506544 634193328906940740

VENTILATOR ASSOCIATED
PNEUMONIAS
current perceptions
Dr.T.V.Rao MD

Professor Department of Microbiology Sri Deva Raj Urs Medical
College, Tamaka, Kolar , India

Tamaka Kolar

doctortvrao@gmail.com

1

Pneumonia
Still the “Old man’s friend?”
• Bacterial, Viral,
Chemical, Aspiration,
Nosocomial,
Community Acquired,
“Walking,”
Bronchopneumonia,
Necrotizing,

Ventilator
associated

2

Pneumonia can be a life threatening
condition
Is Something Serious ?

• Hospital-acquired
pneumonia (HAP)
and ventilatorassociated
pneumonia (VAP), is
an important cause
of morbidity and
mortality in
hospitalized patients.


3

Ventilator associated pneumonia
• Ventilator associated pneumonia (VAP) is
defined as nosocomial pneumonia occurring
in a patient after 48 hours of mechanical
ventilation via a tracheal or tracheostomy
tube. It is commonly classified as either early
onset (occurring within 96 hours of start of
mechanical ventilation) or late onset (>96
hours after start of mechanical ventilation)

4

Early concepts
• As early as 1972, studies have shown that the
airway of mechanically ventilated patients
quickly becomes colonized with gram-negative
organisms. In the past, it was thought that
pathogens came from the ventilator
equipment in use. However, as the problem
was studied and evidence accumulated, it
became evident that the origin of the VAP was
from a source other than the ventilator
equipment.

5

Ventilator Associated Pneumonia (VAP)
- Key Points • VAP is the 2nd most common nosocomial infection =
15% of all hospital acquired infections
• Incidence = 9% to 70% of patients on ventilators
• Increased ICU stay by several days
• Increased avg. hospital stay 1 to 3 weeks
• Mortality = 13% to 55%
• Added costs of $40,000 - $50,000 per stay
Centers for Disease Control and Prevention, 2003.
Rumbak, M. J. (2000). Strategies for prevention and treatment. Journal of Respiratory Disease,
21 (5), p. 321;

6

Centres for Disease and Control
• The diagnosis of
pneumonia in
mechanically ventilated
patients is difficult, and
still there is no "goldstandard" diagnostic
method. It is usually based

on the combination of clinical,
radiological, and
microbiological criteria
defined by Centres for

Disease and Control
(CDC)

7

Challenge and Controversy
• The diagnosis and
management of VAP
remains one of the
most

controversial
and challenging
topics in
management of
critically ill patients.”

8

Who are prone -High Risk Patients
• For Sepsis
–
–
–
–
–

Post op / post procedure / post trauma
Post splenectomy (encapsulated organisms)
Cancer
Transplant / immune supressed
Alcoholic / Malnourished

• For Dying
–
–
–
–

Genetic predisposition (e.g. meningococcus)
Delayed appropriate antibiotics
Yeasts and Enterococcus
Site

• For Both
– Cultural or religious impediment to treatment


9

Nosocomial infection are
Multidrug Resistant
• Many patients with HAP,
VAP, and HCAP are at
increased risk for
colonization and
infection with MDR
pathogens
• HAP and VAP are a
frequent cause of
nosocomial infection that
is associated with a higher
crude mortality than other
hospital-acquired
infections

10

Aspiration
• Aspiration of colonized
pathogenic

microorganisms on the
oropharynx and
gastrointestinal tract is
the main route for the
development of VAP. On
the other hand, the major
risk factor for VAP is
intubation and the
duration of mechanical
ventilation

11

Variation of Incidence Rate
• In different studies, the incidence of VAP was
reported different, depending on the
definition, the type of hospital or ICU, the
population studied, and the type of rate
calculated and varies from 7% to 70% In a
large database, 1-day point prevalence study,
conducted in 1417 European ICUs, pneumonia
accounted for 47% of nosocomial infections

12

Aero digestive ,upper airway + upper
digestive tract contribute pathogens
• The primary route of
VAP pathogenesis is a
combination of two
processes: bacterial
colonization of the aero
digestive (upper airway
+ upper digestive) tract
and the subsequent
aspiration into the
lower airway.

