VENTILATOR ASSOCIATED

PNEUMONIA

Dr. P.K RAJIV

D.C.H, M.D, Pediatrics Fellowship in Neonatology(Australia)
Ahalia hospitals and clinics
Hor Al Anz Dubai.
VENTILATOR ASSOCIATED PNEUMONIA
 Incidence of VAP
Pneumonia (VAP) is defined as nosocomial pneumonia in mechanically ventilated Ventilator-Associated
patient that develops more than 48 hours after initiation of mechanical ventilation. VAP is the second
most common hospital -acquired infection among neonatal intensive care unit patients 41.3%

Incidence of VAP 8.1 to 57.1 %

Bizaro et Al seminars in perinatology2012 : 36

NICU VAP rates In the range upto 37.2 per 1,000 ventilator days.

Garland Et Al 2010 clinic in perinatology 2010:37

Coffin Et Al 2008 infection control hospital epidemiology
Cernada Et Al Neonatlogy update 2014 :105

VAP rates were highest for the 1,001- to 1,500-g and<1,000-g birth weight categories.
Apisarnthanarak Et Al 2003 : 112 Pediatrics
Risk factors in VAP

Length of stay in NICU OR 23.45

Reintubation OR 9.18

Enteral feeding OR 5.59

Mechanical Ventilation OR 4.04

Low birth weight OR 3.16

Premature infants OR 2.66

BPD OR 2.21
Tracheal intubation OR 1.12 Bin tan European journal of
Paediatrics 2014 : 173
Opiate Use in sedation
Blood stream infection
Steroid use Cernada Et Al Neonatology 2014
2014:105
 Risk factors in developing countries

Prematurity(<28 wks)
Birth weight (<1500grms)
Poor immunity ()
Duration of ventilation ()

Reintubation
Duration of NICU stay
Hand hygiene compliance
Ventilator related infection control measures
EVIDENCE BASED ANALYSIS OF VAP IN ELBW

Apisarnthanarak Et Al 2003 : 112 Pediatrics

EVIDENCE BASED ANALYSIS OF VAP IN ELBW

Apisarnthanarak Et Al 2003 : 112 Pediatrics

Description of the most relevant features of studies published in relation to VAP in the neonatal period

Cernada /Brugada /Golombek /Vento Neonatology 2014;105

Newborn Immune Responses
LOWER IMMUNOGLOBULIN LEVELS
COMPLEMENT ACTIVITY DECEASED
GRANULOCYTE CHEMOTAXIS AND KILLING ACTIVITY REDUCED
SKIN AND MUCOUS MEMBRANES HAVE INCREASED PERMEABILITY
CDC Diagnostic Criteria below 1 year
 Microbiological criteria

Bronchoscopic Bronchoalveolar Lavage

Non Bronchoscopic Bronchoalveolar Lavage

1) 25 polymorphonuclear leukocytes/ hpf;

2) More than 2% inflammatory cells;

3) Presence of polymorphonuclear leukocyte cells with

intracellular organisms (ICO) ranging from 2–10%

Cordero L, Sananes M, Dedhiya P, et al: Purulence and Gram-negative bacilli in tracheal aspirates of mechanically ventilated very low birth weight infants. J Perinatal 2001; 21:376.
 VAP Diagnosis Crit. Care Med 1999:27:2537-43

Technique Sensitivity (%) N=103 Specificity(%) N = 103

ET aspirate Culture 93 41

PSB Culture 69 95

BAL Culture 72 88

PSB & BAL Cultures, ICB 90 88

Utility of Gram staining: J Perinatol 2010: 30:270-4

Gram Positive cocci (%) Gran Negative rods (%)

Sensitivity 82 100

Specificity 100 82
 Organisms Isolated In VAP

Tripathi et al / Study of Ventilator Associated Pneumonia in Neonatal Intensive Care Unit Internet Journal of Medical Update 2010 January;5(1):12-19

Internet Journal of Medical Update 2010 January;5(1):12-19

 Pathogenesis of VAP

Endogenous sources of organisms responsible for ventilator-associated pneumonia (VAP). (Courtesy of Walt Earhart, Wheaton Franciscan Healthcare. From:
NeoreviewsPlus August 2010.
 Pathogenesis of VAP

Exogenous sources of organisms responsible for ventilator-associated pneumonia (VAP). (Courtesy of Walt Earhart, Wheaton Franciscan Healthcare.
From: NeoreviewsPlus August 2010.
Relationship between preventative measures and pathogenesis of ventilator-associated pneumonia (VAP).

