Microsoft word - esctaic abstracts 2009 berlin.doc

PREVENTION OF VENTILATOR ASSOCIATED PNEUMONIA: Proposed Methods of VAP Prevention: A large list of methods for preventing VAP can be found in the recent literature. Most of them proved to be ineffective: use of sucralfate, oscillating beds, digestive decontamination, Myney Hayeshuah Medical Center, Bnai Brak & Ben Gurion frequent change of ventilator circuits or aerosolized anti- University of the Negev, Beer Sheva, Israel biotics. In the last couple of years some clinical studies used what is called ‘‘a VAP bundle policy’’ which would Introduction: Hospital acquired pneumonia remains an include : head of bed elevation, interruption of sedation important cause of morbidity and mortality in our on a daily basis, oral suction before each change of posi- intensive care units (ICU), despite advances in antimi- tion, patient early mobilization. The results are encour- crobial therapy, better support care modalities and the use aging but not clear cut, some data showing almost no of a wide-range of preventive measures. This statement, change in VAP incidence when using ‘‘VAP bundle’’ published some years ago, still has a strong support in the reality of our days. Ventilator-associated pneumonia Conclusions: VAP is still a serious complication of (VAP) affects almost one third of all intubated and ven- mechanical ventilation and tracheal intubation. The tilated patients. The cumulative risk is 1% for each day of 100,000 Lives Campaign of the Institute of Health Care in mechanical ventilation. Its impact on ICU cost is signif- the USA promotes six evidence-based safety interventions icant. The length of stay in ICU increases by 4–7 days in which can significantly improve acute care outcome, case of VAP and the cost of care increases by more than $7,000 per patient. Any ventilated patient can develop But the lack of an uniform list of criteria for VAP VAP during his stay in ICU, but there are some risk diagnosis and of a reliable method to prevent it keep VAP factors, which may increase the percentage of VAP: item on the top of the problematic aspects of ICU care. admission from a chronic care environment, current The ‘‘drive for zero’’ tendency in some countries hemodialysis, immunocompromised host, prior use of regarding VAP might do patients more harm than good. This is why it becomes evident that a search for a reliable Pathophysiology: The main causative factor of VAP is method of VAP prevention is perfectly justified and aspiration of supraglottic secretions into the lung parenchyma. The explanation for VAP development is based on the simple fact that tracheal intubation and mechanical ventilation impair the natural defense mechanisms, which are supposed to prevent aspiration of the supravocal cords secretions: the cough reflex and mucocilliary clearance. Beside, injury of tracheal epi- thelial cells and decrease of bacterial adherence to tra- cheal epithelial cells must be added to the list of impaired defense factors affected by prolonged tracheal intubation and mechanical ventilation. Diagnosis: The data from literature are controversial. Some authors would use a simple list of diagnostic criteria: leukocytosis, fever, purulent sputum, radiological infil- trates and absence of any other evident infection focus. But some others would add a positive culture either from a tracheal aspirate or even from bronchoalveolar lavage (BAL). This is the explanation on the fact that some ICUs report a much lower incidence of VAP than that men- tioned in most of the pertinent papers. In the last years, there is an evident trend to artificially lower the incidence of VAP in the USA, since the Medicare payment does not cover ‘‘preventable’’ complications! But the main problem of VAP is that as per today, there is no proved method of prevention!

Source: http://www.esctaic.org/documents/2009de/GurmanA.pdf