MUDr.Pavel Štětka

ARK FN U sv.Anny Brno

� Definice� Etiologie ,bakteriologické a histologické

aspekty� incidence� Klinická diagnoza � Preventivní opatření� Závěr.

Johanson et al. in 1972� 1.nově vzniklý infiltrát na rtg, � 2.TT nad 38,3stC,� 3.leukocytoza � 4. purulentní tracheální aspirát

� ovšem NESPECIFICKÉCultures of tracheal aspirates are not very useful in

establishing the cause of VAP . Although such cultures are highly sensitive, their specificity is low even when they are cultured quantitatively

� five RCTs (1367 patientsfive RCTs (1367 patientsfive RCTs (1367 patientsfive RCTs (1367 patients) AUTHORS' ) AUTHORS' ) AUTHORS' ) AUTHORS' CONCLUSIONS: There is no evidence that the use CONCLUSIONS: There is no evidence that the use CONCLUSIONS: There is no evidence that the use CONCLUSIONS: There is no evidence that the use of quantitative cultures of respiratory secretions of quantitative cultures of respiratory secretions of quantitative cultures of respiratory secretions of quantitative cultures of respiratory secretions results in reduced mortality, reduced time in ICU results in reduced mortality, reduced time in ICU results in reduced mortality, reduced time in ICU results in reduced mortality, reduced time in ICU and on mechanical ventilation, or higher rates of and on mechanical ventilation, or higher rates of and on mechanical ventilation, or higher rates of and on mechanical ventilation, or higher rates of antibiotic change when compared to qualitative antibiotic change when compared to qualitative antibiotic change when compared to qualitative antibiotic change when compared to qualitative cultures in patients with VAP. Similar results were cultures in patients with VAP. Similar results were cultures in patients with VAP. Similar results were cultures in patients with VAP. Similar results were observed when invasive strategies were compared observed when invasive strategies were compared observed when invasive strategies were compared observed when invasive strategies were compared with nonwith nonwith nonwith non----invasive strategies.invasive strategies.invasive strategies.invasive strategies.

� VAP přesná dg. –tato kritéria jsou ovšem založená na invazívních procedurách n neobvyklých klin.manifestacích n.komplikacích VAP ####histopathologické vyš. vzorku plicní tkáněz otevřené plicní biopsie #### rychlá kavitace plicního infiltrátu při absenci tumoru n.tbc #### positivní kultivace pleuralní tekutiny ####průkaz stejné bakterie se shod.antibiogramem isolované z krve a sekretu resp.traktu bez jiného zjistitelného zdroje bakteriémie#### histopathologické vyš.plicní tkáně získáné při pitvě

� #### early-onset VAP (pneumonia od 2 do 5 dne po intubaci-STPN,STAU, HAEIN

� #### late-onset VAP – po 5 až 7 dni GNB, Enterobacteriacea, MRSA, event.CAALB

� VAPVAPVAPVAP VentilatorVentilatorVentilatorVentilator----associated pneumonia (VAP) je nejassociated pneumonia (VAP) je nejassociated pneumonia (VAP) je nejassociated pneumonia (VAP) je nejččččastastastastěěěějjjjšíšíšíšínosokominosokominosokominosokomiáááálnlnlnlníííí infekcinfekcinfekcinfekcíííí na ICUna ICUna ICUna ICU

� Incidence 10Incidence 10Incidence 10Incidence 10----40% 40% 40% 40% � ZdvojnZdvojnZdvojnZdvojnáááásobuje mortalitu pacientsobuje mortalitu pacientsobuje mortalitu pacientsobuje mortalitu pacientůůůů na ICU na ICU na ICU na ICU � ProdluProdluProdluProdlužžžžuje dobu hospitalizaceuje dobu hospitalizaceuje dobu hospitalizaceuje dobu hospitalizace´́́́LOStj.loenght of stayLOStj.loenght of stayLOStj.loenght of stayLOStj.loenght of stay (>6 days)(>6 days)(>6 days)(>6 days)� ZvyZvyZvyZvyššššuje nuje nuje nuje nááááklady (>$10000 per episode) klady (>$10000 per episode) klady (>$10000 per episode) klady (>$10000 per episode) � Safdar N, Dezfulian C, Collard HR, Saint S.Clinical and

economic consequences of ventilator-associated pneumonia: a systematic review.Crit Care Med. 2005 Oct;33(10):2184-93.

