thrombosis (DVT)
Prophylaxis
There is increase risk of thomboembolism in
mechanically ventilated patient.
There is no any data association between DVT
prophylaxis and decreasing rates of VAP.
VAP rates decreased most dramatically in hospitals
where all elements of the Ventilator Bundle were
implemented, including this one.
Chest. 2004;126(3 Suppl):338S-400S.

Daily oral care
Dental plaque- due to absence of
mechanical chewing and the saliva and
they are reservoir for potential
pathogens that causes VAP.
Mechanical intervention
Tooth brushing , Rinsing of oral cavity
to remove dental plaque
Pharmacological intervention
0.12% CHLORHEXIDINE ORAL RINSE
15 ml twice daily
Am J Crit Care. 2009 Sep;18(5):428-437

 Oral decontamination
2%genta+2%Colistin+2%Vanco paste QID
 Selective decontamination of digestive
tract(SDD)-
2%polymyxin+tobra+Amphotericine paste oral
application QID.
Solution 100mg poly+80mg tobra+500mg ampho
QID throu NG.
IV Cefuroxime 1.5g TID first 4days.
Daily oral care
Promotes growth of resistant bacteria

Daily oral care
• Best Practice??
–Daily assessment to determine oral health
–Brush q 12 hours to prevent plaque
–Oral cleansing q 2-4 hours to promote healing
and maintain integrity of oral tissues
–Use of an alcohol-free, antiseptic oral rinse to
prevent or reduce bacterial load of
oropharynx
–Routine suctioning of mouth to manage oral
secretions and minimize risk of aspiration
–Use of a moisturizer
Am J Crit Care (2005)

Gastric volume monitoring
 standard clinical practice to monitor the patient's
gastric residual volume at regular
intervals and/or prior to increasing the infusion rate
of gastric tube feeding
 Hoping to minimize the risk of unrecognized gastric
fluid accumulation and vomiting resulting in
pneumonia

 several studies have shown that measurement of
gastric residuals correlates poorly with aspiration risk
and is associated with a decrease in calorie delivery.
 A randomized trial has shown that the rate of VAP
was not higher in patients who did not undergo
monitoring of gastric residuals.
Gastric volume monitoring
Not recommended now a days

Probiotics
 Not effective in preventing VAP
as per various randomized
controlled trials.
 Most commonly
used: Lactobacillus spp

Airway Management
• Mechanical ventilation
– Avoidance of Endotracheal intubation
• Mask ventilation trials , NIPPV
• Minimize duration on MV
– Orotracheal intubation
• Nasotracheal intubation slightly increase the risk for
VAP
• Avoid Reintubations- increases risk of VAP 6 fold
(Am resp.criti car med.1995;152(1):137-141)
– Cuff management
HVLP ETT cuff VAP rate 20% , LVHP ETT cuff VAP rate 20%
(Text book of criti. Care. 5 th Edit. Mitchell P.Fink SHOEMAKER)
Maintain at 25-30 cm H2O

Airway Management
• Suctioning
– In-line suctioning using closed technique than open
technique
– Normal saline
• Should not be routinely used to suction pts
• Causes desaturation
• Does not increase removal of secretions
• Can potentially dislodge bacteria from ETT to LRT
• Should be used to rinse the suction catheter after suctioning
• Maintaining adequate hydration, proper humidification of
ventilatory circuit, nebulizer, mucolytic agent can help to
decrease the viscosity and eliminate the need for saline
lavage
(Am. jour.crical care nurse 2007 vol. 27; 32-36:)

Suctioning
• Oral suction devices
– Policies for use and storage not written
– Harbor potentially pathogenic bacteria within 24 hours
– 71% of nurses store the device in its packaging (STAMP)
– Best practice???
• Change suction catheter every day
• Rinse with sterile water or NS
• Allow to air dry

Subglottal suctioning
 Should be done using a 14 Fr sterile suction catheter:
– Prior to ETT rotation
– Prior to lying patient supine
– Prior to Extubation

Continuous subglottic suctioning
 ETT with dedicated lumen to continuously or
intermittently suction above the cuff may
reduce the risk of VAP.
Am J Respire cri car Med Oct.. 2010
 Should be used for patients expected to require >48
or 72 hours of mechanical ventilation.
 Cost more than standard endotracheal tubes and are
not widely available
Subglottic drainage

Device for Continuous aspiration of
subglottic secreations

Ventilator Circuit-Management
 Vent circuit should not be routinely opened once
ventilation is initiated
 Disconnection of ventilation tubing can lead to
loss of PEEP and alveolar de-recruitment
 If circuit must be disconnected, clamp ETT with
padded Kelly forceps to avoid PEEP loss

 Expiratory condensation should be removed via
the trap in the tubing
 Inspiratory condensation – if clean, may be
drained back into the water reservoir
 Ventilator circuit can be changed weekly, unless it
is soiled with blood or vomitus
Ventilator Circuit-Management

Ventilator Circuits Humidification Systems
 Appropriate Humidification
of inspired air
 Active Humidification or
Passive Humidification
 Heat and Humidity Exchangers
(HMEs) should not be routinely
changed unless:
– Visibly soiled
– > 5 cm H2O auto-PEEP

• Convert to Heated
Humidification (HH) if:
– Ventilated longer than 96 hours
– Thick/bloody secretions
– Resp. Acidosis
– Air leak from chest tube or
around airway
– VT < 300 cc or > 750 cc

Silver-coated endotracheal tube
 Silver-coated ETTs reduce the
incidence of VAP but not of
other important outcomes.
 (NASCENT) trial.

Enteral Feedings
 Early enternal feeding decrease bacterial colonization
and rate of VAP
 Bolus feeding should be avoided to minimize the risk
of aspiration
 Elevate HOB 30 - 45 degrees
 Routinely verify tube placement
 No CDC recommendations for:
– Preferential use of small bore tubes
– Continuous versus intermittent feeding
– Post pyloric placement CDC (2003)

Patient turning
Routine turning of patient for every 2 hrs increase
pulmonary drainage and decrease the risk of VAP.
Use of beds with continues lateral rotation can
decrease the incidence of pneumonia but do not
decreases mortality or duration of MV
(critical care 2002;30(9):1983-1986)

Recent advances
 National healthcare safety(NHSN) and CDC
proposed-
 VAP terminology changed to VAC (ventilated associated
conditions and complications) not necessarily limited VAP.
 VAP Surveillance definination algorithm.
Chest x ray is not included , and diagnosis is mainly depend on
worsening of gas exchange, clinical features, isolation of
microorganism in resp.secreation.

 ETT- with continuous subglottic suction, ployurethrene cuff,
Sponge cuff , Silver nitrate and antibiotic coated ETTs.
 VAP industrial complex- kinetic beds, inlines suction
catheters
 VAP bunddle with 7 components – 5+ Replacing NGT
to orogastric tube and Hand washing by health care
personnel.
IMPLEMENTATION and ENFORCEMENT of VAP bundle
Recent advances

ventilator Associated Pneumonia -By Dr.Tinku Joseph

ventilator Associated Pneumonia -By Dr.Tinku Joseph

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ventilator Associated Pneumonia -By Dr.Tinku Joseph