Adapted from Garland JS. Strategies to prevent ventilator-associated pneumonia in neonates. Clin Perinatol. 2010;37(3):638. Copyright 2010.
Radiological Features

New or progressive infiltrate : air bronchogram specificity

Consolidation
Cavitations or pneumoceles
Radiological Features

New or progressive infiltrate : air bronchogram specificity

Consolidation
Cavitation or pneumoceles
Radiological Features
 VAP care bundle approach

In December 2004, the Institute

for Healthcare Improvement
(IHI) challenged hospitals to
save 100,000 lives by June 2006

The team approach using the IHI

bundle has been shown to be ZAP VAP
successful in reducing VAP

Curley, M. A., et al 2006. Tailoring the Institute for Health Care Improvement 100,000 Lives Campaign to pediatric settings : The example of ventilator-associated pneumonia.
 VAP care bundle

Hand hygiene
Oral hygiene
Suction technique
HOB elevated 30 degrees or higher,lateral
position
Stress Ulcer Prophylaxis
Off sedation
Daily Assessment of readiness to wean

Comprehensive evidence based clinical practice guidelines for ventilator associated pneumonia: CDC 2004
Neonatal Ventilator-Associated Pneumonia: An Under diagnosed Problem in the Neonatal Intensive Care
Units 2017 Saudi Arabia

The quality-of-evidence of these interventions with good impact on VAP rates

• Hand hygiene – Wearing gloves when in contact with secretions

• Minimizing days of ventilation by daily evaluation for readiness to be extubated to nasal continuous
airway pressure –

• Preventing unplanned extubation by creating a uniform procedure for securing endotracheal tubes and
avoid reintubation –

• Suctioning orophaynx

• Preventing gastric distension –

• Changing ventilator circuit only when visibly soiled or malfunctioning –

Removing condensate from ventilator circuit frequently
Al –Alaiyan et al J Pediatr Neonatal Care 2017, 7(3): 00288
Neonatal Ventilator-Associated Pneumonia: An Under diagnosed Problem in the Neonatal Intensive Care
Units 2017 Saudi Arabia

The following recommended interventions do not have clear benefit

 Oral care with antiseptic or colostrum –

 Elevation of head of bed 30-45degrees –

 In-Line (closed) suctioning

Al –Alaiyan et al J Pediatr Neonatal Care 2017, 7(3): 00288

 Infrastructure & Staff training

Establish (VAP) quality improvement team in

intensive care units and develop a protocol for
prevention of VAP.

Integrate VAP prevention program to staff

orientation & refreshment program in ICU/ HDU /
ventilator wards.

Provide adequate coaching & supervision to staff

on intubation & care of ventilated patients until
they are competent to work independently.
 Crowding And Under Staffing
In a prospective study in 2011-2013 of
Nosocomial infection, there was a significant
drop in VAP Rate
When a move was made to a larger NICU with
50% more manpower and segregation of
infected cases . The open bay concept was
changed to laminar flow systems in the cubicle
concept .

Air flow 0.5 micron or larger particle size

Less than 100,000 particles per cubic foot

Nurse :baby Ratio 1:1 Ventilated ELBW

Nurse : Baby Ratio 1:2 Ventilated

Zhou et al American Journal of Infection control 41 (2013 ) 1059-64

General care
General care
General care
 Non Sterile Gloves For General Care

Discard per baby per care

One intervention which could change the dynamics of HAI cycle

 STERILE GLOVE FOR ALL VENTILATOR RELATED ACTIVITY

ET SUCTION , DRAINING CONDENSATE FROM VENTILATOR TUBING , POSITIONING BABY WITH ET TUBE
Position of infant
Position of infant
 ORAL CARE
DOES APPLICATION OF ORAL CHLORHEXIDINE DECREASE THE INCIDENCE OF VENTILATOR ASSOCIATED PNEUMONIA
IN NEONATES: A RANDOMIZED CONTROLLED TRIAL
N. Gupta1, S. Dutta1, P. Kumar1, P. Ray2, A.K. Saxena3
1Pediatrics, 2Microbiology, 3Radiodiagnosis, PGIMER, Chandigarh, India

Background and aim: Oral chlorhexidine (CHX) application decreases the incidence of ventilator associated pneumonia (VAP)
in adults. This study aimed to determine the effectiveness of oral CHX application in decreasing the incidence of VAP in
neonates.