13

When does VAP occur?
• Cook et al showed . . .
– 40.1% developed before day 5
– 41.2% developed between days 6 and 10
– 11.3% developed between days 11-15
– 2.8% developed between days 16 and 20
– 4.5% developed after day 21

Cook et al. Incidence of and risk factors for ventilator-associated pneumonia
in critically ill patients.

14

Time frame of intubation and risk
• Risk of pneumonia at
intubation days
– 3.3% per day at day 5
– 2.3% per day at day
10
– 1.3% per day at day
15

.

15

PAHOGENESIS
– The pathogenesis of
ventilator-associated
pneumonia usually
requires that two
important processes
take place:
• Bacterial colonization of
the aero digestive tract
• The aspiration of
contaminated secretions
into the lower airway.


16

Mechanical device also
contributes the events


17

Etiology
• Bacteria cause
most cases of HAP,
VAP, and HCAP
and many
infections are
polymicrobial;
rates are especially
high in patients
with ARDS

18

Causative Organisms
• Early onset:
–
–
–
–
–

Haemophilus influenza
Streptococcus pneumoniae
Staphylococcus aureus (methicillin sensitive)
Escherichia coli
Klebseilla

• Late onset:

– Pseudomonas aeruginosa
– Acinetobacter

– Staphylococcus aureus (methicillin
resistant)
• Most strains responsible for early onset VAP
are antibiotic sensitive. Those responsible for
late onset VAP are usually multiple antibiotic
resistant
Am J Resp Crit Care (1995)


19

Summary of pathogens responsible for VAP in a study of 420 patients.

Hunter J D Postgrad Med J 2006;82:172-178

©2006 by The Fellowship of Postgraduate Medicine

20

Drug resistance a concern in Ventilator
Associated Pneumonias
• A. baumanni was the
most common emerging
isolated pathogen many
of them were multidrugresistant (MDR) or pan
drug-resistant (PDR). The
other common isolated
pathogens were K.
pneumoniae, P.
aeruginosa and
methicillin-resistant
S. aureus (MRSA).

21

Other Isolates in Ventilator associated
Pneumonias
– Pseudomonas aeruginosa.
• the most common MDR gram-negative bacterial pathogen
causing HAP/VAP, has intrinsic resistance to many
antimicrobial agents

– Klebsiella, Enterobacter, and Serratia species.
• Klebsiella species
– intrinsically resistant to ampicillin and other aminopenicillins and
can acquire resistance to cephalosporins and aztreonam by the
production of extended-spectrum –lactamases (ESBLs)

– However ESBL-producing strains remain susceptible to
carbapenems ?
• Enterobacter species
• Citrobacter and Serratia species
22

Acinetobacter species
– Acinetobacter species

• More than 85% of
isolates are
susceptible to
carbapenems, but
resistance is
increasing , Most
recent concern.
• Stenotrophomonas
maltophilia, and
Burkholderia cepacia:
– resistant to
carbapenems ?

23

Newer Carbapenemases
• As of June 2010, there
were three reported
cases of
Enterobacteriaceae
isolates bearing this
newly described
resistance mechanism in
the US, the CDC stated
that "All three U.S.
isolates were from
patients who received
recent medical care in
India."

Staphylococcus aureus and
Streptococcus pneumoniae
– Methicillin-resistant Staphylococcus aureus
• vancomycin-intermediate S. aureus
– sensitive to linezolid
– linezolid resistance has emerged in S. aureus, but is currently
rare ?

