2. Case- 50yrs old man transferred from KKH on 26/12/1433
Mr. MIAH HASAN,
as case of RTA-head injury with Cx spine # C4-C6(operated),Infected stage 4 sacral Bed Sore
with respiratory failure (neural mediated RF).
DAY-148 in ICU/hospital
DAY 1468 on ventilator(tracheostomy) SIMV mode Vt-500ml, RR-12/min, Fio2 45%,
Since five days Fio2- 65-75% ,PEEP -8, to maintainSpo2 above 95% and
Pco2 -78mmHg , ABG-RES. ACIDOSIS WITH HYPOXIEMIA
O/E- Temp38.9 degree celcius HR-102b/min ,BP-98/58mmHg ,RR-28breaths/min,
pallor, emaciated, on noradrenaline & dopamine
BED SORES partially clean with health granulation tissue
Diarrhea since 10 days
S/E -RS- mucopurulent resp secretion B/L crackles Rt>Lt ,
P/A and CVS-unremarkable CNS- conscious, vague response to vc, Quadriplegic
LAB. R - Wbc-22,Hb-9.5g/dl , plt- 93 alb-2.46mg/dl TP-5.9mg/dl wbc-41(4/5)
Sputum analysis- Candida, GPC-++ Pus cells-+++, Stool analysis –NBF
Sputum-c/s(4/5/33)-pseu.auerginosa, klebsiella pneumonia. Sensitive to Ceftazidime,
Tienam. CXR– will review
TREATMENT- Antibiotics,zantac, iron folic acid, clexan and supportive treatment NGT
FEEDING partially supported by parenteral . Antibiotic- tienam and cipro
5. case-- ABDUL BADER 55yrs lady transferred from KKH on
6/4/1433 as a case of POST-CPR, BRAIN ANOXIA ,DCM.
DAY 29th in ICU and on VENTILATOR
SIMV mode(Tracheostomy) Vt- 500ml, RR-6/min, PS- 7mbar, Pinsp- 20,
Fio2-30% consistent on same parameters with Sp02>97%
O/E: Temp.38.5degree celcius, RR-14/min HR-70/min,
BP -98/60mmHg, Spo2 -99%
S/E : RS- mucoid secretion, conducted sounds
CVS/PER ABD- Unremarkable, CNS- unconscious GCS- 5T/15
Wbc-8, Hg-8.9,alb-3.4mg/dl , ABG- Met. Alkalosis, CXR-will review
Blood c/s –CONS sen to vanco, Sputum c/s-NBG Urine c/s-NGB
Urine analysis(20/4/33)-pus cells-15-20/hpf, Rbcs 10-15/hpf, epith. Cells-
6-8 (11/4/33, 17/4/33—consistant pus cells and Rbcs)on 3/5- 2-3 pus cel
TREATMENT-Aspirin, Plavix, Clexan, Captopril, Zocar, Amiodarone,
Depakin, Adol, Zantac, NGT feeding and supportive treatment.
Mechanical ventilator is one of the important life
saving devices used in conditions like
Respiratory failure (main indication)
Protection of airways
However, as like any other devices/ medications
MV also associated with complications like
Hemodynamic instability, Pneumothorax, VALI and
VENTILATOR ASSOCIATED PNEUMONIA
8. What is VAP?
A Nosocomial pneumonia associated with
mechanical ventilation (either by
Endotracheal tube or Tracheostomy) that
develops within 48 hours or more of
hospital admission and which was not
present at the time of admission.
National institute of health excellence (NICE)-2007
center for disease control and prevention
-within 3-4days of MV
less virulent, community acquired
organism- Str.pneumonia, H. influenzae
-After 3-4 days of MV
More virulent, hospital acquired organism-
Pseudomonas, Acinetobacter, MRSA, Enterobacteriaceae
•Hospital acquired pneumonia (HAP) is the
second most common hospital infection.
• VAP is the most common intensive care unit
• 90% of all nosocomial infections occurring
in ventilated patients are pneumonias.
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.
The incidence of VAP is highest in the
Trauma, Burns, Neurosurgical pts. Postop.