Method: In this open-label controlled trial, neonates requiring endotracheal intubation for mechanical ventilation were
randomly assigned to 'chlorhexidine' and 'no chlorhexidine' group. The CHX group received applications of CHX (0.2% w/v,
Chlorhex Plus, Dr. Reddy's Laboratory, Hyderabad, India) every 8hrs from randomization until extubation, by a cotton
applicator on the oral mucosa. The control group received standard care. The primary outcome was number of episodes of
VAP per 1000 person-ventilation hours. VAP was defined using standard CDC criteria for infants < 1year of age.

Results: One hundred four neonates were enrolled (CHX =51, control=53). The mean gestation was 32.4±4 and 32.9±3.4weeks,
while the median [IQR] age at intubation was 48.0 [26.0, 219.0] and 50.0 [13.0, 130.0] hours in CHX and control groups
respectively. The incidence rate of VAP was 1.9 and 2.6 episodes per 1000 person-ventilation hours in CHX and control groups
respectively [incidence rate difference = -0.7 (95% CI: - 2.5 to1.1, p = 0.4)]. No subject had local or systemic adverse reactions
to CHX.
Conclusion: Oral application of CHX was well tolerated in neonates. However, it did not decrease the incidence of VAP
significantly.
 PROTOCOL RECOMMENDED WITH EVIDENCE

Clinical Issues in Neonatal Care 2016 Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate
Carla D. Weber , MS, CCNS-Neonatal, RNC
Clinical Issues in Neonatal Care 2016 Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate
Carla D. Weber , MS, CCNS-Neonatal, RNC
Clinical Issues in Neonatal Care 2016 Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate Carla
D. Weber , MS, CCNS-Neonatal, RNC
Clinical Issues in Neonatal Care 2016 Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the
Ventilated Neonate Carla D. Weber , MS, CCNS-Neonatal, RNC
Clinical Issues in Neonatal Care 2016 Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate Carla
D. Weber , MS, CCNS-Neonatal, RNC
Clinical Issues in Neonatal Care 2016 Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate Carla D. Weber , MS, CCNS-Neonatal
Clinical Issues in Neonatal Care 2016 Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate Carla D. Weber , MS, CCNS-Neonatal
 VAP rates and implemented protocol components

Clinical Issues in Neonatal Care 2016 Applying Adult Ventilator-associated Pneumonia Bundle Evidence to the Ventilated Neonate Carla D. Weber , MS, CCNS-Neonatal
 Treatment of VAP
Use of early, appropriate, and broad-spectrum antibiotics
CDC GUIDELINES FOR DIAGNOSING VAP
Diagnostic Algorithm For Neonatal VAP .

Cernada et al Neonatology 2014;105:98–107

Duration Of Antibiotic Therapy
 TREATMENT OF VAP
The use of colistin in VAP caused by carbapenem

resistant Acinetobacter species

Use of aerosolized antibiotics colistin

De-escalation of antibiotics based on patients’

culture results and clinical improvement

Shorter duration of antibiotics for patients with uncomplicated VAP upto 8

days to prevent multidrug resistance
Antibiotic therapy for VAP
Zhou et al. / American Journal of Infection Control 41 (2013) 1059-6
The NICU environment

Reinforcement of hand hygiene practices

Periodic educational activities on VAP prevention

Rational waste disposal

Enhancement of patient isolation and ventilator disinfection

Shorten duration of mechanical ventilation

Enhance the respiratory management of patients

Ventilator care was provided by specialized nursing team, and

the closed endotracheal suctioning system was changed every
72 hours or as clinically indicated.18 The ventilator circuit was
changed between patients or if it was soiled or damaged. Other
measures included keeping the ventilator circuits lower than the
endotracheal tube and frequently draining water from condensation
in the ventilator circuit.

