Ventilator-associated pneumonia
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Ventilator-associated pneumonia (VAP) is a sub-type of hospital-acquired pneumonia (HAP) which occurs in people who are receiving mechanical ventilation. VAP is not characterized by the causative agents; rather, as its name implies, definition of VAP is restricted to patients undergoing mechanical ventilation while in a hospital. The diagnoses of VAP is difficult but usually requires a new infiltrate on chest x-ray plus two or more of: fever of >38.3 °C, leukocytosis of >12 × 109/ml, purulent tracheobronchial secretions, and/or reduction in gas exchange.[1] In order to appropriately categorize the causative agent or mechanism it is usually recommended to obtain a culture prior to initiating mechanical ventilation as a reference.
Signs and symptoms
People who are on mechanical ventilation are often sedated and are rarely able to communicate. As such, many of the typical symptoms of pneumonia will either be absent or unable to be obtained. The most important signs are fever, low body temperature, new purulent sputum, and hypoxemia (decreasing amounts of oxygen in the blood).
Diagnosis
A diagnosis of ventilator-associated pneumonia is made when the patient has a new diagnosis of pneumonia after having mechanical ventilation initiated. VAP should be suspected in any person on mechanical ventilation exhibiting increasing numbers of white blood cells on blood testing, and new shadows (infiltrates) on a chest x-ray as is indicative of a pneumonia. Blood cultures may reveal the microorganisms causing VAP.
Two strategies exist for diagnosing VAP. One strategy collects cultures from the trachea of people with symptoms of VAP plus a new or enlarging infiltrate on chest x-ray. The other is more invasive and advocates a bronchoscopy plus bronchoalveolar lavage (BAL) for people with symptoms of VAP plus a new or enlarging infiltrate on chest x-ray. In both cases, VAP is not diagnosed when cultures are negative and another source of the symptoms is sought.
Pathophysiology
It is thought by many, that VAP primarily occurs because the endotracheal or tracheostomy tube allows free passage of bacteria into the lower segments of the lung in a person who often has underlying lung or immune problems. Bacteria travel in small droplets both through the endotracheal tube and around the cuff. Often, bacteria colonize the endotracheal or tracheostomy tube and are embolized into the lungs with each breath. Bacteria may also be brought down into the lungs with procedures such as deep suctioning or bronchoscopy. Another possibility is that the bacteria already exist in the mucus lining the bronchial tree, and are just kept in check by the body's first line of defenses. Ciliary action of the cells lining the trachea drive the mucus superiorly, leading to a build-up of fluids around the inflated cuff where there is little to no airway clearance. The bacteria can then colonize easily without disturbance and then rise in numbers enough to become infective. The droplets that are driven into the airstream and into the lung fields are lofted by way of Bernoulli's principle. There is also a condition called oxidative damage that occurs when concentrations of pure oxygen come into prolonged contact with cells and this damages the cilia of the cells, thus inhibiting their action as part of the body's first line of defense.–Cite error: The <ref> tag has too many names (see the help page).
People who do not have risk factors for MDR organisms may be treated differently depending on local knowledge of prevalent bacteria. Appropriate antibiotics may include ceftriaxone, ciprofloxacin, levofloxacin, or ampicillin/sulbactam.
As of 2005, there is ongoing research into inhaled antibiotics as an adjunct to conventional therapy. Tobramycin and polymyxin B are commonly used in certain centres but there is no clinical evidence to support their use.
Prevention
Prevention of VAP involves limiting exposure to resistant bacteria, discontinuing mechanical ventilation as soon as possible, and a variety of strategies to limit infection while intubated. Resistant bacteria are spread in much the same ways as any communicable disease. Proper hand washing, sterile technique for invasive procedures, and isolation of individuals with known resistant organisms are all mandatory for effective infection control. A variety of aggressive weaning protocols to limit the amount of time a person spends intubated have been proposed. One important aspect is limiting the amount of sedation that a ventilated person receives.
