Transcript Slide 1
Journal Club Journal Club Background to the paper • Pneumonia is THE MOST COMMON nosocomial infection in ICU patients • 12 to 18 cases per 1000 ventilator days • Oropharyngeal colonisation • Aspiration of oropharyngeal bugs! Outcomes Primary outcome • Frequency of suspected pneumonia in a semirecumbent & supine posture. Secondary outcome • Compare frequency of microbiol confirmed pneumonia in the 2 groups. Methods • • • • • Recruited for 1 year 1000 bed tertiary hospital Stress ulcer prophylaxis Continous enteral feeding Gastric aspiration every 4 hours Methods II Exclusions • Recent abdo surgery in last 7 days • Neurosurgery in last 7 days • Refractory shock • Previous endotracheal intubation in last 30 days Methods III • Random allocation to 0 deg or 45 deg head up • Computer generated randomization list • • • • • Clin suspicion defined: new infiltrates on CXR Fever > 38.3 WCC <4 or >12. Purulent tracheal secretions Pathogenic organism in BAL PSB VAP: Why is it Important? • VAP occurs in 10-25% of patients undergoing mechanical ventilation (4-16 cases/1000 ventilator days • Patients stay in ICU on average 4-9 more days • Attributable mortality 20-50% • High morbidity and mortality • Preventable with simple technology Trial profile Baseline data Micro data Pneumonia results Major Results HOB Elevation Leads to Significant Deduction in VAP 25 % VAP 20 15 10 5 0 Dravulovic et al. Lancet 1999;354:1851-1858 Supine Ventilator Associated Pneumonia (VAP) Practice Alert 13 HOB Elevation Results • 86 mechanically ventilated patients randomized to either supine (flat) vs semi-recumbent (45 degrees) to assess relationship to nosocomial pneumonia • Trial stopped early • Clinically suspected pneumonia decreased from 34% to 8% (p=0.003) in semi-recumbent group • Microbiologically confirmed pneumonia was reduced from 23% to 5% in the semi-recumbent group (p=0.018) • The semi-recumbent body position reduces frequency and risk of pneumonia. • The risk of pneumonia increased with longer duration of mechanical ventilation and with decreased consciousness. Continuous Removal of Subglottic Secretions Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation. CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005 Ventilator Associated Pneumonia (VAP) Practice Alert 16 HOB Elevation • Torres et al, Annals of Int Med 1992;116:540-543 • Ibanez et al. JPEN 1992;16:419-422 • Orozco-Levi et al. Am J Respir Crit Care Med 1995;152:1387-1390 • Drakulovic et al. Lancet 1999;354:1851-1858 • Davis et al. Crit Care 2001;5:81-87 • Grap et al. Am J of Crit Care 2005 14:325-332 HOB at 30-45º Ventilator Associated Pneumonia (VAP) Practice Alert 17 Is HOB Elevation Done? • Grap et al. Am J Crit Care 1999;8:475-480 • Grap et al. Am J Crit Care 2005;14:325-332 60 Degrees of HOB Elevation % with HOB Elevation Despite effectiveness of HOB elevation, compliance is poor. 40 20 0 to 20 21 to 30 31 to 40 > 40 0 Ventilator Associated Pneumonia (VAP) Practice Alert 18