Mortality rate is 27% &43%with antibiotic
critical care societies collaborative(CCSCs)
Mortality rate in VAP caused by Pseudomonas
or Acinetobacter is as high as 76%
Crit Care Med (2004)
Increases ventilatory support requirements
and ICU stay by 4.3 days
Increases hospital LOS by 4 to 9 days
Increases medical cost
Critical Care Medicine 2005;33:2184-93
13. Causative Organisms
Staphylococcus aureus (methicillin sensitive)
Staphylococcus aureus (methicillin resistant)
Most strains responsible for early onset VAP are
antibiotic sensitive. Those responsible for late onset
VAP are usually multiple antibiotic resistant
Am J Resp Crit Care (1995)
15. RISK FACTORS FOR VAP
-Underlying medical conditions-
COPD, obesity, ARDS, gastro esophageal disease,
burn, trauma, MODS etc--
-Patients’ body position
-Level of consciousness- impaired LOC, delirium,
-Number of intubations- Reintubations
-Medications (Antibiotics, sedation, NM blockers)
• Device related:
- MV with Endotracheal tube, trcheostomy
-Number of intubations- reintubation
-Use of humidifier
-Nasogastric or orogastric tubes
• Personnel related:
-Improper hand washing
-Failure to change gloves between contacts with pts
-Not wearing personal protective equipment when
Bacteria enter the lower respiratory tract via
Aspiration of organisms from the oropharynx
and GI tract (most common cause)
Inhalation of bacteria
18. ASPIRATION- Primary Route of
Bacterial Entry into LRT
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.
Inhalation of aerosols containing bacteria :
-Contaminated RT equipment
-from other patients/ healthcare personnel's
-Inadequate disinfection/sterilization technique
-Cross Contamination (Hands)
20. HOW DO WE DIAGNOSE? 2-1-2
Radiographic evidence x 2 consecutive days
New, progressive or persistent infiltrate
Consolidation, opacity, or cavitation
At least 1 of the following:
Fever (> 38 degrees C) with no other recognized cause
Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000
At least 2 of the following:
New onset of purulent sputum or change in character of
New onset or worsening cough, dyspnea, or tachypnea
Rales or bronchial breath sounds
Worsening of gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)
Microbiological criteria (optional)
At least one of the following:
• Positive growth in blood culture not related to another
source of infection.
• Positive growth culture pleural fluid.
• Bronchoaleveolar lavage
> 105colony forming units/ml.
sensivity &specificity 42-93% &45-100%
specimen brushing >103cfu/ml (33-100% & 50-
•Histopathological evidence of pneumonia
•RADIOLOGICAL FINDING AND 2 CLINICAL
CRITERIA SENCIVITY OF DIAGNOSING VAP
IS 69% AND THE SPECIFICITY IS 75%
• SAMPLING OF RESPIRATORY SECREATION
can be obtained from distal or proximal airway however
the sensivity and specificity is more with distal airway
sample(Bronchoalveolar lavage(BAL) , Protected specimen
•ABSENCE OF RADIOLOGICAL FINDING
HELPFUL FOR EXCLUDING THE DIAGNOSIS
23. A new streamlined surveillance defintion for
Any one of the following
1. Opacity, infiltrate, or consolidation that appears, evolves, or persists over 72 hrs
Any one of the following
1. Temperature 100.4°F within past 24 hrs
2. White blood cell 4,000 or 12,000 white blood cells/mm3 within past 24 hrs
Both of the following
1. Two days of stable or decreasing daily minimum FIO2 followed by increase in
daily minimum FIO2 15 points sustained for 2 calendar days OR 2 days of stable or
decreasing daily minimum positive end-expiratory pressure followed by increase in
daily minimum positive end-expiratory pressure by 2.5 cm H2O sustained for 2
2. Gram-negative stain of respiratory secretions with moderate (2+) or more
neutrophils per low power field within 72 hrs.
Critical care med 2012 vol.40,no.1
24. 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
-Use gram stain results if possible
• GENERAL APPROACH FOR INFECTION CONTROL
Selection of antibiotics:
Early onset of VAP and no risk for MDR -
Cefrioxone, fluroquinolones, ampicillin-sublactum
Late onset of VAP and risk for MDR-
Beta lactam/betalactamase inhibitors-
Amonoglycocides with vancomycine,linezoid
ANTIBIOTCS TO BE ADJUSTED FURTHER ON THE
26. Risk Factors for drug resistance
ABX in last 14 days
Prior culture with MRO
Chronic primary lung pathology
Acute or long term care hospitalization within
Tracheostomy for > 5 day
27. DURATION OF TREATMENT
- Depends on severity,
- Time to clinical response and micro organism response
- Isolation of microorganism
- Longer duration >14-21days risk of toxicity and resistance
- Shorter duration<7days- risk of recurrence
-standard duration of treatment 7-14 days
- Longer durtion 14-21 days may be indicated in
Multilobular involvement, cavitation, gram-ve
necrotising pneumonia, isolation of Pseudomonas,
Specific practices have been shown to decrease
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)
Conventional Infection control Aproach
•DESIGN OF ICU-
Adequate space, lighting, proper function of ventilatory
system, facilities for hand washing, Isolation room.
