Ventilator-Associated Pneumonia (VAP): Clinical Focus

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The Scope of the Problem

Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections and can impact more than 20% of mechanically ventilated patients. It is associated with:

  • Increased morbidity and mortality — Mortality rates vary but may exceed 10%
  • Prolonged mechanical ventilation
  • Increased hospital length of stay — by 2 days
  • Extended use of antimicrobial medication
  • Increased costs — $40,000 per patient or $1.2 billion annually in the United States.

VAP occurs as a result of a bacterial infection of the pulmonary parenchyma of mechanically ventilated patients. Infection can occur as a result of some bacterial invasion of the sterile lower respiratory tract such as aspiration, use of contaminated equipment, ingestion of contaminated medications, or colonization of the aerodigestive tract. Consequently, the development of a standard, reliable, and valid definition for VAP has been difficult to identify.

(AACN, 2016)
http://www.aacn.org/dm/resource/resourceportal.aspx?menu=practice&topic=vap

 

Element

Practice

Evidence

Rationale

Perform hand hygiene before and after touching the patient or the ventilator

Daily spontaneous awakening trials and spontaneous breathing trials

  • Ongoing assessment of readiness to extubate with minimum documentation at least every 24 hours.
  • Every day the care team should actively discuss whether the patient still needs to be intubated and what steps are necessary to move towards extubation.

I. High Highly confident that the true effect lies close to that of the estimated size and direction of the effect. Evidence is rated as high quality when there is a wide range of studies with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.

  • Daily spontaneous breathing trials are associated with extubation 1–2 days earlier compared with usual care.
  • Pair spontaneous breathing trials with spontaneous awakening trials
  • Patients are more likely to pass a spontaneous breathing trial and be extubated if they are maximally awake at the time of the breathing trial.

Maintain head of bed 30-45 degrees as long as tolerated

  • Keep the head of the bed elevated to 30-45 degrees for all ventilated patients beyond infancy.
  • Consider the use of a visual measuring device (e.g. protractor painted on bedside) to ensure the angle is correct.

III. Low The true effect may be substantially different from the estimated size and direction of the effect. Evidence is rated as low quality when supporting studies have major flaws, there is important variation between studies, the confidence interval of the summary estimate is very wide, or there are no rigorous studies, only expert consensus.

A meta-analysis found a significant impact on VAP. In addition, enteral feeding in the supine position substantially increases the risk of developing VAP.

Use an endotracheal tube with a dorsal lumen above the cuff to allow drainage by continuous suctioning of tracheal secretions that accumulate in the subglottic area

Endotracheal tubes with subglottic secretion drainage ports are therefore recommended only as a basic practice for patients likely to require greater than 48–72 hours of intubation.

II. Moderate The true effect is likely to be close to the estimated size and direction of the effect, but there is a possibility that it is substantially different. Evidence is rated as moderate quality when there are only a few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide.

Provide endotracheal tubes with subglottic secretion drainage ports for patients likely to require greater than 48 or 72 hours of intubation

Perform regular oral care minimally every 12 hours

  • Brushing teeth and gums with a soft bristle toothbrush and product for plaque removal, or use a gauze and sterile water for patients without teeth ideally every 12 hours.
  • Perform oral care (moistening mouth and lips, removal of oropharyngeal secretions) every 4 hours and before repositioning patient.

Limited evidence to support practice, although there is increasing evidence being published

Association between oral microbiome and respiratory pathogens causing pneumonia

Minimize disruption to circuit, inspect ventilator circuit for gross contamination daily and if present change circuit. Remove condensation from the ventilator circuit and keep the circuit closed during removal

  • Perform inspection of circuit at least every 8 hours for condensation and/or gross contamination. Drain condensation. Only change circuit for gross contamination.
  • Visually inspect ventilator for condensation or contamination.
  • Change ventilator circuit when visibly soiled.
  • Drain ventilator circuit if fluid has accumulated.
  • Avoid changing of the ventilator circuit on a routine basis.

I. High Highly confident that the true effect lies close to that of the estimated size and direction of the effect. Evidence is rated as high quality when there is a wide range of studies with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval

Change the ventilator circuit only if visibly soiled or malfunctioning

Solutions for Patient Safety, 2016 (http://www.solutionsforpatientsafety.org/wp-content/uploads/SPS-Prevention-Bundles.pdf)

Michael Klompas, Richard Branson, Eric C. Eichenwald, Linda R. Greene, Michael D. Howell, Grace Lee, Shelley S. Magill, Lisa L. Maragakis, Gregory P. Priebe, Kathleen Speck, Deborah S. Yokoe and Sean M. Berenholtz (2014). Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update. Infection Control & Hospital Epidemiology, 35, pp 915-936. doi:10.1086/677144.

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