VAP: A Preventable Disease

Ruben D Restrepo MD RRT FAARCRuben D Restrepo MD RRT FAARC

Professor of Respiratory CareProfessor of Respiratory Care

The University of Texas Health Science Center at San AntonioThe University of Texas Health Science Center at San Antonio

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Disclosure: Ruben D. Restrepo, MD, RRT, FAARC

• Teleflex Medical– Speaker– Member, Medical Advisory Board

• Oridion Capnography (Covidien)– Consultant and investigator

• Salter Labs– Consultant

• Fisher & Paykel– Investigator

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• Upon completion of this module, participants should understand and be able to communicate:– Impact of VAP– Diagnostic criteria for VAP and VAE– Recommended strategies to minimize contamination

of equipment used during mechanical ventilation– Evidence Based Clinical Practice Guidelines directed

to reduce incidence of VAP– Role of the VAP Bundle – Risks associated with breathing circuit condensation

and the advantages and disadvantages of current options available for condensation management

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• ICU environment:– Patients are sicker and maybe immunocompromised– Mechanically ventilation: use of life-saving, but

invasive devices (catheters and ETTs)• Superhighways for bacterial invasion

• Magnitude of HAI:– Pneumonia

• 15% of HAI

• 27% of ICU acquired infections

• 24% of infections in coronary care units

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• Magnitude of VAP:– 2nd most common HAI in the US1

• Most common HAI in the ICU– CDC 2006-2007: 2.1-11.0 per 1,000 ventilator days2

– Increased length of stay (LOS) by:• 25 hospital days• 22 ICU days

– Associated cost: $40,000?3 $60,000?4

– 1st cause of death from HAI5

– Attributable mortality as high as 27%5

1. Klevens et al. Public Health Reports 2007;122:160-166. 2. Centers for Disease Control and Prevention. MMWR 2004;53(No. RR-3). 3. Rello J et al. Chest. 2002;122:2115-2121.

4.Warren D et al. CCM. 2003;31:1312-1317. 5. Fagon JY et al. Am J of Med. 1993;94:281-288.

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http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

Scott II RD. The Direct Medical Costs of Healthcare-Associated Infection in US Hospitals and the Benefits of Prevention. CDC 2009; http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

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• 4.5 HAIs/100 hospital admissions• Overall annual direct medical costs of HAI

– $28.4 - $33.8 billion - urban consumers– $35.7 - $45 billion - inpatient hospital services

• Benefits of prevention – $5.7 - $6.8 billion (20% preventable - urban

consumers)– $25.0 - $31.5 billion (70% preventable - inpatient

hospital services).

Scott II RD. The Direct Medical Costs of Healthcare-Associated Infection in US Hospitals and the Benefits of Prevention. CDC 2009; http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

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• According to Stone et al2005

– $36,441 BSI– $25,546 SSI– $9,969 VAP$9,969 VAP– $1,006 CAUTI

• According to Anderson et al2007

– $23,242 BSI– $10,443 SSI– $25,072 VAP$25,072 VAP– $758 CAUTI

Stone PW, et al. Systematic review of economic analyses of health care-associated infections. Am J Infect Control 2005;33:501-509.

Anderson DJ, et al. Under resourced hospital infection control and prevention programs: penny wise, pound foolish? Infect Control Hosp Epidemiol 2007;28:767-773.

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• NASCENT Study (n= 30 VAP vs. n=90 no VAP)• Median total hospital charges for patient case

– $198,200 vs. $96,540 (P< .001)• Median loss to hospital for patient case

– $ 32,140 vs. $19,360 (P= .151)• Services with the highest median charges:

– hospital ($23,190 vs. $11,110) p <0.05– respiratory ($4,838 vs. $2,787) p<0.05

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VAP: An Expensive Proposition

VAP

• New or progressive New or progressive infiltrates on CXR infiltrates on CXR• FeverFever• Abnormal WBC countAbnormal WBC count• Purulent sputumPurulent sputum

Clinical Diagnostic StrategyClinical Diagnostic Strategy

Clinical suspicion• Patient on Mechanical

Ventilation + infiltrate CXR

+ 2/3 findings• Symptoms infection:

– (1) Fever, (2) purulent tracheal secretions

• Laboratory infection:– (3) Leukocytosis or

leukopenia– [Hypoxemia]

Differential diagnosisChemical aspiration

without infectionAtelectasisPulmonary embolismARDSPulmonary hemorrhage Lung contusionDrug reactionOther

VAP Definition(s) VAP Definition(s) Halpern NA et al. CCM 2012Halpern NA et al. CCM 2012

