ventilator associated pneumonia

Ventilator Associated Pneumonia (VAP) is a common and costly cause of complications and death in the intensive care unit (ICU). As a bacterial or viral hospital acquired infection, VAP is most common in patients who have been intubated and placed on mechanical ventilation. VAP can occur as early as 48 hours following intubation. In the United States alone, 250,000 to 300,000 cases are reported annually, and when diagnosed, can add another $20,000 towards the patient’s hospital bill. 4,3

VAP has become one of the most impactful nosocomial infections–a type of infection that originates in hospitals–on patient outcomes and additional health care costs.4

There are many different host factors that contribute to VAP such as; acute respiratory distress syndrome (ARDS), chronic obstructive pulmonary disease (COPD), enteral feeding, post-surgical and burns, sinusitis, trauma, unplanned extubation, and upper respiratory tract colonization.1 The highest occurrence of VAP follows aspiration of oropharyngeal secretions.

 
vap_02.jpg
 

by the numbers


5-10 cases

Incidence rate per 1,000 hospital admissions4

+9 days

VAP extends the average ICU stay from 4 to 13 days3

+$20k

Added cost up to $20,000 per diagnosis3

 

risk factors

VAP is associated with a number of patient factors including acute respiratory distress syndrome (ARDS), chronic obstructive pulmonary disease (COPD), enteral feeding, sinusitis, trauma, burns, unplanned extubation, and upper respiratory tract colonization. The highest occurrence of VAP follows aspiration of oropharyngeal secretions.3

A review article provided by the Australian Medical Journal on VAP1 describes intervention factors that lead to increased occurrences of the infection. Those factors include:

Increased duration of mechanical ventilation
Studies have confirmed that the longer a patient is ventilated the more likely VAP is to develop.8

Frequent change in ventilator circuit
A study by Fink et al. on extended ventilator circuit change concluded that 30-day circuit changes have a lower incidence of VAP rates than 48-hour circuit changes.6

Open versus closed ventilation
Closed ventilation systems, although very costly, have demonstrated to be safer and actually reduce the overall cost of treating mechanically ventilated patients.9

Use of nasogastric tubes
A randomized controlled trial was conducted and found that VAP more frequently developed in patients with nasogastric tubes compared to those who had gastrostomy.10

Reintubation
A major risk factor for VAP is caused by reintubation, often caused by a patient’s aspiration of gastric content.1

Transport out of ICU
A study conducted by A’Court et al., found that 24% of patients transported from ICU developed VAP compared to 4% who stayed in the ICU.7

 

strategies for preventing VAP

 

evidence-based practices

The complications and mortality associated with VAP can be significantly reduced through a variety of evidence-based practices prior to and during intubation, as well as throughout the duration of mechanical ventilation. A 2006 study by Koenig and Truwit2 showed the following practices can drastically reduce the instances of VAP:

  • Diligent respiratory care

  • Hand hygiene

  • Elevation of head of bed

  • Oral and not nasal cannulation

  • Minimization of sedation

  • Institution of weaning protocols

  • Judicious use of antibiotics

Chart sourced from Koenig and Truwit, 2006. (2)

Chart sourced from Koenig and Truwit, 2006. (2)

 

make the commitment

Establish these guidelines at your hospital to eliminate instances of VAP. 

 

references


1. Charles MP, Kali A, Easow JM, Joseph NM, Ravishankar M, Srinivasan S, et al. Ventilator-associated pneumonia. Australas Med J. 2014;7:334–344. doi: 10.4066/AMJ.2014.2105.
2. Koenig, Steve M., Truwit, Jonathon D., Oct. 2006. Ventilator Associated Pneumonia, Diagnosis, Treatment, and Prevention. Clin Microbiol Rev. 19(4): 637–657.
3. van Nieuwenhoven, C. A., E. Buskens, D. C. Bergmans, F. H. van Tiel, G. Ramsay, and M. J. Bonten. 2004. Oral decontamination is cost-saving in the prevention of ventilator-associated pneumonia in intensive care units. Crit. Care Med. 32:126-130.
4. McEachern, R., and G. D. Campbell, Jr. 1998. Hospital-acquired pneumonia: epidemiology, etiology, and treatment. Infect. Dis. Clin. N. Am. 12:761-779.
5. Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M: The prevalence of nosocomial infection in intensive care units in Europe. JAMA 1995, 274: 639-644. 10.1001/jama.1995.03530080055041
6. Fink JB, Krause SA, Barrett L, Schaaff D, Alex CG. Extending ventilator circuit change interval beyond 2 days reduces the likelihood of ventilator-associated pneumonia. Chest. 1998;113:405–11.
7. A'Court CH, Garrard CS, Crook D, Bowler I, Conlon C, Peto T, Anderson E. Microbiological lung surveillance in mechanically ventilated patients, using non-directed bronchial lavage and quantitative culture. Q J Med. 1993;86:635–48.
8. Trouillet JL, Chastre J, Vuagnat A, Joly-Guillou ML, Combaux D, Dombret MC, Gibert C. Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998;157:531–9
9. Darvas JA, Hawkins LG. The closed tracheal suction catheter: 24 hour or 48 hour change? Aust Crit Care. 2003;16:86–92.
10. Kearns PJ, Chin D, Mueller L, Wallace K, Jensen WA, Kirsch CM. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical tri. Crit Care Med. 2000;28:1742–6.