Ventilator-
Associated
Pneumonia
Hello!
I am Wan Ahmad Luqman
Critical Care Nurse,
ICU1,
Hospital Sultan Haji Ahmad Shah, Temerloh
1.
Introduction
Introduction
▣VAP is the 2nd most common nosocomial
infection = 15% of all hospital acquired infections
▣Incidence = 9% to 70% of patients on ventilators
▣Increased ICU stay by several days
▣Increased avg. hospital stay 1 to 3 weeks
▣Mortality = 13% to 55%
▣Added costs of $40,000 - $50,000 per stay
Centers for Disease Control and Prevention, 2003.
Rumbak, M. J. (2000). Strategies for prevention and treatment. Journal of Respiratory Disease, 21 (5)
p. 321;
RM 134,757
Estimated cost to treat VAP per patient
32 cases
Total number of VAP cases for 2015 and 2016
RM 4,312,224
Total cost for the treatment of VAP in 2015 and 2016
Mortality rate for VAP in HoSHAS
2015 2016
No. of mortality in
HoSHAS ICU 172 pt 151 pt
No. of mortality from VAP 16 pt 9 pt
Mortality rate for VAP 9.3% 6%
2.
Prevention of
VAP
Changing Views of VAP
No longer an ‘unfortunate occurrence’
Now a MEDICAL ERROR!
Definition
Definition
Defined as parenchymal
‘’ lung infection occurring
more than 48 hrs after the
initiation of mechanical
ventilation
Morehead & Pinto.
Arch Int Med 2000
Definition of VAP
▣A pneumonia where the patient is on mechanical ventilation for > 2
consecutive calendar days on the date of event,
with day of ventilator placement being Day 1,*
AND
the ventilator was in place on the date of event or the day before.
▣*If the ventilator was in place prior to inpatient admission, the ventilator
day count begins with the admission date to the first inpatient location.
▣If a break in mechanical ventilation occurs for at least one full calendar
day, ventilator day count for ventilator association starts anew upon
reintubation and/or re-initiation of mechanical ventilation.
National Healthcare Safety Network (2022)
Definition of VAP
Definition of VAP
Pathogenesis of
VAP
Prevention of VAP
Prevention of VAP
▣Ventilator care bundle
▣Hand hygiene
▣Using asceptic technique in invasive procedure
▣Subglottic suctioning
▣Cuff pressure
Ventilator care
bundle
Ventilator care bundle
▣IHI has started research on VAP since 2001.
▣They have identified four elements of care for
prevention of these events.
▣In 2010, a fifth element is added.
▣VAP rates has dramatically decrease, with no
VAP in the ICUs that is applied.
▣All 5 elements must be applied for the bundle
to work.
Elevation of the head of bed
Recommended elevation:
30-45 degrees
Rationale:
▣ Decrease risk of aspiration of
gastrointestinal/oropharynge
al/nasopharyngeal contents
▣ Improve patient’s ventilation
and minimize atelectasis.
▣ Can reduce VAP rates of up
to 67%.
Daily sedation vacation + Assessment
of readiness to extubate
Stopping IVI infusion of
sedatives and assess whether
patient is able to extubate
Rationale:
▣ Aim to reduce the ventilation
time- by extubating the
patient timely and as soon as
possible.
Peptic Ulcer Disease (PUD)
prophylaxis
Usage of H2 receptor
antagonist- IV ranitidine or
PPI – IV pantoprazole
Rationale:
▣ Decrease risk of PUD – will
reduce length of ICU stay/
intubation.
Deep Vein Thrombosis (DVT) Prophylaxis
Application of the
‘Mechanical intermittent
pneumatic compression’
OR the TED stocking OR
anticoagulants.
Rationale:
▣ To decrease length of stay by
decreasing the risk of DVT
Daily oral care with
chlorhexidine mouthwash
Usage of chlorhexidine
mouthwash to do oral care
at least per shift.
Rationale:
▣ Dental plaque biofilms can
be colonized by respiratory
pathogens.
▣ Chlorhexidine is an inhibitor
of dental plaque formation
and gingivitis.
▣ Prevent bacterial
colonization of the upper
respiratory tract
Hand hygiene
Strict hand hygiene when
touching patient according
to the ‘5 moments of hand
hygiene’.
Using asceptic technique in invasive
procedure
Includes suctioning and
intubation procedure
Subglottic suctioning
Suction the subglottic area
each time after doing ETT
suctioning.
Prevent microaspiration of
subglottic secretion.
Cuff pressure
Maintain cuff pressure of 20-
30 mmHg
Do not deflate cuff before
suctioning the subglottic
secretion!
MRIC Ventilator care bundle
▣IHI has started research on VAP since 2001.
▣They have identified four elements of care for
prevention of these events.
▣In 2010, a fifth element is added.
▣VAP rates has dramatically decrease, with no
VAP in the ICUs that is applied.
▣All 5 elements must be applied for the bundle
to work.
MRIC Ventilator care bundle
▣IHI has started research on VAP since 2001.
▣They have identified four elements of care for
prevention of these events.
▣In 2010, a fifth element is added.
▣VAP rates has dramatically decrease, with no
VAP in the ICUs that is applied.
▣All 5 elements must be applied for the bundle
to work.
MRIC Ventilator care bundle
▣IHI has started research on VAP since 2001.
▣They have identified four elements of care for
prevention of these events.
▣In 2010, a fifth element is added.
▣VAP rates has dramatically decrease, with no
VAP in the ICUs that is applied.
▣All 5 elements must be applied for the bundle
to work.
MRIC Ventilator care bundle
▣IHI has started research on VAP since 2001.
▣They have identified four elements of care for
prevention of these events.
▣In 2010, a fifth element is added.
▣VAP rates has dramatically decrease, with no
VAP in the ICUs that is applied.
▣All 5 elements must be applied for the bundle
to work.
MRIC Ventilator care bundle
▣IHI has started research on VAP since 2001.
▣They have identified four elements of care for
prevention of these events.
▣In 2010, a fifth element is added.
▣VAP rates has dramatically decrease, with no
VAP in the ICUs that is applied.
▣All 5 elements must be applied for the bundle
to work.
MRIC Ventilator care bundle
▣IHI has started research on VAP since 2001.
▣They have identified four elements of care for
prevention of these events.
▣In 2010, a fifth element is added.
▣VAP rates has dramatically decrease, with no
VAP in the ICUs that is applied.
▣All 5 elements must be applied for the bundle
to work.
MRIC Ventilator care bundle
MRIC Ventilator care bundle
MRIC Ventilator care bundle
MRIC Ventilator care bundle
Daily assessment for readiness to wean
• Rationale same as target light sedation
• Aim to wean off ventilation (and hence ETT) as soon
as possible
• However, also need to avoid inappropriate
premature weaning in patients not ready to wean
• Need to accurately identify patients who are ready
to wean
MRIC Ventilator care bundle
MRIC Ventilator care bundle
MRIC Ventilator care bundle
MRIC Ventilator care bundle
CONCLUSION
What is the most
important factor to
prevent VAP?
Want big impact?
Use big image.
Thanks!
Any questions?