– Streptococcus pneumoniae and Haemophilus
influenzae.
• sensitive to vancomycin or linezolid, and most remain
sensitive to broadspectrum quinolones


26

L. Pneumophila and environment
• Rates of L. pneumophila
vary considerably
between hospitals and
disease occurs more
commonly with
serogroup 1 when the
water supply is
colonized or there is
ongoing construction


27

Influenza too can cause VAP
• Nosocomial virus and fungal
infections are uncommon
causes of HAP and VAP in
immunocompetent patients.
Outbreaks of influenza have
occurred sporadically and
risk of infection can be
substantially reduced with
widespread effective infection
control, vaccination, and use of
anti influenza agents


28

Fungal pathogens can cause
VAP
–Fungal
pathogens.
•Aspergillus
species
•Candida
albicans

29

Pathogenesis – Entry of Pathogens
• Where do the bacteria come from?
– Tracheal colonization- via oropharyngeal
colonization or GI colonization
– Ventilator system

• How do they get into the lung?
– Breakdown of normal host defenses
– Two main routes
• Through the tube
• Around the tube- microaspiration around ETT cuff

30

Oropharyngeal colonization can be
source of VAP
• Scannapieco et al showed a transition in the
colonization of dental plaques in patients in
the ICU
• Control=25 subjects presenting to preventive
dentistry clinic
• Study group=34 noncardiac patients
admitted to medical ICU at VA hospital
(sampled within 12 hours of admission and
every third day)

31

Gastrointestinal colonization
• Increased gastric pH leads to bacterial
overgrowth
• Reflux can then lead to colonization of
oropharynx
• Use of antacids and H2 blockers associated
with GI colonization

Safdar et al. The pathogenesis of ventilator-associated pneumonia:
its relevance to developing effective strategies for prevention

32

Viral Pathogens
• Outbreaks of HAP, VAP, and
HCAP due to viruses, such
as influenza, parainfluenza,
adenovirus, measles, and
respiratory Syncytial virus
have been reported and
are usually seasonal.
• Influenza, pararinfluenza,
adenovirus, and
respiratory Syncytial virus
account for 70% of the
nosocomial viral cases of
HAP,VAP, and HCAP

33

Bio films
• Many species, including
Pseudomonas aeruginosa
and Staphylococcus
aureus, produce bio films,
which surround the
organisms when attached
to endotracheal tubes,
and make them relatively
resistant to the actions of
antibiotics and host
defences.

34

Bio films,
• The surviving
organisms may
play a role in
relapses by
shedding infective
particles from the
endotracheal tube
into the lower
respiratory trac


35

Multidrug resistant organisms are
associated with …
• The prevalence of MDR
pathogens varies by patient
population, hospital, and
type of ICU, which
underscores the need for
local surveillance data
• MDR pathogens are more
commonly isolated from
patients with severe, chronic
underlying disease, those
with risk factors for HCAP,
and patients with late-onset
HAP or VAP

36

Diagnosis?
• A pulmonogist with
25+ years
experience guesses
he is only correct
60% of the time
when diagnosing
pneumonia before
seeing the CXR. A
little better than a
coin-toss.

37

Diagnosis is imprecise and usually
based on a Combination of
–Clinical factors - fever or hypothermia;
change in secretions; cough; apnea/
bradycardia; tachypnea

–Microbiological factors - positive
cultures of blood/sputum/tracheal
aspirate/pleural fluids

–CXR factors - new or changing infiltrates

38

Strategies in Diagnosis in VAP are
multifaceted

• Clinical
Strategy
• Bacteriologic
Strategy
• Comparing
Diagnostic
Strategy


39

Diagnostic practices
• VAP
– Invasive versus non-invasive techniques
– BAL/PBB versus tracheal aspirate
– Quantitative versus non-quantitative methods

• Infection definitions
– Clinician decision or standardised definitions


40

Specimen collection for Optimal Results
• Distal airway samples may be obtained by
using bronchoscopic or nonbronchoscopic
techniques. With nonbronchoscopic
techniques, a catheter is blindly advanced
through the endotracheal tube or
tracheostomy and wedged in the distal airway.
Various sampling methods include blind
bronchial suction (BBS), blind BAL, and blind
PSB sampling.

