Pneumonia, ventilator-associated (VAP): Difference between revisions

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=== 1 - Ventilated 48 hrs ===

VAP is an infectious pneumonia in a patient who, as of the day it was identified (“day of event”) had been on mechanical ventilation (MV), either continuously or intermittently for at least 48 hours before onset of infection.

*{{Discussion}} What constitutes intermittent ventilation? If a patient is extubated for part of the time, is this intermittent or do you mean they remain trached or intubated but are intermittently on the ventilator? Please clarify.--[[User:LKolesar|LKolesar]] 07:17, 2018 November 15 (CST)

*The mechanical ventilation must be delivered via an endotracheal tube or tracheostomy.

*Although it is arbitrary, for this purpose we will consider "intermittent ventilation" to mean this: Over the 48 hours prior to the identification of the VAP, that the patient had been on the ventilator, via an ETT or trach, at least twice for periods of at least 1 hour each.

==== Criteria 1 clarifications ====

*If the '''symptoms''' of infection (pneumonia) are evident prior to being on mechanical ventilation for 48 hours, then it is not a VAP, even if the positive ''culture'' is done after the 48 hour mark. {{Discuss | who=Allan |question= Is this about all of the criteria headings, or only some?}}

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=== 3 - CXR indicators ===

Chest imaging (X-ray) study or studies showing '''at least ONE''' of the following 3 things, that must be new & ''persistent'' OR ''progressive and persistent'': (CDC WORDING CHANGE).

*Chest imaging (X-ray) study or studies showing '''at least ONE''' of the following 3 things, that must be new & ''persistent'' OR ''progressive and persistent'': (CDC WORDING CHANGE).

*Infiltrate

**Infiltrate

*Consolidation

**Consolidation

*Cavitation

**Cavitation

*~~{{Discussion}} What is meant by persistent? This is open to interpretation. How many days must they continue to have~~ the ~~CXR evidence~~ of ~~pneumonia to call it~~ persistent~~? Please clarify or define this word. --[[User~~:~~LKolesar|LKolesar]] 07:21, 2018 November 15 (CST)~~

*Regarding the identification of "persistent" here:

~~==== Criteria 3 clarifications====~~

**Because it is well recognized that there are many non-infectious reasons for fleeting infiltrates in intubated ICU patients (e.g. atelectasis), [[#3 - CXR indicators]] requires that the listed changes be either "New and Persistent" or "Progressive and Persistent". This necessarily means that there must be >1 CXR -- preferably over more than 1 day -- showing the "persistence".

*Because it is well recognized that there are many non-infectious reasons for fleeting infiltrates in intubated ICU patients (e.g. atelectasis), [[#3 - CXR indicators]] requires that the listed changes be either "New and Persistent" or "Progressive and Persistent". This necessarily means that there must be >1 CXR -- preferably over more than 1 day -- showing the "persistence".

**Although it is somewhat arbitrary, we will consider chest imaging findings to be "persistent" if they remain similar (i.e. do not disappear, or mostly disappear) in imaging studies done at least 6 hours apart.

**But, of course, ICU patients who are believed to have significant lung pathology, including pneumonia, typically DO have followup CXRs that will allow for identification of persistence of the changes seen.

**In the (relatively rare situation) in which a ventilated patient qualifies for a VAP ''except'' that NO CXR was done during the next couple of days to demonstrate persistence, you could point out to the physician(s) that the CDC criterion require infiltrates be persistent by chest imaging and therefore we would require a followup CXR to confirm the diagnosis. If there is severe resistance to this from the ICU team, you could refer them to Drs. Garland or Paunovic.

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 === 1 - Ventilated 48 hrs ===
 VAP is an infectious pneumonia in a patient  who, as of the day it was identified (“day of event”) had been on mechanical ventilation (MV), either continuously or intermittently for at least 48 hours before onset of infection.
-*{{Discussion}} What constitutes intermittent ventilation?  If a patient is extubated for part of the time, is this intermittent or do you mean they remain trached or intubated but are intermittently on the ventilator? Please clarify.--[[User:LKolesar|LKolesar]] 07:17, 2018 November 15 (CST)
 *The mechanical ventilation must be delivered via an endotracheal tube or tracheostomy.
+*Although it is arbitrary, for this purpose we will consider "intermittent ventilation" to mean this:  Over the 48 hours prior to the identification of the VAP, that the patient had been on the ventilator, via an ETT or trach, at least twice for periods of at least 1 hour each.
 ==== Criteria 1 clarifications ====
 *If the '''symptoms''' of infection (pneumonia) are evident prior to being on mechanical ventilation for 48 hours, then it is not a VAP, even if the positive ''culture'' is done after the 48 hour mark. {{Discuss | who=Allan |question= Is this about all of the criteria headings, or only some?}}
@@ Line 32: / Line 32: @@
 === 3 - CXR indicators ===
-Chest imaging (X-ray) study or studies showing '''at least ONE''' of the following 3 things, that must be new & ''persistent'' OR ''progressive and persistent'': (CDC WORDING CHANGE).
+*Chest imaging (X-ray) study or studies showing '''at least ONE''' of the following 3 things, that must be new & ''persistent'' OR ''progressive and persistent'': (CDC WORDING CHANGE).
-*Infiltrate
+**Infiltrate
-*Consolidation
+**Consolidation
-*Cavitation
+**Cavitation
-*{{Discussion}} What is meant by persistent? This is open to interpretation.  How many days must they continue to have the CXR evidence of pneumonia to call it persistent? Please clarify or define this word. --[[User:LKolesar|LKolesar]] 07:21, 2018 November 15 (CST)
+*Regarding the identification of "persistent" here:
-==== Criteria 3 clarifications====
+**Because it is well recognized that there are many non-infectious reasons for fleeting infiltrates in intubated ICU patients (e.g. atelectasis), [[#3 - CXR indicators]] requires that the listed changes be either "New and Persistent" or "Progressive and Persistent".  This necessarily means that there must be >1 CXR -- preferably over more than 1 day -- showing the "persistence".
-*Because it is well recognized that there are many non-infectious reasons for fleeting infiltrates in intubated ICU patients (e.g. atelectasis), [[#3 - CXR indicators]] requires that the listed changes be either "New and Persistent" or "Progressive and Persistent".  This necessarily means that there must be >1 CXR -- preferably over more than 1 day -- showing the "persistence".
+**Although it is somewhat arbitrary, we will consider chest imaging findings to be "persistent" if they remain similar (i.e. do not disappear, or mostly disappear) in imaging studies done at least 6 hours apart.
 **But, of course, ICU patients who are believed to have significant lung pathology, including pneumonia, typically DO have followup CXRs that will allow for identification of persistence of the changes seen.
 **In the (relatively rare situation) in which a ventilated patient qualifies for a VAP ''except'' that NO CXR was done during the next couple of days to demonstrate persistence, you could point out to the physician(s) that the CDC criterion require infiltrates be persistent by chest imaging and therefore we would require a followup CXR to confirm the diagnosis. If there is severe resistance to this from the ICU team, you could refer them to Drs. Garland or Paunovic.