Prevention of VAP

(Ventilator-Associated Pneumonia)
The Multimodal Approach of
the ICU “Pneumonia Zero" Program

DR. Dr. Christiana Linda Wahjuni SpOT.,M.Kes.,FICS

Jakarta, 24 November 2018

 Introduction

 Ventilator-associated pneumonia (VAP) is a

healthcare associated infection that can complicate
care of mechanically ventilated patients in the
intensive care unit
 Introduction

 VAP is a common healthcare-associated infection

(HCAI) occurring in 10–20% of patients
mechanically ventilated in the ICU

 significant consequences with

 increased mortality
 increased the length of ICU stay and hospital
stay
 an increase in healthcare costs
 Introduction

 Traditionally, VAP rates have been

measured as an indicator of quality of care

 VAP remains an issue for critically ill adults,

with mortality estimated as high as 10%
 Critically ill patient in ICU

 Ventilator support - respiratory failure

 pneumonia
 Hemodynamic support  shock
 Renal replacement therapy - renal failure
 severe acidosis
 Neurological dysfunction,
 Hematologic disorders
 RISK OF INFECTIONS IN ICU

 Patient hospitalized in ICU are 5 to 10 times more

to HAIs than other hospital patient
 The frequency of infections at different anatomic
sites and risk of infection vary by the type of ICU,
and the frequency of specific pathogens varies by
infections site
 Contributing to the seriousness of HAIs, especially
ICUs, is the increasing incidence of infections
caused by antibiotic-resistance pathogen
 FACTORS THAT INCREASE
CROSS – INFECTIONS in ICU

 Lack of Hand washing facilities

 FACTORS THAT INCREASE
CROSS – INFECTIONS in ICU

 Patient close together or sharing rooms

 FACTORS THAT INCREASE
CROSS – INFECTIONS in ICU

 Patient close together or sharing rooms

 Contaminated surfaces
increase cross-transmission
 FACTORS THAT INCREASE
CROSS – INFECTIONS in ICU

Inadequate cleaning of environtment

 FACTORS THAT INCREASE
CROSS – INFECTIONS in ICU
 Understaffing
 FACTORS THAT INCREASE
CROSS – INFECTIONS in ICU

 Preparation of IVs on the unit

 Lack of isolation facilities

 No separation of clean and dirty area

 Excessive antibiotic use

 Inadequate decontamination of items &

equipments
 Processes that affect the prevalence of
antibiotic-resistant pathogens in an ICU
Endogenous
colonization
Introduction of resistant pathogens De novo ressistance
Selection of pre- Admi
existent resistant flora

Changes in the prevalence of

antibiotic-resistant
pathogens

Exogenous colonization
Failures in infection
control
Advance Source Control to Prevent MDROs

Target Potential Pathogens on Patient

• Aseptic technique
• Early removal of devices Antisepsis of nares
or oropharynx
• Selective digestive tract decontamination
• Antibiotic stewardship
• Skin antisepsis
Advance Source Control to Prevent MDROs

Prevent Cross-Tranmissions
 Hand Hygiene
 Contact precautions
 Isolation
 Cohorting
 Enviromental cleaning
 Antibiotic Strategies to Prevent
Emergence & Spread of Resistance

1. Limit or restrict hospital formularies

2. Use of guidelines or protocols to optimize use
3. Avoid unnecessary antibiotic use
 Antibiotic Strategies to Prevent
Emergence & Spread of Resistance

4. Establish / use-specific antibiograms

5. Antibiotic rotation / cycling
6. Consider use of startegies to promote heterogeneity
7. Maximize antibiotic choices
 Reducing VAP risk

The top five evidence-based nursing practices for

reducing VAP risk in critically ill adults

1. Minimize ventilator exposure

2.Provide excellent oral hygiene care
3.Coordinate care for subglottic suctioning
4.Maintain positioning and encourage mobility
5.Ensure adequate staffing
 1.  Minimize ventilator exposure

1. Encourage and advocate for the use of

noninvasive ventilation approaches, such as
bilevel positive airway pressure or continuous
positive airway pressure
 1.  Minimize ventilator exposure

