VAP and VAP Prevention

Question 1

Ventilaor-Associated Pneumonia (VAP)

Answer 1

Nosocomial pneumonia in mechanically ventilated patients for at least 48 hours

Question 2

Pathogenesis of VAP

Answer 2

1. Oropharyngeal microflora directly passed down to lungs during intubation
2. Oropharynx colonised by gram negative MDRs
3. Endoluminal biofilm within ETT lumen source for bacterial colonisation of lower airway
4. Secretions accumulation above cuff, and leakage into lungs (despite inflated cuffs) via microscopic folds
5. Mucosal damage due to tracheal wall ischaemia
6. Impaired tracheal mucociliary clearance and suboptimal humidification, heating of inhaled air promotes bacterial growth

Question 3

VAP Prevention Bundle

Answer 3

A. General Measures
1. Reduce manipulation of ETT
- Adequate ETT fixation to prevent cuff movement (and reduces microaspiration)
2. Strict hand hygiene and PPE
3. Environmental cleaning
4. Limiting duration of ventilation - active weaning protocols
5. Avoid re-intubation
6. Orotracheal intubation (avoid nasotracheal intubation)

B. Aspiration prevention
1. Cuff pressure 20-30 cm H2O
2. Subglottic secretions suctioning
3. Semi-recumbent position (head elevated 30-45 degrees if not contraindicated)

C. Prevention of contamination
1. Change circuit only when visibly contaminated
2. Avoid scheduled change of circuit
3. Avoid reusing “single use” items
4. Heat moisture exchangers
5. Use filters in mechanical ventilator
6. Condensate in circuit directed AWAY from patient

D. Prevention of colonisation
1. Oral hygiene, brushing teeth/gums/tongue BD
2. Oral seven wash 6-8 hourly (avoid Chlorhexidine - higher mortality)
3. MINIMISE stress ulcer prophylaxis and acid suppression (high pH promotes bacterial overgrowth) - only use when NBM or on steroid
4. +/- prophylactic antibiotics