© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

VAP Intervention Information

Armstrong Institute for Patient Safety and Quality

Objectives

• To review the definition and criteria for Ventilator Associated Pneumonia

• To review interventions included in the VAP Prevention Bundle

• To discuss the recording of the Process and Structural Measures

Fast Facts

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• 10-20% of ventilated patients• Common HAI

– Median rate 1-4.3 per 1000 vent days– 250,000 infections per year

• Most lethal HAI– Mortality likely exceeds 10%– Up to 36,000 deaths per year

• Cost per episode: $23,000

Definition of VAP

• Pneumonia (PNEU) that occurs in patients who are intubated and ventilated at the time of or within 48 hours before the onset of pneumonia. – Three Levels of PNEU – All Considered VAP

• PNEU 1-Clinically Defined • PNEU 2- Pneumonia with Common Bacteriology• PNEU 3-Pneumonia in Immunocompromised

Patient

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NHSN VAP Surveillance Flow Diagram

Interventions

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5 Process Measures

14 Policy or Structural Measures

Process measures: Daily evaluation

1. Head of Bed Elevation (HOB)a. Use of a semi-recumbent position ( ≥ 30 degrees).

2. Spontaneous Awakening and Breathing Trials (SAT & SBT)a. Make a daily assessment of readiness to wean with the use of the SAT and

SBT.

3. Oral Carea. At least 6 times per day

4. Oral Care with Chlorhexidine.a. Should be included in the oral care regimen 2 times per day

5. Subglottic Suctioning* a. Use subglottic suctioning ETTs in patients expected to be mechanically

ventilated for >72 hours

*Note - Not all sites will be using the subglottic suctioning ETTs for this project. If you are not, please use this information as education.

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Policy or Structural measures: Monthly evaluation in TCT

1. Use a closed ETT* suctioning system2. Change close suctioning catheters only as

needed3. Change ventilator circuits only if damaged or

soiled4. Change HME** every 5-7 days and as clinically

indicated5. Provide easy access to NIVV*** equipment and

institute protocols to promote use6. Periodically remove condensate from circuits,

keeping the circuit closed during the removal, taking precautions not to allow condensate to drain toward patient

Armstrong Institute for Patient Safety and Quality8*ETT endotracheal tube; **HME heat moist exchanger; ***NIVV non-invasive ventilation

Policy or Structural measures: Monthly evaluation in TCT

7. Use early mobility protocol8. Perform hand hygiene9. Avoid supine position10. Use standard precautions while suctioning

respiratory tract secretions11. Use orotracheal intubation instead of nasotracheal12. Avoid use of prophylactic systemic antimicrobials13. Avoid non-essential tracheal suctioning14. Avoid gastric over-distention

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Head of Bed Elevation

Head of Bed Elevation : VAP Prevention Guidelines

• Recommends head of bed elevation at an angle of 30–45 degrees for patients with a high risk for aspiration (e.g., a person receiving mechanically assisted ventilation) in the absence of medical contraindication.

• CDC; MMWR Recomm Rep. 2004;53:1-36• Recommends that patients should be kept in a semi-

recumbent position (30-45 degrees) rather than supine to prevent aspiration.

• ATS/IDSA; AJRCCM 2005;171(4):388-416.

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• Recommends the head of bed elevation to be 45 degrees, as long as not contraindicated. • Canadian VAP Prevention Guidelines; J Crit Care

2008;23(1):138-147.• Recommends the use semi-recumbent position (30-45

degrees) as a strategy to prevent aspiration. • SHEA; ICHE 2008;29:S31-S40.

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Head of Bed Elevation : VAP Prevention Guidelines

Spontaneous Awakening and Breathing Trials (SAT &SBT)

Spontaneous Awakening and Breathing Trials : VAP Prevention Guidelines

• Does not specifically address SAT and SBT, however supports weaning.

• CDC; MMWR Recomm Rep. 2004;53:1-36

• Recommends use of daily interruption or lightening of sedation to avoid constant heavy sedation and to facilitate and accelerate weaning.

• Does not specifically address SBT. • ATS/IDSA; AJRCCM 2005;171(4):388-416.

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• Guideline excluded studies that evaluated SAT and SBT.• Canadian VAP Prevention Guidelines; J Crit Care

2008;23(1):138-147.

• Recommends the use of combining a daily assessment of readiness wean and daily sedation interruption.

• SHEA; ICHE 2008;29:S31-S40.

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Spontaneous Awakening and Breathing Trials : VAP Prevention Guidelines

Oral Care with Chlorhexidine

Use Chlorhexidine when performing oral care: VAP Prevention Guidelines

• No specific recommendation can be made for the routine use of an oral chlorhexidine rinse. (Unresolved issue)

• CDC; MMWR Recomm Rep. 2004;53:1-36

• Recommends regular oral care. CHG effective in specific populations (ie: CABG); routine use is not recommended until more data is available.

• ATS/IDSA; AJRCCM 2005;171(4):388-416.

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Chlorhexidine when performing oral care: VAP Prevention Guidelines

• Oral antiseptic CHG should be considered. Based on 1 level 1 and 2 level 2 trials, use of oral antiseptic CHG may decrease VAP. Safety, feasibility, and cost considerations are all very favorable.