2. When mechanical ventilation can’t be avoided

a) work to minimize its duration

b) Ventilator-weaning protocols or evidence-based

care bundles (for example, the Awakening, Breathing
Coordination, Delirium, and Early mobility [ABCDE]
bundle)

c) Daily interruption of sedation (DIS) and

coordination with a spontaneous breathing trial
(SBT)
 2. Provide excellent oral hygiene care

 Some patients sustain injuries to the oral mucosa

during and after the intubation procedure

 Increase in bacteria colonization in the oral

mucosa  the endotracheal tube serving as a
direct route to the lungs

 Adequate oral care can reduce bacterial

overgrowth and reduce the risk for infection
3 Coordinate care for subglottic suctioning

Aspiration of secretions that accumulate around a

mechanically ventilated patient’s ETT  VAP

Subglottic secretion suctioning can be performed by both

the nurse and respiratory therapist

 to help prevent aspiration and subsequent VAP

 reduced the risk for VAP by 45% compared to

patients who didn’t receive this suctioning
 4  Maintain positioning and
encourage mobility

 Keep the head of the bed elevated 30 – 450

 reduce gastric reflux and aspiration
 significant reductions in clinically (76%) and
microbiologically (78%) diagnosed VAP)

 Early-mobility protocols
 coordinate exercise and mobilization with
physical and occupational therapists
 5 Ensure adequate staffing

 Provides nurses with the time, opportunity, and

resources to implement care practices that reduce
risk
 Allows nurses to spend more time with their
patients  which may lead to early identification
of VAP and prompt treatment
 Healthy work environments and interprofessional
collaboration have been associated with lowering
the risk for VAP
 5 Ensure adequate staffing

 Partnering with ICU physicians and the rest of

the interprofessional team, especially respiratory
therapists, is key to encouraging positive team
interactions and reducing VAP risk
Nurses perfectly positioned

 Nurses are particularly well positioned to lead the

healthcare team in VAP prevention
 can help minimize patients’ exposure to
mechanical ventilation
 work collaboratively to develop a ventilator
weaning protocol,
 ensure implementation of evidence-based care that
minimizes VAP risk
 Bundles to prevent VAP: how valuable are they?
Charity Wip and Lena Napolitano.
Current Opinion in Infectious Diseases 2009, 22:159 – 166

 The Ventilator Bundle contains four components,

1. elevation of the head of the bed to 30–450,
2. daily ‘sedation vacation’ and daily assessment of readiness to extubate,
3. peptic ulcer disease prophylaxis,
4. deep venous thrombosis prophylaxis

 Daily spontaneous awakening and breathing trials are associated with

early liberation from mechanical ventilation and VAP reduction

 as oral care and hygiene, chlorhexidine in the posterior pharynx, and

specialized endotracheal tubes (continuous aspiration of subglottic
secretions, silver- coated), should be considered for inclusion in a revised
Ventilator Bundle more specifically aimed at VAP prevention
 Bundle VAP Component
"WHAP"
 Wean Develop of weaning protocol

Before and after contact with patients or

ventilator
 Hand Hygiene Promote use of wateless alcohol hand rub

Elevation head of bed>30 degree

 Aspiration precaution Drain water circuit before patient
positioning
Check gastric residual before feeding

 Prevention of cross contamination

Of respiratory circuit
Of respiratory therapy equipment
Wear glove when in contact with ventilator
Wash hand and use aseptic technique
 Management strategic

 Bundles VAP, UTI, SSI, IADP & Phlebitis

 Surveilans
 Staff education
 Campaign Hand Hygiene
 Intensive Care Unit Room Facilities
Management strategic

 Isolation facilities
 Environtment cleaning
 Decontamination devices
 Waste Management
 Antibiotic stewardship
 Summary

 Healthcare-associated infections, such as ventilator-

associated pneumonia (VAP), are the most common
and most preventable complication of a patient’s
hospital stay

 Their frequency and potential adverse effects

increase in critically ill patients because of impaired
physiology, including a blunted immune response
and multi-organ dysfunction
 Summary

 Traditionally, VAP rates have been measured

as an indicator of quality of care

 VAP remains an issue for critically ill adults,

with mortality estimated as high as 10%