• CDC's National Healthcare Safety Network – Pneumonia that occurs in a patient who was intubated and

ventilated at the time of, or within 48 hrs, “before” the onset of the pneumonia

• ATS and the IDSA (clinically oriented)– Pneumonia that arises >48–72 hrs “after” intubation

• VAP diagnostic criteria require the presence of a new or progressive and persistent radiographic opacity, a change in pulmonary secretions or symptoms, or evidence of impaired gas exchange and systemic signs of infection – Microbiological evidence of lower respiratory tract infection is

optional

NHSN Surveillance for Ventilator-NHSN Surveillance for Ventilator-Associated Events in AdultsAssociated Events in Adults

NHSN Surveillance for Ventilator-NHSN Surveillance for Ventilator-Associated Events in AdultsAssociated Events in Adults

How Will I Find Cases of VAP?How Will I Find Cases of VAP?

•http://www.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf JUNE 2011

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VAP Definition

• 1 Mayhall G. C. Special Issue: Ventilator-Associated Pneumonia or Not? Contemporary Diagnosis. Emerging Infectious Diseases Vol. 7, No. 2, March-April 2001 p. 201.

• 2 Davies, J. Pathogens Associated with the Intensive Care Unit Environment : Considerations for the Respiratory Therapist. Clinical Foundations: A Patient-focused Education Program for Respiratory Care Professionals. December 2009.

Early Onset VAP2

• Occurs in the period of 2-5 days post intubation

• Pathogens responsible are susceptible to antibiotic therapy– Staphylococcus Aureus

(Meth sensitive)– Streptococcus pneumoniae– Hemophilus influenzae– Proteus species– Serratia species– Klebsiella pneumoniae– Escherichia coli

Late Onset VAP2

• >5 days post intubation• Usually caused by antibiotic-

resistant organisms – Pseudomonas aeruginosa, – Methicillin-resistant

Staphylococcus aureus (MRSA),

– Acinetobacter species– Enterobacter species– Vancomycin-resistant

enterococcus (VRE)

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Gacouin A, et al. Late-Onset Ventilator-Associated Pneumonia in Nontrauma Intensive Care Unit Patients Anesth Analg 2009;109:1584-1590

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VAP Pathogenesis

• Bacterial invasion of the pulmonary parenchyma in a patient receiving mechanical ventilation

• Inoculation of the formerly sterile lower respiratory tract typically arises from:– Aspiration of secretions– Colonization of the aero digestive tract– Use of contaminated equipment or medications

Coffin S MD, MPH, Klompas M MD, Classen D MD, et al. Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals. Infection Control Hosp Epidemiol 2008; 29:S31-S40.

Biofilm on ETT

Dispersal of Biofilm With Ventilation

Endotracheal Tube

Subglottic Secretions

Endotracheal Tube Cuff

Pooled Secretions in Airway

VAP Pathogenesis

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Curr Opin Infect Dis. 2013 Jan 2. [Epub ahead of print]

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Risk Factors for VAP

• Risk factors for VAP include:– Modifiable:– Duration of ventilation– Position in bed (supine)– Enteral feeding– Witnessed aspiration– Paralytic agents– Prior antibiotic use


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Risk Factors for VAP

• Risk factors for VAP include:– Nonmodifiable:– Extreme ages– Comorbidities

• Pulmonary disease• HIV/AIDS• Head trauma• MOF• Immunosupression


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Prevention of VAP

• Every Choice Matters– Quality improvement initiatives suggest that many

cases of VAP might be prevented by careful attention to the process of care


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• Reducing risk of VAP– Active surveillance– Hand-hygiene guidelines – NIV whenever possible– Minimize the duration of MV– Daily assessments of readiness to wean and use

weaning protocols– Educate healthcare personnel who care for patients

undergoing ventilation about VAP

Existing Guidelines and RecommendationsAARC – CDC – IHI - IDSA


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SHEA/IDSA Guidelines

• “Compendium of Strategies to Prevent Healthcare-Associated Infections”– SHEA-Society for Healthcare Epidemiology of America/ IDSA-

Infectious Diseases Society of America

– Prioritizing VAP as highly preventable


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SHEA Guidelines: Core Recommendations

• Designed to interrupt the three most common mechanisms by which VAP develops:1. Aspiration of Secretions

2. Colonization of the aero digestive tract

3. Use of contaminated equipment


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Strategies to Reduce Aspiration of Secretions• Maintain patients in a semi recumbent position (30-45°

head of the bed elevation) unless contraindicated– 67% reduction in early onset VAP

• Avoid gastric over distention• Avoid unplanned extubation and reintubation• Use a cuffed endotracheal tube with in-line or subglottic

suctioning– effective in preventing early-onset VAP

• Maintain an endotracheal cuff pressure of at least 20cm H20


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Strategies to Reduce Colonization of the Aero digestive Tract

• Orotracheal intubation is preferable to nasotracheal intubation– Nasotracheal intubation increases the risk of sinusitis,

which may increase the risk for VAP

• Avoid H2–blocking agents and proton pump inhibitors

– Unless at high risk for developing a stress ulcer or stress gastritis.

