Journal Club

Journal Club

Background to the paper

• Pneumonia is THE MOST COMMON nosocomial infection in ICU patients

• 12 to 18 cases per 1000 ventilator days• Oropharyngeal colonisation• Aspiration of oropharyngeal bugs!

Outcomes

Primary outcome• Frequency of suspected pneumonia in a

semirecumbent & supine posture.

Secondary outcome• Compare frequency of microbiol confirmed

pneumonia in the 2 groups.

Methods

• Recruited for 1 year• 1000 bed tertiary hospital• Stress ulcer prophylaxis• Continous enteral feeding• Gastric aspiration every 4 hours

Methods II

Exclusions• Recent abdo surgery in last 7 days• Neurosurgery in last 7 days• Refractory shock• Previous endotracheal intubation in last 30

days

Methods III

• Random allocation to 0 deg or 45 deg head up• Computer generated randomization list

• Clin suspicion defined: new infiltrates on CXR• Fever > 38.3• WCC <4 or >12.• Purulent tracheal secretions• Pathogenic organism in BAL PSB

VAP: Why is it Important?

• VAP occurs in 10-25% of patients undergoing mechanical ventilation (4-16 cases/1000 ventilator days

• Patients stay in ICU on average 4-9 more days

• Attributable mortality 20-50%• High morbidity and mortality• Preventable with simple technology

Trial profile

Baseline data

Micro data

Pneumonia results

Major Results

Ventilator Associated Pneumonia (VAP) Practice Alert

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HOB Elevation Leads to Significant Deduction in VAP

Dravulovic et al. Lancet 1999;354:1851-1858

0

5

10

15

20

25

% V

AP

Supine HOB Elevation

Results

• 86 mechanically ventilated patients randomized to either supine (flat) vs semi-recumbent (45 degrees) to assess relationship to nosocomial pneumonia

• Trial stopped early• Clinically suspected pneumonia decreased from 34% to 8%

(p=0.003) in semi-recumbent group• Microbiologically confirmed pneumonia was reduced from

23% to 5% in the semi-recumbent group (p=0.018)• The semi-recumbent body position reduces frequency and

risk of pneumonia. • The risk of pneumonia increased with longer duration of

mechanical ventilation and with decreased consciousness.

Ventilator Associated Pneumonia (VAP) Practice Alert

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Continuous Removal of Subglottic Secretions

Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation.

CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005

Ventilator Associated Pneumonia (VAP) Practice Alert

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HOB Elevation

HOB at 30-45º

• Torres et al, Annals of Int Med 1992;116:540-543• Ibanez et al. JPEN 1992;16:419-422• Orozco-Levi et al. Am J Respir Crit Care Med

1995;152:1387-1390• Drakulovic et al. Lancet 1999;354:1851-1858• Davis et al. Crit Care 2001;5:81-87• Grap et al. Am J of Crit Care 2005 14:325-332

Ventilator Associated Pneumonia (VAP) Practice Alert18

Is HOB Elevation Done?

Despite effectiveness of HOB elevation,compliance is poor.

• Grap et al. Am J Crit Care 1999;8:475-480

• Grap et al. Am J Crit Care 2005;14:325-332

0

20

40

60

% w

ith

HO

B E

lev

ati

on

0 to 20

21 to 30

31 to 40

> 40

Degrees ofHOB Elevation