41

Bacteriologic Strategy
• Quantitative cultures can
be performed on
endotracheal aspirates or
samples collected either
bronchoscopically or
nonbronchoscopically,
and each technique has its
own diagnostic threshold
and methodologic
limitations. The choice of
method depends on local
expertise, experience,
availability, and cost

42

Nonquantitative or
semiquantitative airway sampling.
• Gram staining and nonquantitative and
semiquantitative cultures of tracheal secretions
have the advantages of reproducibility and of
requiring little technical expertise and no
specialized equipment or technique. However,
these studies add little to the sensitivity and
specificity of the clinical diagnosis of VAP, as the
upper respiratory tract is rapidly, within hours of
intubation, colonized by potential pulmonary
pathogens, even when pneumonia is not present

43

Specimen collection
• Tracheobronchial secretions were collected by
the pulmonologist , following specimen
collection guidelines, after tracheal instillation
of 5 ml saline. The specimens were sent to the
laboratory and cultivated within 1 hour of
collection. A dilution of the tracheal aspirate
was prepared and inoculated with a calibrated
loop on chocolate agar and MacConkey agar

44

Qualitative cultures X Qualitative cultures
• Qualitative cultures were considered positive
when the growth of any micro-organism
occurred, and quantitative cultures were
considered positive when the growth of 105
colony-forming units (cfu)/ml or more was
observed.


45

Culture positivity true or false?
• Qualitative cultures were considered positive
when the growth of any micro-organism
occurred and quantitative cultures were
considered positive when the growth of 105
colony-forming units (cfu)/ml or more was
observed. cultures from tracheal aspirates
were calculated according to standard
formulae

46

Which is optimal sample ?
• Despite numerous publications on the subject,
controversy still exists on the optimal method
of microbiological diagnosis of VAP,As the
trachea and tracheal tube rapidly become
colonised with bacteria in the critically ill
patient, cultures of sputum or tracheal
aspirates may simply yield colonising organism


47

Differentiates between pathogenic
from non pathogenic ?
• Analysing samples using quantitative culture
techniques theoretically permits
differentiation between oropharyngeal
organisms present at low concentrations and
the higher concentrations of pathogenic
organisms.


48

WHY IS THERE NO GOLD STANDARD?
• After more than 10 years of trying multiple
invasive and non-invasive diagnostic
techniques, the procedure which is
specific, sensitive, rapid and inexpensive is yet
to be developed. No studies have shown the
superiority of any specific diagnostic method
currently in use, thus, medical community still
has no gold standard for the diagnosis of VAP

49

Good Microbiology practices reduces
Antibiotic usage
• Invasive tests such as bronchoscope BAL or
protected specimen brush (PSB) may avoid the
extended use of antibiotics for clinically
insignificant organisms, but no direct
consensus or evidence suggests that one test
is superior to the other; all have their
advantages and disadvantages.


50

Precautions in collecting and
transporting
• After proper hand washing and wearing sterile
gloves before suctioning, the endotracheal
secretions were collected by instilling 1-2 ml
of sterile normal saline into the endotracheal
tube and then collecting it back with the help
of sterile mucous trap. The specimen collected
was immediately transported to the
laboratory within one hour of collection.

51

Gram stain is highly

sensitive

Sputum or tracheal suction gram stain
NO ORGANISMS
in non-neutropenic pts.

NO HAP/VAP 94%


52

Gram staining of secretions are
useful in early decisions
• The upper respiratory tract
of patients is colonized with
potential pulmonary
pathogens a few hours after
intubation.
A positive Gram's stain may
guide the initial antibiotic
therapy. However prior
antibiotic and corticosteroid
therapy can reduce the
sensitivity of this technique


53

Bacterial culture of tracheal
secretion
•
•

•

Qualitative culture
- non specific
Semi-quantitative
culture
- low specificity
Quantitative
culture : TS, BAL,
PSB
- increase
specificity

54

Collection of bronchial Secretions
PSB sampling.

55

Bronchoscopic BAL
• Bronchoscopic BAL has
been in use since 1988
(See Figure 1); however,
the BAL technique is still
not completely
standardized. The amount
of liquid instilled into the
lung for specimen
retrieval varies from 130
to 150 ml, with the first
sample being discarded.

56

PSB sampling.