� Shorr AF, Wunderink RG. Dollars and sense in the intensive care unit: the costs of ventilator-associated pneumonia.Crit Care Med. 2003 May;31(5):1582-3.

� 1- kolonizace sekretu horních cest dýchacích-podíl regurgitace žal.obsahu do hypofaryngu

� 2-mikroaspirace podél manžety intubačníkanyly

� 3- překonání obranných mechanismůrespiračního traktu

� #### Methany et al.,CCM 2006 Apr.1007-1015 ::Tracheobronchial aspiration of gastric contents in critt.ill tube-fed patients

� #### Pepsin jako marker –6000vzorků—89%poz.!!!!!

DIGESTIVE TRACTDIGESTIVE TRACTDIGESTIVE TRACTDIGESTIVE TRACT INTERNAL ORGANSINTERNAL ORGANSINTERNAL ORGANSINTERNAL ORGANS

ACQUISITIONACQUISITIONACQUISITIONACQUISITION

CARRIAGECARRIAGECARRIAGECARRIAGE

OVERGROWTHOVERGROWTHOVERGROWTHOVERGROWTH>>>>10na5/g10na5/g10na5/g10na5/g

COLONIZATIONCOLONIZATIONCOLONIZATIONCOLONIZATION

INFECTIONINFECTIONINFECTIONINFECTION

SURVEILLANCE SAMPLESSURVEILLANCE SAMPLESSURVEILLANCE SAMPLESSURVEILLANCE SAMPLES DIAGNOSTIC SAMPLESDIAGNOSTIC SAMPLESDIAGNOSTIC SAMPLESDIAGNOSTIC SAMPLESLOWER AIRWAY,BLOOD,BLADDERLOWER AIRWAY,BLOOD,BLADDERLOWER AIRWAY,BLOOD,BLADDERLOWER AIRWAY,BLOOD,BLADDER

A.NORMA.NORMA.NORMA.NORMÁÁÁÁLNLNLNLNÍÍÍÍ

STRPNEU/oroSTRPNEU/oroSTRPNEU/oroSTRPNEU/oro

HAE INFL/oroHAE INFL/oroHAE INFL/oroHAE INFL/oro

MOR CAT/oroMOR CAT/oroMOR CAT/oroMOR CAT/oro

E COLI/gutE COLI/gutE COLI/gutE COLI/gut

STAU/gut i oroSTAU/gut i oroSTAU/gut i oroSTAU/gut i oro

CAALBI/gut i oroCAALBI/gut i oroCAALBI/gut i oroCAALBI/gut i oro

B.ABNORMB.ABNORMB.ABNORMB.ABNORMÁÁÁÁLNLNLNLNÍÍÍÍ

KLEBSKLEBSKLEBSKLEBS

PROTEUSPROTEUSPROTEUSPROTEUS

ENTEROBAENTEROBAENTEROBAENTEROBA

MORG SPMORG SPMORG SPMORG SP

CITROCITROCITROCITRO

SERRASERRASERRASERRA

PSEUPSEUPSEUPSEU

ACINETACINETACINETACINET

MRSAMRSAMRSAMRSA

� # # # # pravidelná edukace personálu

� # # # # mít protokol prevence VAP

� # # # # pravidelná surveillance VAP –út + čt

� # # # # přísná hygiena rukou a izolace infekčních pacientů

� # # # # NIV místo UPV přes OTK-Girou et al.,Association of NIV with nosocomial infections and survival in critt.ill patients,JAMA 2000

� # # # # OTI místo NTI

� # # # # weaning + sedation protokol tj. redukce ventilator-days

� # # # # uzavřený vs. otevotevotevotevřřřřený systený systený systený systéééém odsm odsm odsm odsáááávvvváááánnnníííí -CLOSED TRACHEAL SUCTION SYSTEMS FOR PREVENTION CLOSED TRACHEAL SUCTION SYSTEMS FOR PREVENTION CLOSED TRACHEAL SUCTION SYSTEMS FOR PREVENTION CLOSED TRACHEAL SUCTION SYSTEMS FOR PREVENTION OF VAP Siempos II, Alfa Institute of Biomedical Sciences, OF VAP Siempos II, Alfa Institute of Biomedical Sciences, OF VAP Siempos II, Alfa Institute of Biomedical Sciences, OF VAP Siempos II, Alfa Institute of Biomedical Sciences,