Education, Adequate number, quality, importance of personal
cleanliness and attention to asceptic procedures.
•Hand washing and Hand rubbing with alcohol based solution.
•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.
32. VAP BUNDLE (VAP reduction rate44.5%)
VAP bundle(4) originated in 2005 from INSTITUTE
OF HEALTH CARE IMPROVEMENT(IHI) & CDC
1. Elevation of the head of the bed (HOB) to between 30 and
2. Daily sedative interruptional and daily assessment of
readiness to extubate.
3. Stress ulcer disease prophylaxis.
4. Deep venous thrombosis (DVT) prophylaxis (unless
5.IN 2010 FIFTH COMPONENT DAILY ORAL CARE
WITH CHLORHEXIDINE IS ADDED.
(criti. care 2012 vol. 40,no.1)
Hand washing is the single most important
(and easiest!!!) method for reducing the
transmission of pathogens
Use of waterless antiseptic preparations is also
acceptable and may increase compliance.
Remember to wash your hands
Before and after patient contact
Beginning and end of work day
Before and after using gloves
After touching contaminated surface
34. HOB 30 - 45 Degrees
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
- Hypotension MAP <70
-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
36. 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
37. Daily Sedative Interruption and Daily
Assessment of Readiness to Extubate
Predisposes patients to:
Gastric regurgitation and aspiration
Difficulty in monitoring neuro status
Increased use of diagnostic procedures
Increase ventilator days
Prolonged ICU and hospital stay
38. Daily Wake Up
Every patient must be awakened daily unless
Daily weaning assessments reduce the duration of
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
Goal is to decrease sedation
39. 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
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
40. Deep Venous Thrombosis
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.
41. DAILY ORAL CARE
Dental plaque- due to absence of mechanical chewing
and the saliva and they are reservoir for potential
pathogens that causes VAP.
Tooth brushing , Rinsing of oral cavity to remove dental plaque
0.12% CHLORHEXIDINE ORAL RINSE
Am J Crit Care. 2009 Sep;18(5):428-437
Oral decontamination- 2%genta+2%Collistin+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.
I/V Cefuroxime 1.5g TID first 4days.
42. DAILY ORAL CARE
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)
Maintaining ETT/TT cuff pressure 20- 30cmH20
Orotracheal rather than nasotracheal intubation
Avoid unnecessary disconnection of MV circuit.
Closed inline suctioning.
Avoid saline instillation for suctioning thick secretion.
Appropriate Humidification of inspired air.
Early Enteral feeding
Turning patient every 2 hrly.
44. Airway Management
Avoidance of Endotracheal intubation
Mask ventilation trials , NIPPV
Minimize duration on MV
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)
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
45. Airway Management
In-line suctioning using closed technique than open
Should not be routinely used to suction pts
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
Oral suction devices (Yankauer)
Policies for use and storage not written
Harbor potentially pathogenic bacteria within 24 hours
71% of nurses store the device in its packaging (STAMP)
Change q day
Rinse with sterile water or NS
Allow to air dry
47. 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
suction above the cuff may
reduce the risk of VAP.
Am J Respire cri car Med Oct.. 2010
48. 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
49. 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:
> 5 cm H2O auto-PEEP
Convert to Heated Humidification (HH) if:
Ventilated longer than 96 hours
Air leak from chest tube or around airway
VT < 300 cc or > 750 cc
51. 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)
52. 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)
53. No Data
to Support These Strategies
• Use of small bore versus large bore gastric
• Continuous versus bolus feeding
• Gastric versus small intestine tubes.
• Closed versus open suctioning methods.
• Kinetic beds.
54. NEW DEVELOPMENT
• 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
Nosocomial pneumonia and especially VAP are the
most frequent infectious complications in the ICU, and
they significantly contribute to morbidity and mortality.
VAP is an important determinant of ICU and hospital
lengths of stay and healthcare costs.
No standard to diagnose.
Several simple preventive measures(VAP bundle) and
timely initiation of appropriate antibiotics ensure better
outcomes in patients with VAP.
Notas del editor
Risk is greatest in patients with trauma or surgery of the head, neck, thorax, or abdomen.
Mechanically ventilated (ETT or trache) for > 48 hours