VAP Definitions. CDC New Approach to VAP Surveillance. Conflict of Interest Disclosure Robert M Kacmarek. Artificial Airways, Cuffs, Bioflim and VAP

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1 Conflict of Interest Disclosure Robert M Kacmarek Artificial Airways, Cuffs, Bioflim and VAP Bob Kacmarek PhD, RRT Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts FOCUS I disclose the following financial relationships with commercial entities that produce healthcare-related products or services relevant to the content I am presenting: Company Relationship Content Area Covidien Consultant Mech Vent Oeange Med Consultant Mech Vent Covidien Grant Mech Vent Venner Medical Grant Artificial Airways National VAP Rate VAP Definitions Komplas, M. Curr Opin Infect Dis Apr;25(2): VAP Surveillance Definition Working Group Algorithm to be applied only if: 18 years old MV 3 days Healthcare facilities CDC New Approach to VAP Surveillance Ventilator Associated Events (VAE) an objective, streamlined, and potentially automatically obtainable data Surveillance system Ventilator Associated Condition (VAC) Infection related Ventilator Associated Condition (IVAC) Possible and Probable VAP 1

2 Ventilator Associated Condition (VAC) Baseline period of stability or improvement > 2 calendar days of stable/decreasing F I O 2 and PEEP Defined by the minimum daily F I O 2 and PEEP After this period the patient has one of the following: Minimum daily F I O 2 increases > 0.20 over baseline and is maintained or further increases for > 2 days Minimum daily PEEP increases > 3 cmh 2 O over baseline and is maintained or further increases for > 2 days PEEP zero or 5 cmh 2 O considered equivalent Ventilator Associated Condition (VAC) Public Reporting Infection Related Ventilator Associated Condition (ivac) On or after day 3 of MV and within 2 days before or after worsening oxygenation the patient meets both of the following: Temperature > 38 or < 36 degrees or WBC >12,000 or < 4,000 AND A new antimicrobial agent(s) started and continued for > 4 days Infection related Ventilator Associated Condition (ivac) Public Reporting Possible VAP Infection related Ventilator Associated Condition (ivac) PLUS Purulent respiratory secretions Positive culture of sputum EA, BAL, lung tissue or PSB Internal use not reported Probable VAP Infection related Ventilator Associated Condition Purulent secretions and one of the following: EA > 10 5 CFU/ml BAL >104 CFU/ml Lung bx > 10 4 CFU/ml PSB > 10 3 CFU/ml PLUS one of the following: Positive pleural culture Positive lung histopathology Positive for Legonella Positive for influenza or parainfluenza, RSV, adenovirus Internal use not reported Surveillance of Ventilator-Associated Events Each 12 hr shift in the RC department database of MV patients minimum F I O 2 and PEEP documented Every month the system reports those patients meeting the VAC criteria Infection control nurses review each of these patients to determine if they meet the ivac criteria Patient meeting the criteria presented to the group to review and determine if Possible or Probable VAP exists. Information reported to each ICU quarterly Muscedere Chest 2013;144: No. American ICU each contributing data on 30 consecutive patients ventilated >48 hours 1320 patients, 139 (10.5%) VAC, 65 ivac (4.9%), 148 (11.2%)VAP Agreement between VAC and VAP was 0.18 and between ivac and VAP 0.19 VAP and VAC associated with greater LOS, LOMV, days of antibiotics and mortality 2

3 Muscedere Chest 2013;144:1453 VAE is NOT Necessarily VAP! Both identify very vulnerable but somewhat different populations The new definition makes reporting more objective and consistent I expect the VAE rate to initially be high but to decrease over time VAE a result of: infection, patient status deteriorating, development of VILI less than optimal ventilation clinician management bias!!! What Does it Mean To RC? Provides an objective measure of the quality of mechanical ventilation provided. Allows us to determine the specific reason why a VAE occurred in a particular patient. Forces us to look at our approach to ventilatory support. Forces physicians/therapists to exam their biases and develop consistent approaches to ventilator support. The overriding goal of the system is to improve quality of mechanical ventilation. Over time the VAE rate should decrease in every institution. Ventilator Associated Pneumonia Should more Properly be Referred to as Artificial Airway Associated Pneumonia!!! Hess CCM 2000 Ventilator Bundles Pirrone et al Current Opinion Infectious Disease 2016;29(2):160 Use of Cal Stat, Proper hand washing technique Maintaining the head of the bed elevated > 30 degrees Frequent and careful oral hygiene, suction above the cuff Proper cuff inflation 25 to 30 cm H 2 O: use of minimal occlusion pressure Stress ulcer prophylaxis Sucralfate recommended over H 2 antagonists because it does not increase gastric ph Increase use of NIV Insure assessment/performance of daily SBT Use MDIs or mesh nebulizers instead of SVNs Oraltracheal instead of nasotracheal intubation 3

4 Preventive Strategies: Out of Bundle New Generation ETT cuffs Subglottic Suctioning Biofilm Prevention Biofilm Removal Endotracheal Intubation and VAP Endotracheal tubes facilitate the colonization of the lower respiratory tract: Formation of a contaminated bioflim on all aspects of the endotracheal tube Mucosal injury with insertion and manipulation Elimination of the cough reflex Development of nosocomial sinusitis Pooling of contaminated secretions above the cuff Silent subclinical aspiration of secretions Dullenkopf ICM 2003;29:1849 Dullenkopf ICM 2003;29:1849 Young BJA 1997;78:557 Young BJA1997;78:557 4

