Prevention of ventilator associated pneumonia
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Transcript of Prevention of ventilator associated pneumonia
Prevention of Ventilator Associated Pneumonia
Steven Podnos MD
Epidemiology
• Most studies confirm that VAP significantly adds to morbidity and mortality
• Occurrence is about 13/1000 ventilator days• Defined as lower respiratory pneumonia
occurring 48 hours after initiation of mechanical ventilation
• VAP is leading cause of death from hospital acquired infection
Pathophysiology
• “Illness” is followed by a change in bacterial adherence to the oropharyngeal mucosa-gram negative bacteria and Staphlococci in particular increase on throat cultures
• VAP is a result of aspiration of oropharyngeal secretions in most cases
• ETT offers “pathway” to lungs
Microbiology
• Gram negative bacteria and Staphlococci• Often multi-resistant organisms• Requires different spectrum of empiric
antibiotic coverage than for Community Acquired Pneumonia
• Accurate isolation of causative organism difficult due to specimen contamination
Factors/Methods in Preventing VAP
• Intermittent Subglottic Secretions drainage/suctioning
• Continuous suctioning may cause tracheal damage
• Ultra-thin polyurethane cuffs help with tracheal occlusion and reduce VAP incidence
• Cuff pressure seems important, but not yet proven
Methods 2
• Kinetic beds/lateral rotation have been shown to decrease VAP, but are expensive
• Saline instillation before suctioning controversial
• Chest PT-potentially useful-hyperinflation and suctioning, vibration
Oral Hygiene
• Oral Chlorhexidine rinses appear useful, but timing, frequency and concentration are unclear
• Tooth Brushing has unclear benefit in VAP prevention, but probably helps dental outcomes
Antibiotics for VAP Prevention
• Multiple trials of IV and topical antibiotics• To date, any decrease in VAP accompanied by
increase in resistant organisms
Bundles
• Avoid ventilator circuit changes• Strict hand hygiene• Sedation vacation, SBT trials• Oral care with Chlorhexidine• Elevate head of bed-better ventilation,
decreased aspiration?• ? Avoid rings, white coats, ties• DVT prophylaxis-also decreases VAP• GI bleed prophylaxis-also decrease VAP