57

• The sensitivity of quantitative BAL is 42 to 93% with a
mean of 73%. Specificity is 45 to
• 100% with a mean of 82%. Specific affected area of the
lung can be visualized and sampled
• • More accurate than sputum or tracheal aspirates
• • May enable physician to identify non-infectious
lesions
• • Detects intracellular organisms in BAL cultures
quickly and specifically
• with highly positive predictive value

58

Bacterial culture of tracheal
secretion
•
•
•

Qualitative culture
- non specific
Semi-quantitative culture
- low specificity
Quantitative culture : TS, BAL, PSB
- increase specificity

59

Protected Specimen Brush
ProBAL© PSB by Mill-Rose
• The protected specimen brush
technique for the diagnosis of
pneumonia has been used for
20 years. This bronchoscopic
technique use a sample
collection brush (protected by
a sheath) inside the scope
channel until the suspect
portion of the lower airway
has been reached. The brush is
then extended into the desired
specimen and withdrawn. This
technique was first described
in 1979 by Wimberly, et al.


60

Semiquantitative
1+ : rare
<10 colonies/plate
2+: few
10-102 colonies/plate
3+: moderate >102-3 colonies/plate
4+: numerous >103-4 colonies/plate
5+: numerous >104 colonies/plate


61

PSB sampling.

62

Qualitative and quantitative
• Qualitative endotracheal aspirates are easy to
obtain but have a high false-positive rate in
ICU patients because of airway colonization.
When quantitative endotracheal-aspirate
cultures are used, a cutoff value of 106 is the
most accurate, with a sensitivity of 38-82%
and a specificity of 72-85%


63

Differing opinions in specimen collection
• Recent studies have consistently shown that
outcome in VAP may not be influenced by
whether cultures are obtained by
bronchoscope or from tracheal aspirates
collected at the bedside. Furthermore, a cost
effectiveness analysis strongly supported the
employment of tracheal aspirates in the
management of VAP.
•

Ruiz M, Torres A, Ewig S, Marcos MA, Alcón A, Lledó R, Asejo MA,Maldonado M: Noninvasive versus invasive microbial investigation in ventilator associated pneumonia:
evaluation of outcome. Am J Respir Crit Care Med 2000, 162:119-125.


64

Severely ill patients need
• In selected groups of severely ill
patients, quantitative cultures of
tracheal aspirates should not
replace qualitative cultures for
confirmation of diagnosis or
management of antibiotic therapy.
•

Ventilator associated pneumonia: comparison betweenquantitative and qualitative cultures of tracheal aspirates Luis
Fernando Aranha Camargo1, Fernando Vinícius De Marco2, Carmen Sílvia Valente Barbas1, Cristiane Hoelz1, Marco Aurélio
Scarpinella Bueno1, Milton Rodrigues Jr1, Verônica Moreira Amado1, Raquel Caserta3, Marinês Dalla Valle Martino4, Jacyr
Pasternak4 and Elias Knobel5


65

Which methods of collection is
better
• Two diagnostic strategies for ventilatorassociated pneumonia — bronchoalveolar
lavage with quantitative culture of the
bronchoalveolar-lavage fluid and endotracheal
aspiration with nonquantitative culture of the
aspirate — are associated with similar clinical
outcomes and similar overall use of antibiotics
• A Randomized Trial of Diagnostic Techniques for Ventilator-Associated
Pneumonia N Engl J Med 2006; 355:2619-2630December 21, 2006


66

False negative – False Positive Results
• Investigators reported
that the clinical diagnosis
of VAP is associated 30–
35% false-negative and
20–25% false-positive
results . And also, ICU
patients do not always
have systemic signs of
infection due to their
underlying disease
(chronic renal failure)

67

Other Supporting Bacterial Cultures
• Bacteraemia and positive pleural effusion
cultures are generally considered to be able to
identify the organisms causing the pneumonia,
if no other source of infection is found.
Therefore, most experts recommend that
investigation of suspected VAP should include
taking two sets of blood samples for culture
and tapping pleural > 10 ml, even though
spread to the blood or pleural space occurs
in < 10% of VAP

68

Multiresistant pathogens in Ventilator
associated pneumonias
• The incidence of
multiresistant
pathogens is also
closely linked to local
factors and varies
widely from one
institution to another.
Consequently, each ICU
must continuously
collect meticulous
epidemiologic data

