VAP BUNDLES

VAP BUNDLES. Moderator Dr Venkatesh Gupta BY Dr Amit Kumar Choudhary DrNB Trainee Manipal Hospital.

Defination of VAP. Ventilator-associated pneumonia (VAP): A pneumonia where the patient is on mechanical ventilation for >2 calendar days on the date of event, with day of ventilator placement being Day 1 , AND the ventilator was in place on the date of event or the day before..

Incidence VAP is reported to affect 5–40% of patients receiving invasive mechanical ventilation for more than 2 days,with large variations depending upon the country, ICU type , and criteria used to identify VAP [1-3].

PATHOGENESIS Bacteria enter the lower respiratory tract via following pathways: Aspiration of organisms from the oropharynx and GI tract (most common cause ) 48 hrs to colonization of bacteria in oro -digestive tract Direct inoculation Inhalation of bacteria.

vapneumonia2.

RISK FACTORS. A) Host Factor- Medical /surgical disease , (COPD, Brain Injury, Trauma Pt , Immunosupression , Malnutrition ( Alb <2.2g/dl ), Advanced age, Supine position, Level of conciousness , Medication-NMB, sedation, steroids, Previous antibiotic use.

B) HEALTHCARE PERSONNEL RELATED Improper hand washing, Failure to change gloves and use mask gown when ever required C) DEVICE RELATED MV with ETT or TRACHEOSTOMY TUBE , MV>48 hrs , Reintubations , NGT or Oro- gastric tube, Use of Humidifier.

Diagnosis of VAP. VAP diagnosis is traditionally defined by the concomitant presence of the three following criteria: clinical suspicion, new or progressive and persistent radiographic infiltrates , and positive microbiological cultures from lower respiratory tract specimens.

Clinical diagnosis. The first step to diagnose VAP is clinical suspicion. Many criteria for suspecting VAP exist (fever, leukocytosis , decline in oxygenation…), but their usefulness, alone or in combination, is not sufficient to diagnose VAP [ 4 ]..

Recent guidelines do not recommend CPIS to diagnose VAP [ 5 , 6]. VAP should rather be suspected in patients with clinical signs of infection, such as at least two of the following criteria :.

VAP New or progressive persistent infiltrate on chest radiograph Present Clinical observation suggesting infection At least two of the following: New onset of fever Purulent endotracheal aspirate Leukocytosis or leucopenia Increased minute ventilation Arterial oxygenation decline Need for increased vasopressor infusion to maintain blood pressure.

Microbiological culture results At least one of the following : Positive blood culture not related to another infection Positive pleural fluid culture Positive quantitative culture from minimally contaminated LRT specimen (e.g. BAL ≥10 4 CFU/mL) Positive quantitative culture from endotracheal aspirate specimen (e.g. ETA ≥10 5 CFU/mL) ≥5 % BAL-obtained cells contain intracellular bacteria on direct microscopic exam Histopathologic exam shows one of the following: Abscess formation or foci of consolidation with intense PMN accumulation in bronchioles and alveoli Positive quantitative culture of lung parenchyma.