Other recommendations for preventing VAP include raising the head of the bed to at least 30 degrees.[citation needed] Antiseptic mouthwashes such as chlorhexidine may also reduce the incidence of VAP, although the evidence is mainly restricted to those who have undergone cardiac surgery.[2]
American and Canadian guidelines strongly recommend the use of supraglottic secretion drainage (SSD) Special tracheal tubes with an incorporated suction lumen as the EVAC tracheal tube form Covidien / Mallinckrodt can be used for that reason. New cuff technology based on polyurethane material in combination with subglottic drainage (SealGuard Evac tracheal tube from Covidien/Mallinckrodt)showed significant delay in early and late onset of VAP.[3]
A recent clinical trial indicates that the use of silver-coated endotracheal tubes may also reduce the incidence of VAP.[4] There is tentative evidence that the use of probiotics may reduced the likelihood of getting VAP, however it is unclear if probiotics have an impact on ICU or in-hospital death.[5]
Epidemiology
Between 8 and 28% of patients receiving mechanical ventilation are affected by VAP.[6] VAP can develop at any time during ventilation, but occurs more often in the first few days after intubation.[citation needed] This is because the intubation process itself contributes to the development of VAP.[citation needed]
Prognosis
VAP occurring early after intubation typically involves fewer resistant organisms and is thus associated with a more favorable outcome. Because respiratory failure requiring mechanical ventilation is itself associated with a high mortality, determination of the exact contribution of VAP to mortality has been difficult. As of 2006, estimates range from 33% to 50% death in patients who develop VAP. Mortality is more likely when VAP is associated with certain microorganisms (Pseudomonas, Acinetobacter), blood stream infections, and ineffective initial antibiotics. VAP is especially common in people who have acute respiratory distress syndrome (ARDS).
Footnotes
- ^ Ventilator-Associated Pneumonia: Diagnosis, Treatment, and Prevention Steven M. Koenig, Jonathon D. Truwit Clin Microbiol Rev. 2006 October; 19(4): 637–657.
- ^ 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 meta-analysis". JAMA Intern Med. 174 (5): 751–61. doi:10.1001/jamainternmed.2014.359. PMID 24663255.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Lorente L, Lecuona M, Jiménez A, Mora ML, Sierra A (2007). "Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia". Am. J. Respir. Crit. Care Med. 176 (11): 1079–83. doi:10.1164/rccm.200705-761OC. PMID 17872488.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Kollef MH; Afessa B; Anzueto A; et al. (August 2008). "Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial". JAMA. 300 (7): 805–13. doi:10.1001/jama.300.7.805. PMID 18714060.
{{cite journal}}: Unknown parameter|author-separator=ignored (help) - ^ Bo, L; Li, J; Tao, T; Bai, Y; Ye, X; Hotchkiss, RS; Kollef, MH; Crooks, NH; Deng, X (Oct 25, 2014). "Probiotics for preventing ventilator-associated pneumonia". The Cochrane database of systematic reviews. 10: CD009066. PMID 25344083.
- ^ Chastre J, Fagon JY (April 2002). "Ventilator-associated pneumonia". Am. J. Respir. Crit. Care Med. 165 (7): 867–903. doi:10.1164/ajrccm.165.7.2105078. PMID 11934711.
References
- American Thoracic Society and the Infectious Diseases Society of America. (2005). "ATS/IDSA Guidelines: Guidelines for the management of adults with HAP, VAP, and HCAP". Am J Respir Crit Care Med. 171 (4): 388–416. doi:10.1164/rccm.200405-644ST. PMID 15699079.
- Niederman, MS. (2006). "Use of broad-spectrum antimicrobials for the treatment of pneumonia in seriously ill patients: maximizing clinical outcomes and minimizing selection of resistant organisms". Clin Infect Dis. 42 (Supp 2): S72–81. doi:10.1086/499405. PMID 16355320.
- Kollef MH (June 2005). "What is ventilator-associated pneumonia and why is it important?". Respir Care. 50 (6): 714–21, discussion 721–4. PMID 15913464.