Rational use of antibiotics Zhou et al. / American Journal of Infection Control 41 (2013) 1059-6
 CHENNAI EXPERIENCE
Of the 265 mechanically ventilated neonates enrolled in the study, 135 neonates
entered the study cohort. The incidence of VAP was 22.22 cases per 100
mechanically ventilated neonates. Klebsiella (66.67%) was the predominant
organism isolated from the lower respiratory tract specimen (LRT) collected
through the endotracheal tube. Home delivery, respiratory dis- tress at admission,
unstable cardiopulmonary assessment at admission defined as atleast one of the
following: unstable airway/abnormal breathing abnormal circulation/altered mental
status, repeated intubations (more than 1), prolonged ventilation, prolonged
duration of hospitalization and level III stay were found to significant risk factors for
VAP by univariate analysis. Factors that retained significance in multivariate logistic
regres- sion model were unstable initial cardio pulmonary assessment (p value =
0.010, adjusted OR: 0.2, 95% CI: 0.0,0.6) and repeat- ed intubations (p value, 0.001,
adjusted OR: 34.3, 95 % CI: 8.3,142.4). The mortality rates for the neonates with VAP
was 50% and for those without VAP was 69.5 % (p value = 0.030).

VAP is a serious nosocomial infection. Preventable risk factors should be addressed in all
neonatal units. Further research is necessary to formulate the guidelines for diagnosis of
VAP in neonates.
Indian J Pediatr (January 2015) 82(1):96 N. Vijayakanthi et al
 LUCKNOW EXPERIENCE

The study group comprised of 98 neonates out of which, 30 neonates developed

VAP (30.6%). VAP rates were 37.2 per 1000 days of mechanical ventilation. Most
common bacterial isolated from endotracheal aspirate of VAP patients was
Klebsiella spp (32.8%), E.coli (23.2%) and Acinetobacter (17.8%) being the other
two common organisms. Very low birth weight (<1500 grams), prematurity
(gestational age < 37 week), duration of mechanical ventilation, number of
reintubations and length of NICU stay were significantly associated with VAP in
bivariate analysis. Multiple regression analysis revealed that duration of
mechanical ventilation (OR 1.10, 95% CI 1.02, 1.21; P = 0.021) and very low birth
weight (OR 3.88, 95% CI 1.05, 14.34; P = 0.042) were two single independent and
statistically significant risk factors for predicting VAP. VAP developed in nearly
one third of intubated neonates having gram negative organisms as
predominant etiological agent.
Semi quantitative assessment of ET aspirates > 10 5 CFU

Tripathi et al / Study of Ventilator Associated Pneumonia in Neonatal Intensive Care Unit

Internet Journal of Medical Update 2010 January;5(1):12-19
LUCKNOW EXPERIENCE

Tripathi et al / Study of Ventilator Associated Pneumonia in Neonatal Intensive Care

Unit Internet Journal of Medical Update 2010 January;5(1):12-19
 LUCKNOW EXPERIENCE Outcome

The mean length of NICU stay

This was significantly longer in patients with VAP as compared to
those with out VAP i.e. 232.7days Vs 19.7 days (p = 0.028).

Mortality rates
This were higher in patients with VAP (40%) and
lower in non-VAP cases (22.06%) (p=0.058).

Tripathi et al / Study of Ventilator Associated Pneumonia in Neonatal Intensive Care Unit

Internet Journal of Medical Update 2010 January;5(1):12-19
 CONCEPTUAL MODEL

VAP Prolonged stay

/Mortality

Prematurity
Prolonged invasive Hand hygiene compliance
ventilation

Blood stream infection

Central Line un
restricted use

Dr. Rajiv P.K 2017 NNF

 STRATEGY SINCE 1992

Infection control

ENTERAL FEEDS
COMPLIANCE OF VENTILATOR CARE PROTOCOL
Hand washing Station Logo 1991 -2017

Three decades of NICU care

Childs Trust Hospital 1991

PVS Memorial Hospital kochin 1992 -1999

Mallya Hospital Bangalore 1999 - 2002

Amrita institute of medical sciences 2002 -2010

NMC speciality Hospital Dubai 2002 -2017

Survival 92.3% above 25 weeks gestation

 Non Sterile Gloves For Routine Care

One intervention which could change the dynamics of HAI cycle Discard per care
 STERILE GLOVE FOR ALL VENTILATOR RELATED ACTIVITY