2016 Clinical Practice Guidelines by the Infectious Diseases %ciety f America and the American Thoracic ] Should patients with suspected VAP be treated based on the results ofinvasive sampling (BAL ÆB, blind mini-BAL) with quantitative culture results, nonin- vosive sampling (endotracheal aspirotion) with quontitütive culture results, or noninvasive sampling with semiquantitative culture results? Recommendation We suggest noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than invasive sampling with quantitative cultures and rather than noninvasive sampling with quantitative cultures (weak recommendation, low-quality evidence) Ifinvasive quantitative cultures are performed, should wtients with suspected YAP whose culture results are below the diagnostic threshold for VAP (PSB with < CFU/ml, BAL with < Iff CFLVmL) have their antibiotics withheld rather than continued? Recommendation Noninvasive sampling with semiquantitative cultures is the preferr± methodology to diagnose VAP; however, the panel reccænizes that invasive quantitative cultures will occasionally iHformed by some clinicians. For patients with suspected VAP whose invasive quantitative culture results are below the diagnostic threshold for VAP, we suggest that antibiotics be withheld rather than continued (weak recommendation, very low-q uality evidence) BAL Bronchoalveolar lavage, Pß 2017 ] In intubated patients suspected Ofhaving VAP should distal quantitative samples obtayned instemi ofproximal quantitGti'Æ samples? Recommendation We suggest obtaining distal quantitative samples (prior to any antibiotic treatment) in order to reduce antibiotic in stable patients with suspected VAP and to improve the accuracy of the results. (weak recommendation, low quality Of evidence) We recommend obtaining a lower respiratory tract sample (distal quantitative or proximal quantitative or qualitative culture) to fccus and narrow the initial empiric antibiotic therapy. (strong recommendation, low quality Of evidence) Activate Win Go to Settings to specimen brush, CFLI colony-forming units.

Limitations and drawbacks A new or progressive persistent pulmonary infiltrate is impossible to demonstrate in many patients with VAP, even using serial chest radiographs Which threshold should be applied to define a “positive” culture when using semiquantitative or quantitative ETA or BALF cultures is controversial, especially for specimens obtained after starting new antibiotics.

Although almost all definitions for suspecting ( and diagnosing ) VAP include radiographic criteria (new or progressive and persistent infiltrates ) In summary, there is no single clinical criterion, biomarker or score that is accurate enough to diagnose VAP. Therefore, VAP should be considered whenever there are new signs of respiratory deterioration potentially attributable to infection (e.g., fever, purulent sputum, leukocytosis , worsening oxygenation, unexplained hypotension, or increasing vasopressor requirements), with or without new or progressive pulmonary infiltrates. Once VAP is suspected , the second step of the diagnostic workup is to perform microbiological sampling.

Care Bundle A care bundle is …... “A systematic method of measuring and improving clinical care processes based on groups of care elements for particular diagnoses and procedures” NHS Modernization Agency.

Any of cgcuts are.

Ventilator Associated Pneumonia Care Bundle -Evidence Based Practices Head Of Bed elevated to 30 ˚ -45 ˚ Daily sedation vacation &daily assessment of readiness to wean ET Tube inserted orally Daily Oral care with chlorhexidine Stress Ulcer Prophylaxis Any Change in character of secretion DVT Prophylaxis ET tube Cuff Pressure Checked HME Filter Changed in 24 Hrs Ventilator Circuit Changed only when visibly soiled.

1.HOB UP 30 DEGREES OR HIGHER Recommended elevation is 30-45 degrees If semi-recumbent or supine 34% incidence VAP ↑ HOB → ↓ risk of aspiration of gastrointestinal contents ↓ risk of aspiration of oropharyngeal secretions ↓ risk of aspiration of nasopharyngeal secretions ↑ HOB improves patients’ ventilation Supine patients have lower spontaneous tidal volumes on PS than those seated in upright position ↑ HOB may aid ventilatory efforts and minimize atelectasis.

2.Daily “Sedation Vacation” and Daily Assessment of Readiness to Wean Correlated with reduction in rate of VAP Sedation vacation results in significant reduction in time on mechanical ventilation Duration of mv decreased from 7.3 days to 4.9 days-study by Kress et al. (NEJM 2000) Weaning is easier when patients are able to assist themselves at extubation with coughing and control of secretions.

