PENCEGAHAN INFEKSI

VENTILATOR ASSOCIATED
PNEUMONIA (VAP)

Ns Novita Simbolon,Skep,Mkep,CIPP,.FISQua

Disampaikan Pada Pelatihan

Pencegahan Dan Pengendalian Infeksi Dasar
Tanggal, 25 – 27 Oktober 2023
 TUJUAN PEMBELAJARAN UMUM

Setelah selesai proses pembelajaran ini peserta mampu menerapkan

bundles dan penegahan pengendalian ventilator Associated
Pneumonia terkait dengan pemasangan ventilasi mekanik sesuai
standar yang sudah ditetapkan
 TUJUAN PEMBELAJARAN KHUSUS
Setelah proses pembelajaran ini peserta mampu:
▪ Menjelaskan latar belakang
▪ Menjelaskan pengertian VAP
▪ Menjelaskan epidemiologi VAP
▪ Menjelaskan tujuan penerapan bundles dan pencegahan dan
pengendalian VAP
▪ Menjelaskan fakto-faktor penyebab VAP
▪ Menjelaskan indikasi pemasangan ventilasi mekanik
▪ Menjelaskan yang memasang ventilasi mekanik
▪ Menjelaskan kriteria VAP
▪ Menjelaskan ruang lingkup bundles VAP
▪ Menjelaskan cara melaksanakan bundles VAP
 POKOK BAHASAN

▪ Latar belakang
▪ Pengertian VAP
▪ Epidemiologi VAP
▪ Tujuan penerapan bundles dan pencegahan dan
pengendalian VAP
▪ Fakto-faktor penyebab VAP
▪ Indikasi pemasangan ventilasi mekanik
▪ Kriteria VAP
▪ Bundles VAP
PENDAHULUAN
▪ Ventilator Associated Pneumonia adalah Infeksi
pneumonia akibat Pemasangan Ventilasi
mekanik

▪ Ventilasi mekanik tidak dapat dihindari karena

kondisi pasien yang gagal napas atau depresi
pernapasan untuk memenuhi kebutuhan
oksigensasi pasien

▪ Untuk mencegah VAP maka dibuatlah suatu

upaya untuk mencegah dengan menerapkan
bundles VAP
 LATAR BELAKANG
VAP adalah masalah HAIs yang terbesar di ICU,
VAP di PICU mencapai 31.7 per 1000 hari pemakaian ventilator (INICC, 2009-
2010) VAP: 8-28% (American Thoracic Society, 2005).
VAP: 32 % (NHSN 2013)
Kuman tertinggi pada VAP adalah Acinetobacter dan E.coli (INICC, 2004-
2008)
VAP berdampak kematian, kerugian, lama rawat menginap, mutu menurun

Craven,2005
NHSN :Nasional Healthcare Safety Network Sumber : Komite PPI RSJPDHK
INICC: International Nosocomial Infection Control Consortium
 PENGERTIAN

Ventilator Associated Pneumonia (VAP) adalah infeksi

pneumonia yang terjadi pada parenkhim paru dengan
Tanpa Ventilasi pasien yang terpasang ventilasi mekanik baik pipa
mekanik /Ventilator endotracheal maupun tracheostomy ≥ dua hari kalender