• Perform regular oral care with an antiseptic solution


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1. Thoroughly clean all respiratory equipment to be sterilized or disinfected (IA)

2. After disinfection, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items (IA)

3. DO NOT routinely change the ventilator breathing circuit. ONLY when visibly soiled or mechanically malfunctioning. (IA)

4. Periodically drain and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward the patient. (IB)

5. Wear gloves to perform the above procedure or handle the fluid (IB)

Strategies to Reduce Use of Contaminated Equipment


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General Measures

1. 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)

2. Use sterile (not distilled non sterile) water to fill bubble humidifiers (II)

3. Change any HME that is in use by a patient when it malfunctions mechanically or becomes visibly soiled (II)

4. Do not routinely change more frequently than every 48 hours a HME that is in use by a patient (II)


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Summary of General Recommendations

• You can make a difference!– Quality improvement initiatives show VAP (and the

associated mortality) might be prevented by careful attention to the process of care

• Focus on preventing three most common mechanisms by which VAP develops:

1.Aspiration of Secretions

2.Colonization of the aero digestive tract

3.Use of contaminated equipment

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AARC Evidence-BasedClinical Practice Guidelines

Hess DR, et al. AARC Evidence-Based Clinical Practice Guidelines. Respir Care 2003:48(9):869-879.

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VAP Bundle

• How do you take these best practices and effectively implement them?– VAP Bundle

• Group of best practices that an institution employs to decrease their incidence of VAP

• Typically evidence based with a monitoring / compliance component

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•VAP Bundle: Evidence of Benefit

• If we accept the reduction of the VAP rate (based on the unreliable current VAP definition) as the only outcome to be improved (independent of the absence of mortality and morbidity benefits), then there is an argument to potentially incorporate a few preventive measures (e.g., elevation of the head of the bed, continuous aspiration of subglottic secretions, oral topical antibiotics) into a VAP bundle.

• However, if we interpret the Joint Commission definition of proven outcome benefits as a reduction in VAP-associated mortality and morbidity, then there are no individual VAP preventive measures that have undergone adequate scientific replication that could be entered into any VAP bundle.

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• If we accept the reduction of the VAP rate (based on the unreliable current VAP definition) as the only outcome to be improved (independent of the absence of mortality and morbidity benefits), then there is an argument to potentially incorporate a few preventive measures (e.g., elevation of the head of the bed, continuous aspiration of subglottic secretions, oral topical antibiotics) into a VAP bundle.

• However, if we interpret the Joint Commission definition of proven outcome benefits as a reduction in VAP-associated mortality and morbidity, then there are no individual VAP preventive measures that have undergone adequate scientific replication that could be entered into any VAP bundle.

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Klompas M MD, Prevention of ventilator-associated pneumonia. Expert Rev. Anti Infect. Ther. 2010;8(7):791-800.

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• Benefits• VAP-Industrial Complex• Reporting of Quality Metrics• The Quest for Zero VAP• The VAP Bureaucracy

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Product Solutions and VAP

• Advanced Heat and Moisture Exchangers• Viral/Bacterial Filters• Water Traps• Closed System Water Traps• Heated-wire circuits• Advanced heated-wire circuits• Maintenance Free Water Removal Accessory• Advanced NIV products

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•ETT: Beyond Silver-coated Imanaka CCM 212

• At extubation, only one ETT in 12 patients with ETTs was colonized in the Mucus Shaver group, whereas 10 ETTs out of 12 patients with ETTs were colonized in the control group.

• Scanning electron microscopy showed little secretions on the ETT from the study group, whereas thick bacterial deposits were on all the ETTs from the control group.

• No adverse events were observed and nursing staff seemed to be satisfied by its feasibility.

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•ETT: Beyond Silver-coated Imanaka CCM 212

• At extubation, only one ETT in 12 patients with ETTs was colonized in the Mucus Shaver group, whereas 10 ETTs out of 12 patients with ETTs were colonized in the control group (8% vs. 83%; p <0.001).

• Scanning electron microscopy showed little secretions on the ETT from the study group, whereas thick bacterial deposits were on all the ETTs from the control group.

• No adverse events were observed and nursing staff seemed to be satisfied by its feasibility.

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Advanced HME’s

• New generation HME allows bypassing aerosol

Advantages:– Eliminates caregiver exposure to de-pressurizing

circuits– Reduces circuit manipulation and cross contamination

potential

Disadvantages:– More expensive than traditional HME’s

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Viral/Bacteria Filters

• Reduce the risk of ventilator cross-contamination between patients.