3) Stress ulcer prophylaxis has been associated with higher VAP rates in some observational studies and in a recent meta-analysis of randomized trials [ 1 , 2, 3]. 1)Huang HB, Jiang W, Wang CY, Qin HY, Du B (2018) Stress ulcer prophylaxis in intensive care unit patients receiving enteral nutrition: a systematic review and meta-analysis. Crit Care 22:20 2) Alhazzani W, Alshamsi F, Belley -Cote E, Heels- Ansdell D, Brignardello -Petersen R, Alquraini M, Perner A, Moller MH, Krag M, Almenawer S,Rochwerg B, Dionne J, Jaeschke R, Alshahrani M, Deane A, Perri D, Thebane L, Al- Omari A, Finfer S, Cook D, Guyatt G (2018) Efficacy and safety of stress ulcer prophylaxis in critically ill patients: a network metaanalysis of randomized trials. Intensive Care Med 44:1–11 3) Sasabuchi Y, Matsui H, Lefor AK, Fushimi K, Yasunaga H (2016) Risks and benefits of stress ulcer prophylaxis for patients with severe sepsis. Crit Care Med 44:e464–e469 A large randomized trial of pantoprazole vs placebo, however , reported no difference between arms in pneumonia rates [125]. At the same time, stress ulcer prophylaxis had a relatively modest effect on gastrointestinal bleeding rates (2.5% vs 4.2%) and no impact on transfusion requirements or mortality rates. Additional large randomized trials are underway..

4.Deep Vein Thrombosis ( DVT) Prophylaxis Higher incidence of DVT in critical illness Risk of venous thromboembolism is reduced if prophylaxis is consistently applied TARGET: patients undergoing surgery, trauma patients, acutely ill medical patients, and ICU patients.

Oral Care With Chlorohexidine Recent studies have also called into question the effectiveness and safety of oral chlorhexidine . There is no association between oral care with chlorhexidine and lower VAP rates on meta-analysis of double-blind randomized trials [ref]. Ref) Klompas M, Speck K, Howell MD, Greene LR, Berenholtz SM ( 2014) Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and metaanalysis . JAMA Intern Med 174:751–761.

More concerningly , some meta-analyses and observational studies have reported that oral care with chlorhexidine may increase mortality rates, perhaps because some patients may aspirate some of the antiseptic triggering acute lung injury [91, 95, 99, 100, 111, 112]. Klompas M (2017) Oropharyngeal decontamination with antiseptics to prevent ventilator-associated pneumonia: rethinking the benefits of chlorhexidine . Semin Respir Crit Care Med 38:381–390 Harris BD, Thomas GA, Greene MH, Spires SS, Talbot TR (2018) Ventilator bundle compliance and risk of ventilator-associated events. Infect Control Hosp Epidemiol 39:637–643 Klompas M, Speck K, Howell MD, Greene LR, Berenholtz SM (2014) Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and metaanalysis . JAMA Intern Med 174:751–761 Price R, MacLennan G, Glen J, Su DC (2014) Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. BMJ 348:g2197 Klompas M, Li L, Kleinman K, Szumita PM, Massaro AF (2016) Associations between ventilator bundle components and outcomes. JAMA Intern Med 176:1277–1283 Deschepper M, Waegeman W, Eeckloo K, Vogelaers D, Blot S ( 2018) Effects of chlorhexidine gluconate oral care on hospital mortality:a hospital-wide, observational cohort study. Intensive Care Med 44:1017–1026.

A cluster randomized de-adoption study is currently underway to better characterize the safety and effectiveness of oral chlorhexidine for ventilated patients [ref]. Dale CM, Rose L, Carbone S, Smith OM, Burry L, Fan E, Amaral ACK, McCredie VA, Pinto R, Quinonez CR, Sutherland S, Scales DC, Cuthbertson BH (2019) Protocol for a multi-centered, stepped wedge, cluster randomized controlled trial of the de-adoption of oral chlorhexidine prophylaxis and implementation of an oral care bundle for mechanicallyventilated critically ill patients: the CHORAL study. Trials 20:603.

Manually monitoring cuff pressures every 8 h to minimize inadvertent drops in endotracheal tube cuff pressure was no better at preventing VAP. A meta-analysis of three randomized trials of automated cuff pressure monitoring did report significantly lower VAP rates with automated cuff pressure systems [ref]. Nseir S, Lorente L, Ferrer M, Rouze A, Gonzalez O, Bassi GL, Duhamel A , Torres A (2015) Continuous control of tracheal cuff pressure for VAP prevention: a collaborative meta-analysis of individual participant data . Ann Intensive Care 5:43.