ET SUCTION , DRAINING CONDENSATE FROM VENTILATOR TUBING , POSITIONING BABY WITH ET TUBE
 LOGISTICS OF VAP CONTROL

VAP RATE PER 1000 VENTILATOR HOURS

2

VAP bundle
10
Non Invasive Ventilation

Respiratory Care Practices Compliance

20
Hand Hygeine Practises Compliance
40
Manpower Ratio 1:1 and 1:2
 RESTRICTED USE OF KEY ELEMENTS IN VAP

INVASIVE VENTILATION

TPN

ARTERIAL CATHETER

COMPLIANCE OF PRACTISES

CENTRAL LINE and BSI

 Central Line Blessing or Bane

Restricted use above 28 weeks gestation is recommended . In our unit in 7 years we had no blood
stream infection, catheter related infection ,or ventilator associated pneumonia above 28 weeks
gestation and no mortality treating 2700 babies... Blood stream infection as a precursor to VAP
leads to higher mortality. Do we need central line vacation. Vicious cycle of Blood stream infection
and length of stay , exacerbated by VAP
NON INVASIVE VENTILATION

If you do not ventilate a baby you do not get BPD

Richard Polin

SYNCHRONISED NASAL INTERMITTENT POSITIVE PRESSURE

VENTILATION
 PROPOSED VAP BUNDLE FOR INDIA CONSIDERATIONS

 HAND HYGEINE practices

 After hand disinfection
 Non sterile disposable gloves per care /care
 Sterile gloves and gown for ventilator related care
 Closed hand care for routine care and ventilator related care
 Closed suction system for ET suction
 Closed system for central line Hany Aly Et al 2003
 Is Bloodstream Infection Preventable Among Premature Infants?
Pediatrics 2005;115: 1513–1518;
System used for
administration of
medications through a
central line. PICC indicates
peripherally inserted central
catheter;
HALS, hyperalimentation;
LIPIDS, intralipids
Applying the closed
medication system was
associated with reduced BSI
rates in our unit from 46.7%
and 5.6%

Hany Aly, MD*; Victor Herson, MD‡; Anne Duncan, RN*; Jill Herr, MSN‡; Jean Bender, APRN‡; Kantilal Patel, PhD§; and Ayman A. E. El-Mohandes, MD, MPH
1997
PROPOSED VAP BUNDLE FOR INDIA CONSIDERATIONS

Restricted use of central lines above 28 weeks gestation /

days UAC 4/UVC 7 ( CDC 14 )/ PICC 14
( CDC no time frame )
Enteral feed advance.

Restricted use if central lines below 28 weeks

days Uac 4 / Uvc 7 ( 14 CDC) / Picc 21
( CDC no time frame )
Enteral feed advance
PROPOSED VAP BUNDLE FOR INDIA CONSIDERATIONS

Aggressive weaning to NIV CPAP /SNIPPV ( hospital days and

duration of ventilation )

Surveillance of multidrug resistance

Head of department / associates practice in same

hospital ( compliance )

Training every 3 months with audit of progress

( psychology of compliance )
PROPOSED VAP BUNDLE FOR INDIA CONSIDERATIONS
RESPIRATORY CARE
Drain condensate away from baby by keeping reservoir below baby level

Separate suction catheters and system for oral and ET

Do not open closed system to drain condensate 2-4 hourly

Closed suction system changed weekly / visibly soiled

ET suction only when clinically indicated.

Oroparyngeal suction before position change and 4 hourly

Avoid emergency intubation and extubation

Lateral position of baby than supine

Head end up position 15- 30 degree

Adequate humidification of gas

VAP is the second most common hospital-acquired infection associated with an excess
of 2 days Summary
of mechanical ventilation. Educational interventions and efforts to improve
adherence to hand hygiene have been associated with de-creased VAP rates.by at least
60 % in some centers.

Involves minimum cost

PRIMUM No CERE
ESSENTIALS OF NEONATAL VENTILATION RAJIV VIDYASAGAR SATYAN 2018 ELSEVIER

This is the third textbook in the world dedicated to neonatal

ventilation
and the only book in the world giving bedside ventilation
navigation
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to conceptualize, implement and coordinate and 3 years with
elsevier
rigid quality standards.. This will be the first neonatal ventilation
book
from elsevier from developing countries. This book will have 45 of
the
worlds best stalwarts from USA ,UK, Australia , Germany ,UAE
and
India to write the specific chapters, in which i was co author is
some
key chapters. This was my life ambition and is the first
book ,addressing this standardization of ventilator care, so far not
attempted in the world in 40 years.This is targetted as a expert
counsel book for all nicus in the world . www.drpkrajiv.net