Ventilator Acquired

Pneumonia
Dr Alan Race
BSc (Hons) PhD FRCA
Objectives

1. What the examiners say.

2. Definitions
3. Mechanisms and risk factors
4. Bugs
5. Prevention – care bundles
Ventilator associated pneumonia (VAP)
Pass rate 44.3%
Common condition
Poorly answered.
Poor definition of VAP
No details of the care bundles - specifics
Highlights
• Ventilator-associated pneumonia > 48-72 hours post tracheal
intubation
• 30% of all mechanically ventilated patients
• Early stages of mechanical ventilation
• Mortality may be as high as 50%

• Cost: Mean hospitalization costs were $99,598 for patients with VAP
and $59,770 for others – reference available
Definition - tricky
1. Pneumonia
2. Ventilated
3. > 48 hrs
What is pneumonia?
CDC pneumonia:
• CXR:
• Infiltrates
• Consolidation
• Cavitation
• Signs of infection:
• T > 38 oC
• WCC
• Altered mentation
Definition continued…
• ETT > 48 hours…

• Two of new onset:

• purulent sputum
• cough or dyspnoea or tachypneoa
• Crackles/bronchial breathing
• Worsening gas exchange
Gold star…
• Microbiological criteria:
• Blood cultures (no other source)
• Cultured pleural fluid
• BAL (> 10^4 colony forming units/ml)
• protected specimen brushing (>10^3 colony forming units/ml)
• > 5% intracellular bacteria on direct microscopic examination of gram stained
BAL
• Histopathological evidence of pneumonia
Mechanism and risk factors
• The presence of a tracheal tube increases the risk of pneumonia by
up to 21 fold.

• The likely mechanisms are

• Micro-aspiration around the cuff and during intubation
• Biofilm within the tracheal tube
• Muco-ciliary clearance
• IPPV (driving bacteria into the respiratory tree)
Mechanism and risk factors
• Additional risk factors include:
• High severity of illness
• Immuno-supression
• Chronic lung disease
• ARDS
• Reintubations
• Increased gastric pH (including gastric acid suppression medications)
• Supine position
• Enteral feeding
• Cuff pressure < 20 mmHg
Bugs
• Pathogens vary depending the duration of hospital admission and
ventilation

• Early vs late
Bugs
• Early VAP <72 hours
• Common pathogens
• Streptococcus pneumoniae
• Haemophilus influenza
• Staphylococcus aureus
• Klebsiella pneumoniae
• Escherichia coli
Bugs
• Late VAP > 72 hours
• More gram negative bacteria; higher incidence of
antibiotic resistance
• Common pathogens include:
• Pseudomonas aeruginosa
• MRSA
• Acinetobacter
• Strenotrophomonas maltophilia
Prevention
• Hand washing policy.
• Oral care with chlorhexidine
• Head of bed angle > 30 degrees
• Subglottic suction
• Maintain cuff pressure > 20 mmHg
• Consider silver/antibiotic coated tubes
• Extubate at earliest opportunity, with strategies to facilitate
early extubation (eg daily sedation holds)
• Avoid re-intubation
• Selective oral and digestive decontamination
Decontamination of the digestive tract
• Decontamination of the digestive tract may constitute one of several
strategies:

• Selective digestive decontamination (SDD):

• Prophylaxis of VAP
• Good and bad bugs
Decontamination of the digestive tract
• Selective digestive decontamination (SDD) (cont):
• Four components:
1. Enteral antimicrobials: poorly absorbed agents – oropharynx/NGT. Typically
tobramycin, polymyxin E and amphotericin B.
2. Parenteral antibiotics: a short course (4 days) of an antipseudomonal (typically a
cephalosporin)
3. Strict hygiene practice
4. Surveillance cultures from rectum and throat – watch for resistant organisms
Decontamination of the digestive tract
• Selective digestive decontamination (SDD) (cont):
• Selective oral decontamination (SOD)
• Poorly absorbed paste antimicrobial paste to the mouth (not nasogastric or parenteral
component)
• Topical oropharyngeal antisepsis agents
• Chorhexadine gel or solution
Decontamination of the digestive tract
• Selective digestive decontamination (SDD) (cont):

• Many RTCs and systematic reviews have been conducted – most in

continental Europe

• SOD and SDD

• reduce the incidence of respiratory tract infection (NNT ~ 4)
• bacteraemia and mortality (NNT ~ 18);
• antiseptic decontamination of the oropharynx are equivocal.
Decontamination of the digestive tract
• Despite the mortality benefit associated with SDD and SOD, uptake
has been limited, even in Europe…
• Why:
• ?Antimicrobial resistance – not supported by the trials
• ?Research methods – questioned
• ?SOD and SDD – resources
You now understand…

1. What the examiners want.

2. Definitions
3. Mechanisms and risk factors
4. Bugs
5. Prevention – care bundles