HME Filter Patients may acquire ventilator-associated pneumonia (VAP) by aspirating the condensate that originates in the ventilator circuit upon use of a conventional humidifier. The bacteria that colonize the patients themselves can proliferate in the condensate and then return to the airways and lungs when the patient aspirates this contaminated material. Therefore, the use of HME might contribute to preventing pneumonia and lowering the VAP incidence. Though Menegueti et al. BMC Anesthesiology 2014 in their meta analysis suggest that HME does not decrease VAP incidence or mortality in critically ill patients.

Maintain ventilator circuits Change the ventilator circuit only if visibly soiled or malfunctioning (quality of evidence: I). a. Changing the ventilator circuit as needed rather than on a fixed schedule has no impact on VAP rates or patient outcomes but decreases costs..

The prevention practices that have most consistently been associated with improving objective outcomes for ventilated patients have been those focused on avoiding intubation and minimizing exposure to invasive ventilation by using high flow oxygen or noninvasive ventilation as alternatives to intubation, lightening sedation, using spontaneous breathing trials to prompt early extubation, and early mobilization . These interventions appear to be synergistic in sofar as minimizing sedation facilitates mobilization and early extubation . Observational studies of quality improvement collaboratives have reported that bundling these practices together is associated with earlier extubation and lower mortality rates [7-11]. It will be important, however, to confirm these findings in randomized trials given the many potential sources of bias in observational studies [ 11]. Table summarizes current knowledge about VAP prevention..

Intervention Headof&d elevation [1 161 Tapered endotracheal tube cuffs and ultrathin polyure- thane [102, 1041 Automated endotracheal tube cuff pressure monitoring subglottic secretion drainage 194] Oral care with chlorhexidine [99, IN, 112] selective oral and digestive decontaminatbn [93, 1 1 9] Probiotics [163) Probable impact on VAP rates May bwer rates No impact May lower rates May bwer rates Unclear Likely lowers VAP rates Unclear Comments Understudied, few and contradictory randomized trials In vivo studies dxument persistently high rates of sub- clinical aspiration despite the theoretical advantages of these designs Understudied, merits further evaluation Extensively studied but despite lowerVAP rates no Impact on duration of måanical ventilation, ICIJ length-of- stay, ventilator-asscciated events, or mortality. Unclear impact on antibiotic utilization Extensively studied. Most individual studies ra;ative. Meta-analysis of open-latel studies suggest lower VAP rates but met-analysis of double-blind studies find no impact. May increase mortality rates. Oral care with sterile water prefered Extensively studied. Less net antibiotic utilization and bwer mortality rates in Dutch studies. No impacton mortality in units with high baseline rates of antibiotic resistance and antibiotic utilization Many studies but most of limited Lower VAP rates on met-analysis but to restricting to double-blind studies.

Selective oral and digestivedecontmination [93, 119) Probiotics[1631 Stress ulcer prophylaxis [92, 123, 125) VAP prevention bundles [128] Likely lysVAPrates Unclear May increase VAP rates likely rates Extensively studied less net antibiotic utilization and low mortality rates in Dutch studies, No impact on mortality in units wth high baseline rates of antibiotic resistance and antibiotic utilization Many studies but most of limited quality, mixed results. lowerVAP signal when restricting t double-blind studies Observational studies and some met-analyses suggest higher VAP rates but? recent large randomized trial found no impact atensively studied, almost exclusively in before-after and time-series analyse} Maybe associated with lower mor- tality rates. Most benefit likely from minimizing sedation and encouraging early extubation.

Non-PharmacoIogical Measures Non-PharmacoIogicaI measures Infection control Handwashing Early weaning NIV Staffing ETT/OGT Cuff pressure Avoid circuit A's Semirecumbency Kinetic beds ETF CDC cccs ATSI IDSA Recommendations Surveillance Clorhexidine RT guidelines VCOPD/Low 02 u Staff (1:1) Subglottic suction cm H20 Only contaminated 3045 degrees Surgery/Neuro.