• Canadian VAP Prevention Guidelines; J Crit Care 2008;23(1):138-147.

• Perform regular oral care with an antiseptic solution. While the use of CHG is not specifically addressed, the 3 studies cited by the guideline all focused on cardiovascular surgery and demonstrated the efficacy of CHG.

• SHEA; ICHE 2008;29:S31-S40.

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CHG Oral Care: Evidence

• Gingival and dental plaque rapidly becomes colonized with bacteria in intubated patients due to poor oral hygiene and lack of mechanical elimination

• Meticulous oral care reduces microbial burden in upper airway

• Safety and feasibility of CHG oral care are favorable DeRiso A. Chest. 1996;109:1556.

Chan E. BMJ. 2007;10:1136. Chlebicki M Crit Care Med 2007;35:595.

Oral Antiseptics: 2011 Systematic Review and Meta-Analysis

• 12 RCTs evaluating CHG (2341 patients)• Overall 38% VAP reduction

– RR 0.72, 95%CI 0.55-0.94• Results varied by CHG concentration

– 2% > 0.2% > 0.12%• Cardiac Surgery ICUs 59% VAP reduction

– RR 0.41, 95% CI 0.17-0.98

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Labeau Lancet Infect Dis 2011;11:845-54

Oral Antiseptics: A Systematic Review and Meta-Analysis

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Labeau Lancet Infect Dis 2011;11:845-54

Oral Antiseptics: A Systematic Review and Meta-Analysis

• Variation by ICU Type• Cardiac Surgery only (n=2, 914 patients)

– RR 0.41, 95% CI 0.17-0.98• Mixed ICUs (n=10, 1294 patients)

– RR 0.77, 95% CI 0.58-1.02• Surgery or Trauma (n=2, 273 patients)

– RR 0.67, 95% CI 0.50-0.88

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Labeau Lancet Infect Dis 2011;11:845-54

CHG Oral Care: Recommendations

• Chlorhexidine 0.12% oral solution (15 ml bid until 24 hours after extubation) for all intubated patients

• Contraindications– Hypersensitivity to component of solution– <2 months of age– There is the possibility of direct contact with

meninges• Brush patients’ teeth bid with soft toothbrush to

remove dental plaque prior to using CHG• Oral Care should be performed q4; • Oral Care with CHG should be performed q12.

Subglottic suctioning ETTs in patients mechanically ventilated for >72 hours*

*Note - Not all sites will be using the subglottic suctioning ETTs for this project. If you are not, please use this information as education.

Subglottic suctioning ETTs: VAP Prevention Guidelines

• Recommend ETTs with a dorsal lumen above the cuff to allow drainage (by continuous or frequent intermittent suctioning) of tracheal secretions.

• CDC; MMWR Recomm Rep. 2004;53:1-36

• Recommend specially designed endotracheal tube (dorsal lumen) for continuous aspiration of subglottic secretions

• ATS/IDSA; AJRCCM 2005;171(4):388-416.

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Subglottic suctioning ETTs: VAP Prevention Guidelines

• Recommended subglottic secretion drainage in patients expected to be mechanically ventilated for more than 72 hours.

• Canadian VAP Prevention Guidelines; J Crit Care 2008;23(1):138-147.

• Recommend the use of cuffed ETT with in line or subglottic suctioning.

• SHEA; ICHE 2008;29:S31-S40.

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Subglottic suctioning ETTs: Evidence

• Drainage of subglottic secretions lessens the risk of aspiration

• Specially designed endotracheal tubes have been developed to provide continuous or intermittent subglottic secretion removal

Kollef M. Chest. 1999;116:1339. Smulders K. Chest 2002;121:858.

Valles J, et al. Ann Intern Med. 1995;122:179.

Subglottic Suctioning ETTs

Subglottic Suctioning ETTs: Evidence

• 13 RCTs evaluating subglottic secretion drainage (2442 patients)

• Overall 45% VAP reduction – RR 0.55 (95% CI 0.46–0.66)– NNT = 11

• 1.5 day ICU LOS reduction • 1.1 day duration of MV reduction

Muscedere J. Crit Care Med. 2011;39:1985.

Subglottic Suctioning ETTs: A Systematic Review and Meta-Analysis

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Muscedere J. Crit Care Med. 2011;39:1985.

Subglottic Suctioning ETTs: A Systematic Review and Meta-Analysis

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Muscedere J. Crit Care Med. 2011;39:1985.

• Similar results if limited to studies of high methodologic quality• Two studies evaluated only cardiac surgery patients (n=1057)

Subglottic Suctioning ETTs: A Cost Effectiveness Analysis

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Conclusion: Regular utilization of CSS-ETs may produce significant cost savings,

irrespective of the increased costs of CSS-ETs.

Muscedere J. Crit Care Med. 2011;39:1985.

Subglottic Suctioning ETTs: Recommendations

• Continuous subglottic suctioning system recommended for patients expected to be mechanically ventilated for >72 hours

• Unanswered questions– How to identify pts that will require MV > 3

days; most studies used SDD ETTs for all patients undergoing major surgery

– Should ETTs be changed if patients require MV > 3 days.

How to Measure your VAP Rate

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VAP Rates

# VAP Cases _______________ x 1000 # ventilator days

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