1. Ventilator
Associated Pneumonia
(VAP)
DR. PHILIP

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%,
PEEP-3mbar, PS-16mbar
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

3. 22/4/33

4. 1/5/1433

5. case-- ABDUL BADER 55yrs lady transferred from KKH on
Mrs. FARIYAL
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.
Received Vancomycin.

6. CXR-

7. INTRODUCTION
Mechanical ventilator is one of the important life
saving devices used in conditions like
Respiratory failure (main indication)
Protection of airways
Head injury
Post operative
Shock
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

9. TYPES--
EARLY ONSET:
-within 3-4days of MV
less virulent, community acquired
organism- Str.pneumonia, H. influenzae
LATE ONSET:
-After 3-4 days of MV
More virulent, hospital acquired organism-
Pseudomonas, Acinetobacter, MRSA, Enterobacteriaceae

10. EPIDEMIOLOGY
•Hospital acquired pneumonia (HAP) is the
second most common hospital infection.
• VAP is the most common intensive care unit
(ICU) infection.
• 90% of all nosocomial infections occurring
in ventilated patients are pneumonias.

11. INCIDENCE
 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
following groups:
Trauma, Burns, Neurosurgical pts. Postop.
 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)

12. Cont…
VAP
 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

13. Causative Organisms
 Early onset:
 Hemophilus influenza
 Streptococcus pneumoniae
 Staphylococcus aureus (methicillin sensitive)
 Escherichia coli
 Klebsiella
 Late onset:
 Pseudomonas aeruginosa
 Acinetobacter
 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)

14. RISK FACTORS

15. RISK FACTORS FOR VAP
 Host related:
-Underlying medical conditions-
COPD, obesity, ARDS, gastro esophageal disease,
burn, trauma, MODS etc--
-Immunosuppression, Malnutrition(S.Albumin<2.2g/dl)
-Advanced age
-Patients’ body position
-Level of consciousness- impaired LOC, delirium,
coma.
-Number of intubations- Reintubations
-Medications (Antibiotics, sedation, NM blockers)

16. Cont..
• Device related:
- MV with Endotracheal tube, trcheostomy
-Prolonged MV
-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

17. 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

18. 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.

19. Cont..
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)

20. HOW DO WE DIAGNOSE? 2-1-2
 Radiographic evidence x 2 consecutive days
 New, progressive or persistent infiltrate
 Consolidation, opacity, or cavitation
 Clinical sings
At least 1 of the following:
 Fever (> 38 degrees C) with no other recognized cause
 Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000
WBC/mm3)
 At least 2 of the following:
 New onset of purulent sputum or change in character of
secretions
 New onset or worsening cough, dyspnea, or tachypnea
 Rales or bronchial breath sounds
 Worsening of gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)

21. CONT…
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%
Protected
specimen brushing >103cfu/ml (33-100% & 50-
100%) chest.Apr2000;117(4suppl2):198-2002)
•Histopathological evidence of pneumonia

22. Cont--
•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
brush sampling(PAB).
•ABSENCE OF RADIOLOGICAL FINDING
HELPFUL FOR EXCLUDING THE DIAGNOSIS
OF VAP

23. A new streamlined surveillance defintion for
ventilator-associated pneumonia
Any one of the following
1. Opacity, infiltrate, or consolidation that appears, evolves, or persists over 72 hrs
2. Cavitation
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
calendar days
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
-Surveillance cultures
-Use gram stain results if possible

25. TREATMENT
• GENERAL APPROACH FOR INFECTION CONTROL
• ANTIBIOTICS-
Selection of antibiotics:
Early onset of VAP and no risk for MDR -
Cefrioxone, fluroquinolones, ampicillin-sublactum
Late onset of VAP and risk for MDR-
Antipseudomonal cephalosporin(cfepime,ceftazidime)
Carbapenems(imipenem,meronem),
Beta lactam/betalactamase inhibitors-
piperacillin-tazobactam
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
 Immunocompromised
 Chronic primary lung pathology
 Acute or long term care hospitalization within
14 days
 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,
Acnetobacter

28. Further inpatient care
About 30% of pts. Fail to respond-

29. PREVENTION
 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)

30. PREVENTION
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.
•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.

31. EFFECT OF VAP BUNDLE CARE

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
45 degrees.
2. Daily sedative interruptional and daily assessment of
readiness to extubate.
3. Stress ulcer disease prophylaxis.
4. Deep venous thrombosis (DVT) prophylaxis (unless
contraindicated)
5.IN 2010 FIFTH COMPONENT DAILY ORAL CARE
WITH CHLORHEXIDINE IS ADDED.
(criti. care 2012 vol. 40,no.1)

33. HANDWASHING
 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
contraindicated

35. 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

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
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

38. 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

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
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

40. 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.

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.
MECHANICAL INTERVENTION
Tooth brushing , Rinsing of oral cavity to remove dental plaque
PHARMACOLOGICAL INTERVENTION
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
 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)

43. PREVENTION
 NIPPV
 Subglottic suction
 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
 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

45. 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

46. Suctioning
 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)
 Best practice???
 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:
 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

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
tubes
• 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

56. SUMMARY
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.