Advantages: – Ease of use– Depending on efficiency ratings, potential for risk reduction

against transmission of bacteria and viruses

Disadvantages: – During HH, condensation leading to increased Raw = frequent

change– Required frequent breaking of the circuit, exposing patient and

caregiver to cross-contamination

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Water Traps

• Collects the water that condenses in the breathing circuit.

Advantages: – Relatively inexpensive and often Integrated into the

breathing circuit

Disadvantages: – Labor intensive

– Potential clinician exposure to contaminants

– Requires circuit “breaks” = cross contamination

• “The condensate that accumulates in the ventilator circuit is contaminated and care should be taken to avoid its cross-contamination of other patients.” (AARC)

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Closed System Water Traps

• Vacuum-activated suctioning water traps Advantages: – Keeps condensate from collecting in the ventilator circuit

with the use of intermittent or continuous suction. – Maintains a closed system: no circuit “breaks.Disadvantages: – Not Passive in nature--requires some clinician

interaction and management to suction out condensate– Dew Point not lowered, some condensation may still

pass to the ventilator

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Heated-Wire Circuits (Advantages)

• Breathing circuit may decrease or eliminate condensate

(dependent on circuit and heated humidifier settings)

• Solution integrated into breathing circuit• Clinician familiarity and comfort• Some heated humidifiers allow for adjustment of heated

wire power (i.e. temperature gradient) to control the amount of condensate in the breathing circuit

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Heated-Wire Circuits (Disadvantages)

• Ambient conditions that cool the circuit = circuit condensate – air conditioning, window, cold rooms– “milking” of the breathing circuit to fix is not recommended

and could be a safety hazard.• Manufacturer change-out protocols may not be “duration of

patient stay” which requires “breaking” the ventilator circuit making it difficult to comply with VAP risk reduction protocols

• Some circuits feature a super heated expiratory limb, which can lead to condensate forming in the ventilator (ECRI)

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Advanced Heated-Wire Circuits

• Heated expiratory limb made from a unique material that allows water vapor to diffuse through the tubing wall and permeate to the atmosphere

Advantages: – Promotes a closed system for the expiratory limb– Reduces expiratory limb maintenance for the clinician– Extends the usable life of the expiratory limb filter– May reduce the humidity level enough to prevent the gas from cooling and

reaching its dew point within the ventilator flow sensor

Disadvantages: – Fragile, highly susceptible to damage during normal handling– Requires 7-day change out protocol– Design does not allow for universal use

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Maintenance Free Water Removal Accessory

• Maintenance free water removal from the expiratory limb of the breathing circuit during mechanical ventilation

Advantages– Reduce circuit manipulation and cross-contamination potential– Eliminate the need to interrupt ventilation– Reduce the amount of time handling and disposing of condensation.– Minimize exposure to de-pressurizing circuits– Avoid accumulation of condensation in the ventilator

Disadvantages– At ventilator placement may require caregiver to drain pooled

condensate into the device

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DO NOT INTUBATE: Advanced NIV Products• Advances in noninvasive positive pressure ventilation

(NPPV) products and protocols continue to improve the success rates of therapy– Masks:

• Designed exclusively for NIV, mask cushions are now focused on patient comfort and therapy compliance

– Ventilators:• New modes of ventilation are advancing use of NPPV

– Heated Humidifiers• Heated humidifiers are now compatible with NPPV therapy,

allowing the delivery of heat and humidity, improving therapy comfort

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DO NOT INTUBATE: High Flow Oxygen Therapy

• Sound alternative to NPPV• Increased evidence:

– Indications– Patient selection– Positive outcomes

• Mechanical devices

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Summary

Infection Protection:

Every Choice Matters

VAP Prevention: RTs Making a Difference VAP Prevention: RTs Making a Difference Arroliga A et al. Respir Care 2012Arroliga A et al. Respir Care 2012

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Accredited Respiratory Education Programs

• Advances in Respiratory Therapy– Peer-to-Peer program: content created, reviewed and

presented by respected respiratory thought leaders– Focused on topics/therapeutic areas which enhance

clinical outcomes

• Clinical Foundations:– Self-Study program available via mail or web

(www.clinicalfoundations.org)– Topics Include Delivering Optimal Humidification,

Difficult airway management, Trends in NIV, and Infection Prevention Strategies for the RT

• www. FirstDoNoHarm.com Website:– Online resource devoted to preventing infections,

saving lives and cutting costs– Includes latest unbiased, authoritative information on

preventing VAP

Thank you for your attention!

Documents

VAP: A Preventable Disease