69

Uncommon microbes are often
missed
• Legionella species , anaerobes
fungi viruses, and even
Pneumocystis carinii should be
mentioned as potential causative
agents but are not considered to
be common in the context of
pneumonia acquired during MV.
However, several of these
causative agents may be more
common and potentially
underreported because of
difficulties involved with the
diagnostic


70

Immunological methods in
Diagnosis
• A recently described immunological method
for the diagnosis of VAP holds great promise
for the future. The triggering receptor
expressed on myeloid cells (TREM-1) is a
member of the immunoglobulin super
family, and is involved in the acute
inflammatory response. Neutrophils express
high levels of TREM-1 on exposure to infected
tissues.

71

Newer Methods in Diagnosis
• Gibot and colleagues prospectively studied 148
mechanically ventilated patients with suspected
VAP. A rapid immunoblot technique was used to
measure soluble triggering receptor expressed
on myeloid cells TREM-1 in bronchoalveolar
lavage fluid. They showed that the presence of
soluble TREM-1 in the bronchoalveolar lavage
(BAL) fluid was a highly accurate method for the
diagnosis of fungal or bacterial pneumonia with a
sensitivity of 98% and a specificity of 90%.

72

How much a clinician needs from
Microbiology
• Culture results are currently used to guide
adjustment or withdrawal of antibiotic therapy
rather than to decide whether to treat or not.
The practice of changing therapy with culture
results has resulted in reduced consumption of

antibiotics.
• Conversely, studies have shown that overtreatment with antibiotics may select organisms
such as Pseudomonas aeruginosaand

Acinetobacter calcoaceticus

73

Evidence-based early and
appropriate therapy in VAP
Mortality

Inappropriate

Mortality

Appropriate

Mortality

Early

Mortality


74

Benchmarking prescribing practice
• Triggers to starting antibiotics
– Regular sampling versus clinician guided
– Timing in relation to investigation

• Choice of antibiotic regimen
– Early empiric broad-spectrum cover versus narrow
spectrum with escalation

• De-escalation practice
• Duration of prescription

75

Best option in choosing Antibiotics
• Considerations in making selection
–
–
–
–

Setting (community, NH, hospital)
Suspected organism (GNRs, GPCs)
Host factors (immunosuppression)
Local susceptibility patterns

• Initial empiric and broad; subsequent narrowing

–Concept is to not miss the organism
with initial coverage and then deescalate when able to do it.

76

Continuous Removal of Subglottic
Secretions


Use an ET tube
with continuous
suction through
a dorsal lumen
above the cuff
to prevent
drainage
accumulation


77

No uniformity in treatment schedules
• However, despite these
advances, the majority
of issues related to the
management of VAP
remain unresolved and
are subject to
controversy. This is
particularly true for the
diagnostic evaluation of
the patient with
suspected VAP.

78

Clinical diagnosis of ventilator-associated
pneumonia
What is not controversial?
• Clinical criteria for the diagnosis of VAP
have a limited diagnostic accuracy.
• This is true for single criteria such as infiltrates
in chest radiograph, fever or
hypothermia, leukocytosis or
leucopoenia, and increase in the amount
and/or purulence of tracheobronchial
secretions, as well as for diagnostic rules
incorporating some of these criteria.

79

Handwashing
What role does handwashing play in
nosocomial pneumonias?
The greatest role


80

VAP Prevention
• Wash hands before
and after
suctioning,
touching ventilator
equipment, and/or
coming into
contact with
respiratory
secretions.


81

Epidemiological data differs from
situations
• The incidence of
multiresistant
pathogens is also
closely linked to local
factors and varies
widely from one
institution to another.
Consequently, each ICU
must continuously
collect meticulous
epidemiologic data

82

Can we deliver a successful
Treatment
• Successful treatment of patients with VAP
remains a difficult and complex undertaking.
Despite broad clinical experience with this
disease, no consensus has been reached
concerning issues as basic as the optimal
antimicrobial regimen or its duration. In
fact, to date, evaluation of various
antimicrobial strategies for the treatment of
bacterial VAP has been difficult for several
reasons.