Terpasang Ventilasi mekanik /Ventilator

 PENGERTIAN

Bundle Ventilator adalah serangkaian intervensi

keperawatan berbasis bukti, diterapkan untuk
mencegah insiden VAP

Bundle hanya terdiri dari 3 - 5 intervensi keperawatan

PATOGENESIS
 DAMPAK VAP

✓ Lama hari rawat meningkat

✓ Penggunaan antibiotika meningkat
✓ Biaya meningkat
✓ Angka kesakitan meningkat
✓ Angka kematian meningkat
✓ Biaya menurun
✓ Tuntutan hukum
 FAKTOR RISIKO VAP
Endogen
✓ Immunocompromised
✓ Penyakit penyerta
✓ Usia Ekstrem
✓ Male gender
✓ Malnutrisi
✓ Gangguan mental
✓ MOF (Multi Organ Failure)
✓ Acut Renal Failure
✓ ARDS
✓ Ulcer Diseases
✓ Pembedahan (Neuro, thorax,
cardiac)
✓ Kolonisasi mikroorganisme
digestive dan oropharing
Exogen
✓ Pemakaian Ventilator
✓ Kebersihan tangan tidak adekuat
✓ Teknik aseptik tidak adekuat
✓ Pemakaian antibiotika
✓ Pemakaian APD tidak tepat dan
benar
✓ Posisi pasien supine
✓ Lama pemakaian ventilator
✓ Sumber daya kurang (men, metode,
material)
✓ Re-intubasi
✓ Pergantian sirkuit ventilator
✓ Sumber daya (men, metode, machine,
material
 MIKROORGANISME PENYEBAB
❖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
MIKROORGANISME VAP
 Table 1: Specific Site Algorithms for Clinically Defined Pneumonia (PNU1)
Imaging Test Evidence
Two or more serial chest imaging test results
with at least one of the following:
New and persistent or Progressive and
persistent
• Infiltrate • Consolidation • Cavitation
Note: In patients without underlying
pulmonary or cardiac disease (for example:
respiratory distress syndrome, broncho
pulmonary dysplasia, pulmonary edema, or
chronic obstructive pulmonary disease), one
definitive imaging test result is acceptable.1
Signs/Symptoms
ANY PATIENT, at least one of the following:
• Fever (>38.0°C ) • Leukopenia (≤4000 WBC/mm3 ) or leukocytosis (>12,000 WBC/mm3 )
• For adults >70 years old, altered mental status with no other recognized cause
And at least two of the following:
• New onset of purulent sputum or change in character of sputum4 , or increased respiratory
secretions, or increased suctioning requirements
• New onset or worsening cough, or dyspnea, or tachypnea5
• Rales6 or bronchial breath sounds
• Worsening gas exchange (for example: O2 desaturations (for example: PaO2/FiO2 <240),
increased oxygen requirements, or increased ventilator demand)
ALTERNATE CRITERIA, for child >1 year old or ≤12 years old,
at least three of the following:
• Fever (>38. 0°C) or hypothermia (< 36 .0°C )
Leukopenia (≤4000 WBC/mm3 ) or leukocytosis (≥15,000 WBC/mm3 )
• New onset of purulent sputum or change in character of sputum4 , or increased respiratory
secretions, or increased suctioning requirements
• New onset or worsening cough, or dyspnea, apnea, or tachypnea5 .
• Rales6 or bronchial breath sounds
• Worsening gas exchange (for example: O2 desaturations [for example pulse oximetry < 94%,
increased oxygen requirement or increased ventilation demand
Table 2: Specific Site Algorithms for Pneumonia with Common Bacterial or
Filamentous Fungal Pathogens and Specific Laboratory Findings (PNU2)
Imaging Test Evidence
Two or more serial chest
imaging test results with at
least one of the following: New
and persistent or Progressive
and persistent • Infiltrate •
Consolidation • Cavitation
In patients without underlying
pulmonary or cardiac disease
(for example: respiratory
distress syndrome,
bronchopulmonary dysplasia,
pulmonary edema, or chronic
obstructive pulmonary
disease), one definitive chest
imaging test result is
acceptable
Signs/Symptoms
At least one of the following:
• Fever (>38.0°C)
• Leukopenia (≤4000 WBC/mm3 ) or
leukocytosis (>12,000 WBC/mm3 )
• For adults >70 years old, altered mental
status with no other recognized cause And at
least one of the following:
• New onset of purulent sputum or change in
character of sputum , or increased respiratory
secretions, or increased suctioning
requirements
• New onset or worsening cough, or dyspnea
or tachypnea
• Rales or bronchial breath sounds
• Worsening gas exchange (for example: O2
desaturations [for example: PaO2/FiO2
<240), increased oxygen requirements, or
increased ventilator demand)
Laboratory
At least one of the following:
• Organism identified from blood,
• Organism identified from pleural fluid
