VAP Incidence and Mortality

• Ventilator-associated pneumonia (VAP) is the second most common nosocomial infection in the United States. It is estimated to occur in 9% to 25% of ICU patients.^1-3
• VAP is associated with increasing ICU stays by up to 22 days and hospital stays by up to 25 days.⁴
• Mortality that is directly attributable to VAP is estimated to be as high as 27.1%.⁵

Associated Cost of VAP

• VAP is associated with more than $40,000 in increased hospital costs per patient and may be higher in certain types of patient care units.³
• A study in a shock trauma ICU found that VAP costs $57,000 per occurrence.⁶

Pathogenesis and Risk Factors

• Aspiration of oral and/or gastric secretions is the primary route of bacterial entry into the lungs and is believed to be a primary factor in the development of VAP.
• Each day on mechanical ventilation increases patient risk for VAP by 1% to 3%.⁷
• Independent predictors of VAP include burns, trauma, central nervous system disease, respiratory disease, cardiac disease, mechanical ventilation in the previous 24 hours, witnessed aspiration and paralytic agents.⁷

Continuous Aspiration of Subglottic Secretions

• Continuous aspiration of subglottic secretions (CASS) removes oral and/or gastric secretions from above the endotracheal tube cuff before they can be aspirated. CASS must be done with a specialized endotracheal tube with a separate dorsal suction lumen.
• Five randomized, controlled studies examined the efficacy of CASS in reducing VAP. Their findings are summarized in the chart below.

Outcome Improvements with CASS

• A meta-analysis of the five studies found that, in patients expected to be ventilated >72 hours, continuous aspiration of subglottic secretions:
  • Reduced the risk of ventilator-associated pneumonia by nearly half
  • Reduced ICU length of stay by 3 days
  • Reduced duration of mechanical ventilation by 2 days
  • Delayed the onset of VAP by 6.9 days¹³

Guidelines and Recommendations

• Based on the available evidence, the following organizations recommend use of CASS to reduce the incidence of ventilator-associated pneumonia:
  • American Thoracic Society/ Infectious Diseases Society of America (ATS/IDSA) – Level I¹⁴
  • Centers for Disease Control (CDC) – Category II¹⁵
  • American Association of Critical Care Nurses (AACN)¹⁶
  • Agency for Healthcare Research and Quality (AHRQ)¹⁷

References

1. Ibrahim EH, Tracy L, Hill C, et al. The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest. 2001;120:555-561.
2. Craven DE, Steger KA. Nosocomial pneumonia in mechanically ventilated adult patients: epidemiology and prevention in 1996. Semin Respir Infect. 1996;11:32-53.
3. Rello J, Ollendorf DA, et al. Epidemiology and outcomes of ventilator-associated pneumonia in a large US database. Chest. 2002;122:2115-2121.
4. Warren D, Shukla S, Olson M, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Critical Care Medicine. 2003;31:1312-1317.
5. Fagon JY, Chastre J, et al. Nosocomial Pneumonia in Ventilated Patients: A Cohort Study Evaluating Attributable Mortality and Hospital Stay. The American Journal of Medicine. 1993;94:281-288.
6. Cocanour C, Ostrosky-Zeichner L, Peninger M, et al. Cost of a ventilator-associated pneumonia in a shock trauma intensive care unit. Surgical Infections. 2005;6:65-72.
7. Cook D, Walter S, et al. Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Annals of Internal Medicine. 1998;129:433-440.
8. Smulders K, van der Hoeven H, Weers-Pothoff I, Vandenbroucke-Grauls, C. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest. 2002;121:858-862.
9. Bo H, He L, Qu J. Influence of the subglottic secretion drainage on the morbidity of ventilator-associated pneumonia in mechanically ventilated patients [in Chinese]. Zhonghua Jie He He Hu Xi Za Zhi. 2000;23:472–474.
10. Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest. 1999;116:1339-1346.
11. Valles J, Artigas A, Rello J, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Annals of Internal Medicine. 1995;122:179-186.
12. Mahul Ph, Auboyer C, Jospe R, et al. Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Medicine. 1992;18:20-25.
13. Dezfulian C, Shojania K, Collard H, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: A meta-analysis. The American Journal of Medicine. 2005;118:11-18.
14. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and
    Healthcare-associated Pneumonia. American Journal of Respiratory Critical Care Medicine. 2005;171:388-416.
15. Guidelines for Preventing Health-Care-Associated Pneumonia, 2003, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. March 26, 2004/53(RR03);1-36.
16. American Association of Critical Care Nurses. Practice Alert: Ventilator-Associated Pneumonia. 2004.
17. Shojania KG, Duncan BW, McDonald KM, et al. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/ Technology Assessment No. 43 (Prepared by the University of California at San Francisco–Stanford Evidence-based Practice Center under Contract No. 290-97-0013), AHRQ Publication No. 01-E058, Rockville, MD: Agency for Healthcare Research and Quality. July 2001.

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