5 Pitts, Fisher ICM 2010 Used Young BJA1997;78:557 lung model 19 different ETT studies Cuff pressure 20 and 30 cmh 2 O PC/PEEP: 10/5, 10/10, 20/5, 20/10, 20/15, 30/10 and 30/15 cmh 2 O; Same with PA/C VC/PEEP: Same PEEP, V T equal to V T during PC: Same with VA/C CPAP 0, 5, 10, and 15 cmh 2 O 64 evaluations per tube; 10 cm height of fluid Volume of fluid leaked in 30 min. Pitts, Fisher ICM 2010 Pitts, Fisher ICM 2010 Manzano CCM 2008;36:2225 VAP PEEP 5-8 6/66, 9.4%; No PEEP 16/65, 25.4% Mahul ICM 1992;18:20 Subglottic Secretion Drainage Mahul et al ICM 1992;18:20-25 Valles et al Ann Intern Med 1995;122: Kollef et al Chest 1999;116: Bo et al Zhonghua Jie He He Hu Xi Za Zhi 2000;23: Smulders et al Chest 2002;121: Lorente et al AJRCCM 2007;176:1079 (Also with a ultrathin polyurethane cuff) Bouza et al Chest 2008;134:938 5

6 Caroff, Klompas et al CCM 2016;44(4):830 Caroff, Klompas et al CCM 2016;44(4):830 Meta- analysis SSD and VAP Caroff, Klompas et al CCM 2016;44(4):830 Duration of Mechanical Ventilation Caroff, Klompas et al CCM 2016;44(4):830 Mortality Caroff, Klompas et al CCM 2016;44(4):830 Significant less antibiotic use SSD Damas et al CCM 2015;43(1):22 Bouza et al Chest 2008;134(4):934 No difference in antibiotic use Lacherade AJRCCM 2010;182(8):910 No difference in VAE Damas et al CCM 2015;43(1):22 No differences in any study regarding strider or reintubation 6

7 Subglottic Suction Intermittent vs. continuous Ventilation 72hrs, pressure < 20 mmhg Subglottic Secretion Drainage Other considerations with SSD systems! Must use special tube in all patients or change ETT Cost considerably higher than standard ETT One suction port position important Potential trauma to airway if continuous suction Rigid tube structure, more trauma External diameter of the SSD tube larger than standard tube must use smaller airway Clogging of the drainage port common Structure of cuff allows for silent aspiration Most useful > 72 hours of mechanical ventilation! Biofilm Biofilm: Scanned Electron Microscopy (SEM) Berra L et al. Intensive Care Med Jun;34(6): Biofilm Prevention Coated ETTs 4. Biofilm Prevention Coated ETTs. Berra L et al. Intensive Care Medicine 2008 Jun;34(6): Berra L et al. Intensive Care Medicine 2008 Jun;34(6): Kolleff, MH et al. JAMA. 2008;300(7):

8 Kollef JAMA 2008;300:805 RCT Pts intubated and ventilated for > 24 hours, Standard ETT vs. Silver coated ETT, 54 Centers US Silver tube VAP rate 4.8%, 37/766 Standard tube VAP rate 7.5%, 56/743, p > 0.03 However, no difference in length of intubation, ICU and Hospital stay, mortality and adverse events More COPD pts in control group Definition of VAP, > 10 4 colony forming units, does not necessarily translate into disease The Ideal Endotracheal Tube Ultrathin polyurethane cuff Silver impregnated Subglottic suction system Same size and rigidity as standard ETT Inexpensive 5. Biofilm Removal ETT cleaning devices Kolobow, T et al. Novel system for complete removal of secretions within the endotracheal tube: the Mucus Shaver. Anesthesiology, Recommendation: Ventilator circuits should not be changed routinely for infection control purposes. The available evidence suggests no patient harm and considerable cost savings associated with extended ventilator circuit change intervals. The maximum duration circuits can be used safely is unknown! Problems with Passive Humidification Increased resistance to gas flow Increased dead space Increased risk of airway occlusion Difficulty delivering aerosolized medication Lacherade AJRCCM 2005;172:1276 8

9 In-Line Catheter Change Frequency Weekly vs daily catheter change no effect on VAP Stoller Respir Care 2003;48:494 No routine change vs daily change, no effect on VAP. Maximum length of use 67days RR 0.99, 95% CI 0.66 to 1.50 p=0.8 Kollef AJRCCM 1997;156:466 In-Line suction catheters should be part of a VAP prevention strategy Routine catheter change not necessary Maximum safe use time unknown Other Circuit Issues Medication nebulizers a potential source of VAP Craven Am J Med 1984;77:834 Manual ventilators a source of airway contamination Woo Am J Med 1986;80:567 Weber ARRD 1990;142:892 Transport out of ICU increases risk of VAP Odds Ratio 3.8, 95% CI 2.6 to 5.8, p < Kollef Chest 1997;112:765 Thank You 9