• Positive quantitative culture or corresponding semi-
quantitative culture result from minimally-
contaminated LRT specimen (specifically, BAL,
protected specimen brushing or endotracheal
aspirate) • ≥5% BAL-obtained cells contain
intracellular bacteria on direct microscopic exam (for
example: Gram’s stain)
• Positive quantitative culture or corresponding semi-
quantitative culture result of lung tissue
• Histopathologic exam shows at least one of the
following evidences of pneumonia:
o Abscess formation or foci of consolidation with
intense PMN accumulation in bronchioles and alveoli
o Evidence of lung parenchyma invasion by fungal
hyphae or pseudohyphae
 Table 3: Specific Site Algorithms for Viral, Legionella, and other
Bacterial Pneumonias with Definitive Laboratory Findings (PNU2)
Imaging Test Evidence
Two or more serial chest imaging
test results with at least one of the
following1:
New and persistent or Progressive
and persistent
• Infiltrate • Consolidation •
Cavitation • Pneumatoceles
Note: In patients without
underlying pulmonary or cardiac
disease (for example: respiratory
distress syndrome,
bronchopulmonary dysplasia,
pulmonary edema, or chronic
obstructive pulmonary disease), one
definitive chest imaging test result is
acceptable
Signs/Symptoms
At least one of the following:
• Fever >38.0°C
• Leukopenia (≤4000 WBC/mm3 ) or
leukocytosis (>12,000 WBC/mm3 )
• For adults >70 years old, altered mental status
with no other recognized cause And at least one
of the following:
• New onset of purulent sputum or change in
character of sputum , or increased respiratory
secretions, or increased suctioning requirements
• New onset or worsening cough or dyspnea, or
tachypnea
• Rales or bronchial breath sounds
• Worsening gas exchange (for example: O2
desaturations [for example: PaO2/FiO2 <240),
increased oxygen requirements, or increased
ventilator demand)
Laboratory
At least one of the following:
• Virus, Bordetella, Legionella, Chlamydia or Mycoplasma
identified from respiratory secretions or tissue by a
culture or non-culture based microbiologic testing
method which is performed for purposes of clinical
diagnosis or treatment (for example: not Active
Surveillance Culture/Testing (ASC/AST).
• Fourfold rise in paired sera (IgG) for pathogen (for
example: influenza viruses, Chlamydia)
• Fourfold rise in Legionella pneumophila serogroup
antibody titer to ≥1:128 in paired acute and convalescent
sera by indirect IFA.
• Detection of L. pneumophila serogroup antigens in
urine by RIA or EIA
 Table 4: Specific Site Algorithm for Pneumonia in
Immunocompromised Patients (PNU3)
Imaging Test Evidence
Two or more serial chest imaging
test results with at least one of the
following1:
New and persistent or Progressive
and persistent
• Infiltrate • Consolidation •
Cavitation
Note: In patients without
underlying pulmonary or cardiac
disease (for example: respiratory
distress syndrome,
bronchopulmonary dysplasia,
pulmonary edema, or chronic
obstructive pulmonary disease), one
definitive chest imaging test result is
acceptable.
Signs/Symptoms
Patient who is immunocompromised
has at least one of the following:
• Fever >38.0°C
• For adults >70 years old, altered
mental status with no other recognized
cause
• New onset of purulent sputum , or
change in character of sputum , or
increased respiratory secretions, or
increased suctioning requirements
• New onset or worsening cough, or
dyspnea, or tachypnea5
• Rales6 or bronchial breath sounds
• Worsening gas exchange (for
example: O2 desaturations for
example: PaO2/FiO2 <240), increased
oxygen requirements, or increased
ventilator demand)
Laboratory
At least one of the following:
• Identification of matching Candida spp.
from blood and one of the following: sputum,
endotracheal aspirate, BAL or protected
specimen brushing.
• Evidence of fungi (excluding Candida and
yeast not otherwise specified) from
minimally-contaminated LRT specimen
(specifically BAL, protected specimen
brushing or endotracheal aspirate) from one
of the following: − Direct microscopic exam −
Positive culture of fungi − Non-culture
diagnostic laboratory test OR Any of the
following from: LABORATORY CRITERIA
DEFINED UNDER PNU2
Reporting Instructions:

There is a hierarchy of specific categories within the major site pneumonia.

If the patient meets criteria for more than one specific site during the infection
window period , report only one:
o If a patient meets criteria for both PNU1 and PNU2, report PNU2.
o If a patient meets criteria for both PNU2 and PNU3, report PNU3.
o If a patient meets criteria for both PNU1 and PNU3, report PNU3.

Pathogens and secondary bloodstream infections can only be reported for

PNU2 and PNU3 specific events.
 BUNDLES VAP
Insersi
✓ Kebersihan tangan
✓ Teknik steril
✓ Pemakaian APD
✓ Sedasi

Maintenen
✓ Kebersihan Tangan
✓ Posisi pasien 300-450
✓ Kebersihan mulut
(setiap 4 jam dan k/p)
✓ Manajemen sekresi
oropharingeal dan
endotrkheal
✓ “Sedation Vacation”
 BUNDLES INSERSI VAP
Kebersihan Tangan
Keberihan Tangan sebelum tindakan aseptik dan setelah menyentuh darah dan
cairan tubuh (seb.insersi dan setelah Insersi)
Teknik steril
Pertahankan teknik steril ketika melakukan intubasi, peralatan ditata sedemikian
rupa sehingga tidak terjadi kontaminasi, Laringoscope blade minimal dilakukan
DTT atau Sterilisasi dan ETT steril disposibel)
Pemakaian APD ; gaun,masker (era pandemic covid 19, masker N95), kaca
mata pelindung mata dan atau pelindung wajah/faceshield , topi ,sarung tangan
steril
Prosedur Sedasi dan Analgesik (PSA)sesuai kebijakan institusi (fentanyl,
propofol, etomidate, midazolam), untuk merelaksasi otot-otot pernapasan
 BUNDLES MAINTENAN VAP
▪ Kebersihan Tangan
Melakukan Kebersihan Tangan setiap memanipulasi ETT dan perangkat
ventilator
▪ Posisi pasien 300-450
kecuali ada kontra indikasi: trauma kepala dan tulang belakang
meminimalkan mikroorganisme aspirasi
▪ Kebersihan mulut
setiap 4 jam dan k/p menggunakan cairan clorhexidine 0.02 %, namun
dapat musak mukosa jika di gunakan jangka panjang, sehingga cukup
menggunakana Nacl 09 % atau air yang sudah dimasak kemudian
didiginkan perlu penelitian lanjut
Bila memungkinkan gosok gigi setiap 12 jam untuk mencegah plag
 BUNDLES MAINTENAN VAP
▪ Manajemen sekresi oropharingeal dan endotrkheal
dilakukan bila ada sekresi dengan teknik steril, cairan pengisap air steril, katerter suction sekali pakai
disposable, jika tidak memungkinkan lakukan dekontaminasi sebelum dipakai kembali, pakai APD
gaun, apron, masker bedah, pada era covid 19 pakai masker N95, pelindung mata dan pelindung
wajah, topi, sarung tangan steril, pada era covid 19 direkomendasikan menggunakan closed suction
(dalam penelitian closed and open suction tdk ada perbedaan : Almansory 2014 dan ada perbedaan
Fackar 2010, tidak sering membuka tubing ventilator

▪ Memperhatikan kelembaban pada humidifire ventilator

Pergantian tubing ventilator tidak secara rutin, kecuali kotor atau rusak
tak berfungsi
 BUNDLES MAINTENAN VAP

▪ Sedasi Vacation
Melakukan pengkajian penggunaan obat sedasi dan dosisnya, termasuk respon
pasien terhadap penggunaan obat sedasi dengan cara membangunkan pasien
untuk menilai responnya apakah sudah dapat dilakukan proses weaning
sebelum dilakukan ekstubasi

Alternatif
Memberikan Peptic ulcer disease Prophylaxis pada pasien
risiko tinggi Memberikan Deep Vein Trombosis (DVT)
Prophylaxis
 KESIMPULAN
❖ Pemasangan Ventilasi mekanik tidak dapat dihindari untuk
memenuhi kebutuhan oksigenisasi pasien
❖ Pemasangan Ventilasi mekanik dapat menimbukan berbagai
komplikasi salah satunya adalah Infeksi pneumonia (VAP)
❖ Untuk mencegah VAP dikembangkanlah suatu cara yang
terstruktur dengan menerapkan bundles, baik saat Insersi maupun
maintenen
❖ Penerapan bundles VAP dapat menurunkan insiden rate VAP
terkait pemasangan Ventilasi mekanik
TERIMA KASIH
SEMOGA BERMANFAAT
SALAM SEHAT SELALU