What I Do for VAP

or Rather
What We Do
Rita Sekarsari
An infection of the lung parenchyma developing
in a patient after 48 hours on mechanical ventilation
(Tai Li Ling, Department of Anaesthesia & Intensive Care Hospital Kuala Lumpur 2004)

9-21%
Early vs Late Onset
< Day 4 > Day 4
18% of all hospital associated infections

 Incidence 10% - 25 % pneumonia associated

ventilator

 6.5% ventilated 10 days, 28% ventilated 30 days

( CDC guideline for prevention of healthcare associated pneumonia
2003, Ann Intern Med 1998 )
*Early Onset
Strep Pneumoniae
H influenza
Staph Aureus

*Late Onset
17 % Pseudomonas
51% Other Gram Negative
We Don’t Do What They Tell Us To !
Rello Chest 2002; 122:656

Not related to Strength of Evidence

60% gram negative bacteria
P.Aeruginosa & Acinetobacter spp higher mortality
rates (87% VS 55% for others)

Advanced age
Severity of illness
Malnutrition
Prolonged mechanical ventilation
Major thoracic or abdomianl surgery
Depressed level of conciousness
MECHANISMS OF RESPIRATORY TRACT
COLONIZATION

GASTRIC TUBE

ENVIROMENTAL OROPHARYNEAL

STOMACH
TRACHEAL TUBE LUNGS

LOWER GI TRACT
BLOOD
 Teach ‘em “Bugline”
Kaye AJIC 2000: 28:197-201

And Keep Teaching ‘em

Conly Am J Infect Control 1989; 17:330-339
 Kategori Rekomendasi
Sangat direkomendasi untuk implementasi dan sangat
didukung oleh pengalaman yang dirancang dengan baik,
IA secara klinik dan studi epidemiologi
Sangat direkomendasi untuk implementasi dan didukung oleh
beberapa pengalaman klinik, atau studi epidemiologi dan teori
IB rasional yang kuat
Diperlukan untuk implementasi, sebagai perintah oleh federal
dan atau regulasi negara atau standard
IC
II Dianjurkan untuk implementasi dan didukung oleh klinik atau
studi epidemiologi atau teori rasional
Tidak Masalah yang tak terpecahkan. Pelatihan yang mana fakta-
direkomenda fakta tidak cukup atau tidak ada konsensus sehubungan
sikan dengan manfaat
A. Stelization or Disinfection & Maintanance of Equipment & Devices

1. General measures
*Thorougly clean all equipment & devices to be sterilized or
desinfected IA

*After disinfection, proceed with appropriate rinsing, drying,

and packaging, taking care not to contaminate the disinfected
items in the process IA

*Preferentially use sterile water for rinsing reusable respiratory

equipment & devices after chemically disinfected IB
2. Mechanical ventilator
*Do not routinely sterilize or
disinfect the internal machinery of
mechanical ventilator II

3. Breathing circuits, humidifiers

*Breathing circuits with
humidifiers
Do not change routinely, on the basis
of duration of use, the breathing
circuit (i.e., ventilator tubing &
exhalation valve & the attached
humidifier) that is in use on an
individual patient. Change the circuit
when it is visibly soiled or
mechanically malfunctioning IA
* Breathing-circuit-tubing condensate
Periodically drain & discard any condensate that collects in
the tubing of a mechanical ventilator, taking precautions not to
allow condensate to drain toward the patient IB

Wear gloves to perform the previous procedure and/or when

handling the fluid IB

Decontaminate hands with soap and water ( if hands are visibly

soiled ) or with an alcohol-based hand rub after performing
the procedure or handling the fluid IA
* Humidifier fluids
Use sterile ( not distiled, nonsterile) water
to fill bubbling humidifiers II

4.Oxygen humidifiers
Follow manufacturers instructions for use of
oxygen humidifiers IIC

Change the humidifier-tubing (including any nasal prongs

or mask) that is in use on one patient when it malfunctions
or becomes visibly contaminated II
5. Small-volume medication nebulizers
* Between treatments on the same patient, clean, disifect,
rinse with sterile water ( if rinsing is need), and dry
small-volume in-line or hand-held medication
nebulizer IB

* Use only sterile fluid for nebulization, and dispense the

fluid into the nebulizer aseptically IA

* Whenever possible, use aerosolized medication in

single dose vials IB
6. Mist tents
* Subjects mist-tent nebulizer, reservoirs, and tubings that
are used on the same patients to daily low-level
disinfections (e.g., with 2% acetic acid) or
pasteurization followed by air-drying II

7. Others devices used in association with

respiratory therapy
* Respirometer and ventilator thermometer: between their
uses on different patients, sterilize or subject to high level
disinfection portable respirometer & ventilator
thermometers IB
* Resuscitation bags
Between their uses on different patients,
sterilize or subject to high level disinfection
reusable hand powered resuscitation bags IB

8. Anesthesia machines & breathing systems

or patient circuits
* Between uses on different patients, clean reusable
compenents of the breathing system or patient circuit
(e.g. face mask) inspiratory and expiratory breathing
tubing, Y piece, reservoir bag, humidifier, and tubing,
and sterilize or subject them to high level liquid
chemical disifection in accordance with the device
manufactures IB
9. Pulmonary-function testing equipment
* Do not routinely sterilize or disinfect the
internal machinery of pulmonary function testing
machines between uses on different patients II