Pharmacological Measures Pharmacological measures Oral care SOD Biofilm formation Prophylactic Abx Stress ulcer prophylaxis Transfusion restriction Glycemic control Sedation Adequate Abx Nutrition ETF CDC cccs ATSI IDSA Recommendations Clorhexidine Controversial @ Pending Subgroups MV>48h -coagulop CAD - Hb <7g1dL Post-Surg/<150 Sedation break Short course Enteral/Post-pyloric.

References. 1)American Thoracic Society, Infectious Diseases Society of America(2005 ) Guidelines for the management of adults with hospital- acquired,ventilator -associated , and healthcare-associated pneumonia. Am JRespir Crit Care Med 171:388–416 2) Reignier J, Mercier E, Le Gouge A, Boulain T, Desachy A, Bellec F, Clavel M , Frat JP, Plantefeve G, Quenot JP, Lascarrou JB, Clinical Research in Intensive C, Sepsis G (2013) Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial . JAMA 309: 249–256 3) Seguin P, Laviolle B, Dahyot-Fizelier C, Dumont R, Veber B, Gergaud S, Asehnoune K, Mimoz O, Donnio PY, Bellissant E, Malledant Y, Study of Povidone Iodine to Reduce Pulmonary Infection in Head T, Cerebral Hemorrhage Patients ICUSG, AtlanRea G (2014) Effect of oropharyngeal povidone -iodine preventive oral care on ventilator-associated pneumonia in severely brain-injured or cerebral hemorrhage patients: a multicenter , randomized controlled trial. Crit Care Med 42: 1–8 4) Klompas M (2007) Does this patient have ventilator-associated pneumonia? JAMA 297:1583–1593 5) Pugin J, Auckenthaler R, Mili N, Janssens J, Lew P, Suter P (1991) Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid . Am Rev Respir Dis 143:1121–1129 5) Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt CE, Margetis D, Michel F,Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar JR, Bruyere R, Chanques G, Adarpef Gfrup (2018) Brief summary of French guidelines for the prevention, diagnosis and treatment of hospital-acquired pneumonia in ICU. Ann Intensive Care 8:104 6) Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB , Napolitano LM, O’Grady NP, Bartlett JG, Carratala J, El Solh AA,Ewig S, Fey PD, File TM Jr , Restrepo MI, Roberts JA, Waterer GW, Cruse P , Knight SL, Brozek JL (2016) Management of adults with hospitalacquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the infectious diseases society of America and the American thoracic society. Clin Infect Dis 63:e61–e111.

ref. 7)Pileggi C, Mascaro V, Bianco A, Nobile CGA, Pavia M (2018) Ventilator bundle and its effects on mortality among ICU patients: a meta-analysis. Crit Care Med 46:1167–1174 8 . Barnes-Daly MA, Phillips G, Ely EW (2017) Improving hospital survival and reducing brain dysfunction at Seven California Community Hospitals: implementing PAD guidelines via the ABCDEF bundle in 6,064 patients . Crit Care Med 45:171–178 9. Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, BarrJ , Byrum D, Carson SS, Devlin JW, Engel HJ, Esbrook CL, Hargett KD,Harmon L, Hielsberg C, Jackson JC, Kelly TL, Kumar V, Millner L, Morse A , Perme CS, Posa PJ, Puntillo KA, Schweickert WD, Stollings JL, Tan A, D’Agostino McGowan L, Ely EW (2019) Caring for critically ill patients with the ABCDEF bundle: results of the ICU liberation collaborative in over 15,000 adults. Crit Care Med 47:3–14 10. Hsieh SJ, Otusanya O, Gershengorn HB, Hope AA, Dayton C, Levi D, Garcia M, Prince D, Mills M, Fein D, Colman S, Gong MN (2019) Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Crit Care Med 47:885–893 11. Klompas M, Kalil AC (2018) Rethinking ventilator bundles. Crit Care Med.