83

Supporting Evidences
• Consequently, most
experts recommend that
two sets of blood cultures
and a thoracentesis for
nonloculated pleural
effusions of ≥10 mm in
diameter on a lateral
decubitus chest
radiograph should be part
of the evaluation of
suspected VAP

84

Handwashing
• Hand washing is the single most
important (and easiest!!!) method for
reducing the transmission of pathogens.
• Use of waterless antiseptic
preparations is also acceptable and may
increase compliance.


85

Oral Care
• Dental plaque contains multiple pathogens
(may include s. aureus and p. aeruginosa)
• After 48 hours, normal oral flora of critically
ill pts changes to more virulent gram (-)
organisms
• Aspiration of oral secretions around the cuff
and ETT occurs in all vented patients
• VAP rates are reduced when oral care
measures are included in a comprehensive
prevention program

86

Probiotics in VAP
• Probiotics prophylaxis of
VAP using Lactobacillus
rhamnosus GG appears safe
and efficacious in a select
population with a very high
risk of
VAP, "Ultimately, probiotics
may fulfil a role in
antimicrobial stewardship
programs given the
reductions in antibiotic
consumption.
• American Journal of Respiratory
and Critical Care Medicine.


87

Patient examination in the Intensive
Care Unit

• MORE IS
MISSED BY
NOT LOOKING
• THAN BY NOT
KNOWING

88

Interdisciplinary rivalry increases
Mortality
• VAP is an excellent
example of a problem
that can best be solved
by interdisciplinary
cooperation rather than
interdisciplinary rivalry
and devaluing the
contributions of
selected members of
the health care team.

89

"Million Lives Campaign”
• "Million Lives Campaign" and included use of
a ventilator bundle of interventions,
developed and implemented the Institute for
Healthcare Improvement (IHI IHI Institute for
Healthcare Improvement (Boston, MA, USA)

..... (http://www.ihi.org/IHI/Topics/


90

Medical Profession is Changing from
Confidence to Confusion ?


91

References
•
•
•
•
•
•
•
•

•
•

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Cutler C> et al. Improving oral care in patients receiving mechanical ventilation. Am J Crit Care 2005; 14(5):
389-394.
Grap M. et al. Preventing VAP: evidence-based care 2004; 16: 349-458.
Keenan S. et al. VAP: prevention, diagnosis, and therapy. Crit Care Clin 2002; 18(1): 107-125.
Kollef M. Prevention of hospital associated and ventilator associated pneumonia. Crit Care Med 2002; 32:
1396-1405.
Marik, P. et al. One good turn deserves another. Crit Care Med 2002; 30(9): 2146-2148.
Anesthesiology: Pneumatikos, Ioannis A. M.D., Ph.D., F.C.C.P.; Dragoumanis, Christos K. M.D., Ph.D.;
Bouros, Demosthenes E. M.D., Ph.D., F.C.C.P. March 2009 - Volume 110 - Issue 3 - pp 673-680
Centers for Disease Control and Prevention, 2003. Rumbak, M. J. (2000). Strategies for prevention and
treatment. Journal of Respiratory Disease, 21 (5), p. 321;
Anesthesiology: Pneumatikos, Ioannis A. M.D., Ph.D., F.C.C.P.; Dragoumanis, Christos K. M.D., Ph.D.;
Bouros, Demosthenes E. M.D., Ph.D., F.C.C.P.vMarch 2009 - Volume 110 - Issue 3 - pp 673-680
Ventilator associated pneumoniaJ D Hunter Correspondence to:  Dr J D Hunter  Department of
Anaesthetics and Intensive Care, Macclesfield District General Hospital, Victoria Road, Macclesfield SK10
3BL, UK; john.hunter@echeshire-tr.nwest.nhs.uk


92

Presented as Guest Lecture at Indian
Association of Medical Microbiologists
(IAMM)- KC held at M.S. Ramaiah Medical
College, Bangalore India on 4th Sept 2010
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