Athens, Greece, Br J Anaesth. 2008 Mar;100(3):299Athens, Greece, Br J Anaesth. 2008 Mar;100(3):299Athens, Greece, Br J Anaesth. 2008 Mar;100(3):299Athens, Greece, Br J Anaesth. 2008 Mar;100(3):299----306306306306

� a metaa metaa metaa meta----analysis of randomized controlled trials (RCTs). Nine analysis of randomized controlled trials (RCTs). Nine analysis of randomized controlled trials (RCTs). Nine analysis of randomized controlled trials (RCTs). Nine RCTs were included in the metaRCTs were included in the metaRCTs were included in the metaRCTs were included in the meta----analysis. There was no analysis. There was no analysis. There was no analysis. There was no difference in the incidence of VAP between patients managed difference in the incidence of VAP between patients managed difference in the incidence of VAP between patients managed difference in the incidence of VAP between patients managed with closed and open TSS [odds ratio (OR)=0.96, 95% with closed and open TSS [odds ratio (OR)=0.96, 95% with closed and open TSS [odds ratio (OR)=0.96, 95% with closed and open TSS [odds ratio (OR)=0.96, 95% confidence intervals (CI) 0.72confidence intervals (CI) 0.72confidence intervals (CI) 0.72confidence intervals (CI) 0.72----1.28].1.28].1.28].1.28].

� . Suctioning with closed systems was associated with . Suctioning with closed systems was associated with . Suctioning with closed systems was associated with . Suctioning with closed systems was associated with LONGER LONGER LONGER LONGER MV DURATIONMV DURATIONMV DURATIONMV DURATION (weighted mean differences: 0.65 days, 95% CI (weighted mean differences: 0.65 days, 95% CI (weighted mean differences: 0.65 days, 95% CI (weighted mean differences: 0.65 days, 95% CI 0.280.280.280.28----1.03) and 1.03) and 1.03) and 1.03) and HIGHER COLONIZATION OF THE RESPIRATORY HIGHER COLONIZATION OF THE RESPIRATORY HIGHER COLONIZATION OF THE RESPIRATORY HIGHER COLONIZATION OF THE RESPIRATORY TRACTTRACTTRACTTRACT (OR=2.88, 95% CI 1.50(OR=2.88, 95% CI 1.50(OR=2.88, 95% CI 1.50(OR=2.88, 95% CI 1.50----5.52) than open TSS. The 5.52) than open TSS. The 5.52) than open TSS. The 5.52) than open TSS. The available evidence suggests that closed as opposed to open available evidence suggests that closed as opposed to open available evidence suggests that closed as opposed to open available evidence suggests that closed as opposed to open TSS usage TSS usage TSS usage TSS usage DID NOT PROVIDE ANY BENEFIT ON VAP INCIDENCE, DID NOT PROVIDE ANY BENEFIT ON VAP INCIDENCE, DID NOT PROVIDE ANY BENEFIT ON VAP INCIDENCE, DID NOT PROVIDE ANY BENEFIT ON VAP INCIDENCE, MORTALITY, OR ICU STAY OF MV PATIENTS.MORTALITY, OR ICU STAY OF MV PATIENTS.MORTALITY, OR ICU STAY OF MV PATIENTS.MORTALITY, OR ICU STAY OF MV PATIENTS.

� # # # # otk polyurethanová manžeta redukujícímikroaspirace ,která normálně až v 9/10 případů

� Influence of an endotracheal tube with polyurethane cuff and subglottic secret drainage on pneumonia Lorente l, . am j respir crit care med. 2007 dec 1;176:1079-83

� to compare the incidence of VAP, using an endotracheal tube with polyurethane cuff and subglottic secretion drainage (ett-puc-ssd) versus a conventional endotracheal tube (ett-c) with polyvinyl cuff, without subglottic secretion drainage.