* Change the mouthpiece of a peak flow meter or

the mouthpiece and filter of a spirometer between
uses on different patients II
B. Prevention of Person to Person Transmition of Bacteria

1. Standard Precautions

* Hand Hygine : decontaminate hands as described

previously before and after contact with a patient
who has an ETT or tracheostomy tube in place, and
before and after contact with any respiratory device
that use on the patient, whether or not gloves
are worn IA
* Gloving
Wear gloves for handling respiratory secretions
or objects contaminated with respiratory secretions
of any patient IB

Change gloves and decontaminate hands as described

previously between contacts with different patients;
after handling respiratory secretion or objects
contaminated with secretions from one patient
and before contact with another patient, object, or
environmental surface; and between contact with
a contaminated body site and respiratory tract of, or
respiratory IA
2. Care of patients with tracheostomy

* Perform tracheostomy under aseptic

conditions II

* When changing a tracheostomy tube, wear a gown,

use aseptic technique, and replace the tube with one
that has undergone sterilization or high level
disinfection IB
3. Suctioning of respiratory tract secretions
* If the open system suction is employed, use
sterile, single use catheter II

* Use only sterile fluid to remove secretions from

the suction catheter if the catheter is to be used
for re-entry into the patient’s lower respiratory
tract II
HOB elevation at 30 - 45 o

Oral hygiene and Nasal hygiene

Turning and Positioning

Endotracheal Suctioning as needed

Avoidance of Large Gastric Volumes

Oral (non nasal) intubation; avoid
nasal intubation for more than
48 hours

Early extubation

Need for NGT

Verification of tube placement

Gastric Residuals, checked 4-6 hours

 Infection Control Team
Internal Vs External
Kaye et al AJIC 2000; 28: 197-201
Paterson CCM 2003; 31S:25S-28S

Gloves in Handling Airway

Pittet et al Archives of Intern Med 1999; 159:821-826

Aprons ?
Barrier methods not really shown for VAP
Klein NEJM 1989; 320:1714-172
Hand Wiping
&
Washing

Trampuz et al. Mayo Clinic Proceedings 2004; 79:109-116

 Hot Water Humidifier Vs HME ?
Boots et al. Crit Care Med 1996; 25: 1707-1702
Kirton Chest 1997; 112:1055-59

Condensate- Double Heater Wire Circuit ?

Craven et al Am Rev Respir Dis 1984; 129:625-28

Circuit Change - We never do this

Kollef Chest 1998; 113:267-268
Preoxygenation ? Yes !
How Deep ? Carina & withdraw 1 cm before suction
How Hard ? 80-150 mmHg
How Long ? 10-15 secs

How Big ? 50% Airway Diameter

Number of Passes? 3

How Frequent ? Every 4 hours

otherwise as required
Instilling What ? Nothing !

Suck ‘Em Out

Lewis Resp Care 2002; 47: 808-17

Day Intensive and Critical Care Nurse 2002: 18: 79-89
Johnson et al Crit Care Med 1994; 22:658-666
 Maintain Cuff Pressures
> 20 cm H2O

Rello Am J Respir Crit Care Med 1996; 154:111-115

Tube Out - Never by Accident

Reintubation - elective OK

De Lassence et al Anesthesiology 2002; 97: 148-156

Chlorhexidine/Alcohol Mouth Care

Q 4hr

DeRisso II Chest 1995; 109: 1558-1561

Rumback CCM 1995; 23:1200-1203

Brushing Teeth
Benefit ?

Q 8hr
 NG Tube
Oral or Out
Sinusitis
Meduri Chest 1994; 106:221-35
Holzapfel Am J Resp Crit Care Med 1999; 159:695-701
Rouby Amer J Respir Crit Care Med 1994; 150:776-783

Tracheostomy Policy ?
OR 6.71
(CI95 3.91-7.50)
I am not sure about this?
Ibrahim Chest 2001; 120:555-61
Rello Chest 2003; 124:2239
 Feed Me

Continuous !
Post-Pyloric ??
Smaller Tubes ??
Acidified Feeds??
Immunoenhanced Feeds ??

Valles Sepsis 1998; 1:199-209

Goncalves JPEN 2004; 28:60
Heyland JPEN 2002; 26:S51-57
Kearns Crit Care Med 2000; 28: 1742-6
Keep ‘Em Empty

• OG rather than NG
• NG out early
• Regular suck out

Joshi Am J Med 1992; 93: 135-142

 Sit ‘Em Up !
Make Sure 45o

Rotate the Bed ??

Not for Medical
Not if I’m awake!
De Boisblanc Chest 1993; 1543-1547
Kollef JAMA 1993; 1965-1970
•X Selective
Decontamination

•-/+ Stress Ulcer

Prophylaxis

Sanchez et al Am J Respir Crit Care Med 1998; 158:908-906

Cook et al NEJM 1998; 338:791-797
Physiotherapy

Ntoumenopoulos, Intensive Care Med. 2002; 28:850-856

Sedation Protocols
X
Working on it !

Rello Chest 1992; 102: 525-529

Staff Levels
1:1
& 1 on the floor

Needleman NEJM 2002; 246:1715-22

 Noninvasive Ventilation
Nosocomial Infections and Pneumonia Reduced
NIV Vs Controls
9-31% 8-73%
Girou Eur Respir J 2003 42; 72s-76s

Beware - need to make

diagnosis!
Diagnosis