Preventing VAPPreventing VAP

- evidence for a care bundle - evidence for a care bundle

VAPVAP

• Incidence

~ 10 - 30% ventilated patients

7-15 / 1000 ventilator days

• Atributable mortality of 0-50%

• Atributable increase LOS of ~ 3 weeks

Prevent VAP Care BundlePrevent VAP Care Bundle

Reduce time on ventilator:• Assess sedation requirements daily• Assess suitability for weaning and extubation daily

While on ventilator:• Semi-recumbent positioning• Oral chlorhexidine • ? Subglottic drainage

128 ventilated patients

Randomised: daily sedation break and titration v. standard care

Outcomes: duration of ventilation, ICU & hospital stay

Outcomes of sedation break RCT

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0Tim

e (

days)

ProtocolControl

Ventilator ICU Hospital

p=0.004

p=0.02

p=0.19

Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.

Brook AD, Ahrens TS, Schaiff R et al Crit Care Med.1999;27:2609-15

321 ventilated patients

Randomised: nurse-led sedation protocol v. standard care

Outcomes: duration of ventilation, ICU & hospital stay

Outcomes of Sedation Protocol RCT

0.0

5.0

10.0

15.0

20.0

25.0

Ventilator days ICU days Hosp days

Du

rati

on

(d

ays)

Protocol

Control

Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.

Brook AD, Ahrens TS, Schaiff R et al Crit Care Med.1999;27:2609-15

P=0.003 P=0.013

P<0.001

300 ventilated patients

Randomised: daily weaning trial v. standard care

Outcomes: duration of ventilation, ICU & hospital stay

RCT of protocol-directed v. physician-directed weaning from mechanical ventilation.

Kollef MH, Shapiro SD, Silver P et al. Crit Care Med. 1997; 25:567-74

RCT of protocol-directed v. physician-directed weaning from mechanical ventilation.

Kollef MH, Shapiro SD, Silver P et al. Crit Care Med. 1997; 25:567-74

Avoiding VentilationAvoiding Ventilation

• Daily sedation titration and weaning protocols will reduce ventilator days and ICU stay

• VAP may be less common

• 86 ventilated patients• VAP in

23% supine patients

(28.4/1000 Vent d)

v.

5% semi-recumbent

(7.3/1000 Vent d)

NNT (95%CI) = 6 (3-23)

Study group Semi-recumbent n = 112

Standardn = 109

Average bed elevationDay 1Day 7

28.1o

22.6o

9.8o

16.1o

VAP 11.6%

10.2/1000 Vent d

7.3%

7.8/1000 Vent d

Semi-recumbencySemi-recumbency

• 45o head-up tilt is very difficult to achieve

• No benefit of semi-recumbency ~30o over standard care ~10o

• Supine position is harmful

Oro-pharyngeal AntisepticsOro-pharyngeal Antiseptics

Crit Care Med 2007; 35:595–602

Subglottic drainageSubglottic drainage

• In patients expected to be ventilated > 3 days• In patients to be intubated de novo

• Halves the risk of VAP

• NNT = 8 (95% CI 5-15)

• Shortens ventilation 2 days & ICU stay 3 days

Prevent VAP Care BundlePrevent VAP Care Bundle

• Assess sedation requirements daily• Assess suitability for weaning and extubation daily

• Semi-recumbent position• Oral chlorhexidine • ? Subglottic drainage

Do VAP prevention programmes Do VAP prevention programmes work?work?

Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Zack JE et al Crit Care Med 2002; 30: 2407-12

An educational intervention to reduce VAP in an integrated health system: a comparison of effects.Babcock HM et al Chest 2004; 125: 2224-31

Reducing VAP rates through a staff education programme.Salahuddin N et al J Hosp Infect. 2004; 57 :223-7

Adherence to simple and effective measures reduces the incidence of VAP.Baxter AD et al Can J Anaesth. 2005; 52: 535-41

54

Rate per 1000 ventilator days

VAP in five ICUs at BarnesVAP in five ICUs at Barnes ––JewishJewishhospital: October 1999hospital: October 1999––September 2001September 2001

20

0

5

10

15

Oct1999

Dec Feb Apr Jun Aug Oct Dec Feb Apr Jun Aug

Interventionrespiratory therapy

2000 2001

Mean

NNISa

Zack et al. Crit Care Med 2002;30:2407 –2412a National Nosocomial Infection Surveillance (NNIS) data

VAP in Critical Care, RIEVAP in Critical Care, RIE

0

510

1520

2530

3540

45

Month

VA

P p

er

10

00

Ve

nt

Da

ys

UCL

LCL

Process Avg

UWL

LWL

ConclusionConclusion

• There is reasonable evidence from RCTs and their metanalyses to support the elements of the proposed ‘ Prevent VAP Care Bundle’

• Other groups have halved VAP rates through education programmes, reinforcing adoption of protocols to prevent VAP