� METHODS: Clinical randomized trial in a 24-bed medical-surgical intensive care unit. Patients expected to require mechanical ventilation for more than 24 hours were randomly assigned to one of two groups: one was ventilated with ETT-PUC-SSD and the other with ETT-C.

� RESULTS: Tracheal aspirate samples were obtained during endotracheal intubation, then twice per week and finally on extubation. VAP was found in 31 of 140 (22.1%) 22.1%) 22.1%) 22.1%) patients in the ETT-C group and in 11 of 140 (7.9%)7.9%)7.9%)7.9%) in the ETT-PUC-SSD group (P = 0.001)

� CONCLUSIONS: The use of an endotracheal tube with polyurethane cuff and subglottic secretion drainage helps prevent earlyprevent earlyprevent earlyprevent early---- and lateand lateand lateand late----onset VAP. onset VAP. onset VAP. onset VAP.

��Oblast bez zOblast bez zááhybhybůů ((TTěěsnsnííccíízzóónana))mimořádné utěsněníbez záhybů a kanálků > posílené těsnící schopnosti

�Ultra-tenká manžeta (< 15 mikronů) eliminuje kapilárnísíly

�Tvar manžety zajišťuje optimální utěsnění pro téměř všechny typy a rozměry trachey

Stěna trachey

Záhyby manžety

� Cardiac surgery patients are at risk for postoperative Cardiac surgery patients are at risk for postoperative Cardiac surgery patients are at risk for postoperative Cardiac surgery patients are at risk for postoperative pneumonia.pneumonia.pneumonia.pneumonia. PeriPeriPeriPeri----operative microoperative microoperative microoperative micro----aspiration of aspiration of aspiration of aspiration of oropharyngeal contentoropharyngeal contentoropharyngeal contentoropharyngeal content is a possible cause of the is a possible cause of the is a possible cause of the is a possible cause of the pathofysiology of postoperative pneumonia.pathofysiology of postoperative pneumonia.pathofysiology of postoperative pneumonia.pathofysiology of postoperative pneumonia. We speculated We speculated We speculated We speculated that the use of a polythat the use of a polythat the use of a polythat the use of a poly----urethane cuffed endotracheal tube urethane cuffed endotracheal tube urethane cuffed endotracheal tube urethane cuffed endotracheal tube (PUC ETT) (Seal(PUC ETT) (Seal(PUC ETT) (Seal(PUC ETT) (Seal----GuardGuardGuardGuard®®®®) could be protective due to ) could be protective due to ) could be protective due to ) could be protective due to enhanced sealing of the pharyngotracheal barrier.enhanced sealing of the pharyngotracheal barrier.enhanced sealing of the pharyngotracheal barrier.enhanced sealing of the pharyngotracheal barrier.

� Results Results Results Results 59 patients were included,59 patients were included,59 patients were included,59 patients were included, 30 patients received 30 patients received 30 patients received 30 patients received polypolypolypoly----urethane cuffed ETT,urethane cuffed ETT,urethane cuffed ETT,urethane cuffed ETT, patients received conventional patients received conventional patients received conventional patients received conventional PVC ETT,PVC ETT,PVC ETT,PVC ETT,

� Conclusions: Use of a polyConclusions: Use of a polyConclusions: Use of a polyConclusions: Use of a poly----urethane cuffed ETT was urethane cuffed ETT was urethane cuffed ETT was urethane cuffed ETT was associated associated associated associated with a lower rate of early postoperative with a lower rate of early postoperative with a lower rate of early postoperative with a lower rate of early postoperative pneumonia in cardiac surgery patientspneumonia in cardiac surgery patientspneumonia in cardiac surgery patientspneumonia in cardiac surgery patients

� # # # # Subglotická drenáž =odsávání nad balónkem, frekvence kolikrát denně ?

