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VAP: A Preventable Disease

VAP: A Preventable Disease. Ruben D Restrepo MD RRT FAARC Professor of Respiratory Care The University of Texas Health Science Center at San Antonio. Disclosure: Ruben D. Restrepo, MD, RRT, FAARC. Teleflex Medical Speaker Member, Medical Advisory Board Oridion Capnography (Covidien)

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VAP: A Preventable Disease

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  1. VAP: A Preventable Disease

  2. Ruben D Restrepo MD RRT FAARC Professor of Respiratory Care The University of Texas Health Science Center at San Antonio

  3. 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

  4. Objectives • 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

  5. Hospital-Acquired Infections - VAP • 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

  6. Hospital-Acquired Infections - VAP • 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 • 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.

  7. How expensive are HAIs? 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

  8. Direct Medical Cost of HAI . ‘07 US • 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

  9. Attributable Cost Estimates • According to Stone et al2005 • $36,441 BSI • $25,546 SSI • $9,969 VAP • $1,006 CAUTI • According to Anderson et al2007 • $23,242 BSI • $10,443 SSI • $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.

  10. 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

  11. VAP: An Expensive Proposition

  12. VAP • New or progressive infiltrates on CXR • Fever • Abnormal WBC count • Purulent sputum MV > 48 h 10%-20% Most common HAI in critical care patients.

  13. 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 diagnosis Chemical aspiration without infection Atelectasis Pulmonary embolism ARDS Pulmonary hemorrhage Lung contusion Drug reaction Other Clinical Diagnostic Strategy

  14. VAP Definition(s) Halpern 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

  15. NHSN Surveillance for Ventilator-Associated Events in Adults

  16. NHSN Surveillance for Ventilator-Associated Events in Adults

  17. How Will I Find Cases of VAP?

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

  19. VAP Definition 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) • 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.

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

  21. 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.

  22. VAP Pathogenesis Endotracheal Tube Subglottic Secretions Endotracheal Tube Cuff Biofilm on ETT Pooled Secretions in Airway Dispersal of Biofilm With Ventilation

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

  24. 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 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.

  25. Risk Factors for VAP • Risk factors for VAP include: • Nonmodifiable: • Extreme ages • Comorbidities • Pulmonary disease • HIV/AIDS • Head trauma • MOF • Immunosupression 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.

  26. 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 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.

  27. Existing Guidelines and RecommendationsAARC – CDC – IHI - IDSA • 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 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.

  28. “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 SHEA/IDSA Guidelines 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.

  29. SHEA Guidelines: Core Recommendations • Designed to interrupt the three most common mechanisms by which VAP develops: • Aspiration of Secretions • Colonization of the aero digestive tract • Use of contaminated equipment 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.

  30. 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 Strategies to Reduce Aspiration of Secretions 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.

  31. 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 Strategies to Reduce Colonization of the Aero digestive Tract 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.

  32. Strategies to Reduce Use of Contaminated Equipment • Thoroughly clean all respiratory equipment to be sterilized or disinfected (IA) • After disinfection, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items (IA) • DO NOT routinely change the ventilator breathing circuit. ONLY when visibly soiled or mechanically malfunctioning. (IA) • 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) • Wear gloves to perform the above procedure or handle the fluid (IB) 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.

  33. General Measures • 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) • Use sterile (not distilled non sterile) water to fill bubble humidifiers (II) • Change any HME that is in use by a patient when it malfunctions mechanically or becomes visibly soiled (II) • Do not routinely change more frequently than every 48 hours a HME that is in use by a patient (II) 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.

  34. 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: • Aspiration of Secretions • Colonization of the aero digestive tract • Use of contaminated equipment

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

  36. 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

  37. 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.

  38. 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.

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

  40. VAP Bundle: Evidence of Benefit • Benefits • VAP-Industrial Complex • Reporting of Quality Metrics • The Quest for Zero VAP • The VAP Bureaucracy

  41. 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 Product Solutions and VAP

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