� Cameron Dezfulian, MD-Subglottic secretion drainage for preventing VAP: a meta-analysis—AmJMed 2005- snížení early-onset VAP, LOS 3 dny, UPV 2 dny

� # # # # udržování stálého tlaku v manžetě otk dnes i speciální přístroje

� # # # # neprovádět pravidelnou výměnu okruhu ventilátoru u jednoho pacienta!! ale nynínedělat vůbec

� # # # # HME místo aktivního zvlhčování ? neprokázán rozdíl, výměna až po 72 hodinách , určitá skupina až týden

� ¨̈̈̈RESULTS: Thirteen randomized controlled trials, RESULTS: Thirteen randomized controlled trials, RESULTS: Thirteen randomized controlled trials, RESULTS: Thirteen randomized controlled trials, studying studying studying studying 2,580 patients2,580 patients2,580 patients2,580 patients, were included. , were included. , were included. , were included. HMEs HMEs HMEs HMEs were cheaperwere cheaperwere cheaperwere cheaper than HHs in each of the randomized than HHs in each of the randomized than HHs in each of the randomized than HHs in each of the randomized controlled trials. controlled trials. controlled trials. controlled trials.

� CONCLUSION: The available evidence CONCLUSION: The available evidence CONCLUSION: The available evidence CONCLUSION: The available evidence does not does not does not does not support the preferential performancesupport the preferential performancesupport the preferential performancesupport the preferential performance of either of either of either of either passive or active humidifiers in mechanical passive or active humidifiers in mechanical passive or active humidifiers in mechanical passive or active humidifiers in mechanical ventilation patients in terms of ventilatorventilation patients in terms of ventilatorventilation patients in terms of ventilatorventilation patients in terms of ventilator----associated pneumonia incidence, mortality, or associated pneumonia incidence, mortality, or associated pneumonia incidence, mortality, or associated pneumonia incidence, mortality, or morbiditymorbiditymorbiditymorbidity

� CONCLUSION: CONCLUSION: CONCLUSION: CONCLUSION: The LoTrach system The LoTrach system The LoTrach system The LoTrach system has been designed to has been designed to has been designed to has been designed to facilitate the provision of a number of evidencefacilitate the provision of a number of evidencefacilitate the provision of a number of evidencefacilitate the provision of a number of evidence----based based based based interventions that have been shown to reduce VAP. Pulmonary interventions that have been shown to reduce VAP. Pulmonary interventions that have been shown to reduce VAP. Pulmonary interventions that have been shown to reduce VAP. Pulmonary aspiration is ubiquitous with conventional cuffs but prevented aspiration is ubiquitous with conventional cuffs but prevented aspiration is ubiquitous with conventional cuffs but prevented aspiration is ubiquitous with conventional cuffs but prevented by the cuff of the LoTrach system when held at a constant and by the cuff of the LoTrach system when held at a constant and by the cuff of the LoTrach system when held at a constant and by the cuff of the LoTrach system when held at a constant and safe pressure against the tracheal wall with a cuff pressure safe pressure against the tracheal wall with a cuff pressure safe pressure against the tracheal wall with a cuff pressure safe pressure against the tracheal wall with a cuff pressure controller. Other aspects incorporated in the ETT are aimed at controller. Other aspects incorporated in the ETT are aimed at controller. Other aspects incorporated in the ETT are aimed at controller. Other aspects incorporated in the ETT are aimed at clearing the secretions from the subglottic space, preventing clearing the secretions from the subglottic space, preventing clearing the secretions from the subglottic space, preventing clearing the secretions from the subglottic space, preventing tube occlusion and accidental extubation, and avoiding tube occlusion and accidental extubation, and avoiding tube occlusion and accidental extubation, and avoiding tube occlusion and accidental extubation, and avoiding damage to the airway. damage to the airway. damage to the airway. damage to the airway.

� In this way the LoTrach system employs a multifactorial In this way the LoTrach system employs a multifactorial In this way the LoTrach system employs a multifactorial In this way the LoTrach system employs a multifactorial approach to the prevention of VAP and the cost savings from approach to the prevention of VAP and the cost savings from approach to the prevention of VAP and the cost savings from approach to the prevention of VAP and the cost savings from LoTrach rather than a standard ETT will be considerable LoTrach rather than a standard ETT will be considerable LoTrach rather than a standard ETT will be considerable LoTrach rather than a standard ETT will be considerable because of an average because of an average because of an average because of an average 3 day reduction in ICU length of stay 3 day reduction in ICU length of stay 3 day reduction in ICU length of stay 3 day reduction in ICU length of stay related to this.related to this.related to this.related to this. It thus has the potential to be a very useful tool It thus has the potential to be a very useful tool It thus has the potential to be a very useful tool It thus has the potential to be a very useful tool in the ICU setting in the prevention of VAP.in the ICU setting in the prevention of VAP.in the ICU setting in the prevention of VAP.in the ICU setting in the prevention of VAP.

� Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in ICU-Outcomera study group.Anaesthesiology 2002,Jul,148-56

� Res. 8%8%8%8% incidence

� Relative risk of VAP 5,35,35,35,3

� # # # # OrofaryngeOrofaryngeOrofaryngeOrofaryngeáááálnlnlnlníííí dekontaminace chlorhexidinemdekontaminace chlorhexidinemdekontaminace chlorhexidinemdekontaminace chlorhexidinem� SYSTEMATIC LITERATURE REVIEW OF ORAL HYGIENE PRACTICES FOR SYSTEMATIC LITERATURE REVIEW OF ORAL HYGIENE PRACTICES FOR SYSTEMATIC LITERATURE REVIEW OF ORAL HYGIENE PRACTICES FOR SYSTEMATIC LITERATURE REVIEW OF ORAL HYGIENE PRACTICES FOR

INTENSIVE CARE PATIENTS RECEIVING MEC VEN Berry AM, Am J Crit INTENSIVE CARE PATIENTS RECEIVING MEC VEN Berry AM, Am J Crit INTENSIVE CARE PATIENTS RECEIVING MEC VEN Berry AM, Am J Crit INTENSIVE CARE PATIENTS RECEIVING MEC VEN Berry AM, Am J Crit

Care. 2007 Nov;16(6):552Care. 2007 Nov;16(6):552Care. 2007 Nov;16(6):552Care. 2007 Nov;16(6):552----62; quiz 563.62; quiz 563.62; quiz 563.62; quiz 563.

� BACKGROUND: Oropharyngeal colonization with pathogenic organisms contributes to the development of ventilator-associated pneumonia in intensive care units. Although considered basic and potentially nonessential nursing care, oral hygiene has been proposed as a key intervention for reducing ventilator-associated pneumonia. Nevertheless, evidence from randomized controlled trials that could inform best practice is limited.

� METHODS: Articles published from 1985 to 2006� RESULTS: The search yielded 55 articles: 11

prospective controlled trials, 20 observational studies, and 24 descriptive reports.

� CONCLUSIONS: Despite the importance of providing oral hygiene to intensive care patients receiving mechanical ventilation, highhighhighhigh----level evidence level evidence level evidence level evidence from rigorous randomized controlled trials or high-quality systematic reviews that could inform clinical practice is scarce. is scarce. is scarce. is scarce.

� The one intervention not included in the IHI bundle is The one intervention not included in the IHI bundle is The one intervention not included in the IHI bundle is The one intervention not included in the IHI bundle is oral hygieneoral hygieneoral hygieneoral hygiene.... The The The The purpose of this project is to support the premise that oral carepurpose of this project is to support the premise that oral carepurpose of this project is to support the premise that oral carepurpose of this project is to support the premise that oral care, including , including , including , including timed toothbrushingtimed toothbrushingtimed toothbrushingtimed toothbrushing, combined with the VAP bundle can mitigate and , combined with the VAP bundle can mitigate and , combined with the VAP bundle can mitigate and , combined with the VAP bundle can mitigate and prevent the occurrence of VAP. prevent the occurrence of VAP. prevent the occurrence of VAP. prevent the occurrence of VAP.

� mechanically ventilated patients on a 24mechanically ventilated patients on a 24mechanically ventilated patients on a 24mechanically ventilated patients on a 24----bed stroke, neurologic, and bed stroke, neurologic, and bed stroke, neurologic, and bed stroke, neurologic, and medical ICU. medical ICU. medical ICU. medical ICU.

� Patients were randomized into a control group that performed usuPatients were randomized into a control group that performed usuPatients were randomized into a control group that performed usuPatients were randomized into a control group that performed usual oral al oral al oral al oral care or an intervention group that care or an intervention group that care or an intervention group that care or an intervention group that brushed teeth every 8 hours. brushed teeth every 8 hours. brushed teeth every 8 hours. brushed teeth every 8 hours.

� The results were immediate and startling, as the VAP rate droppeThe results were immediate and startling, as the VAP rate droppeThe results were immediate and startling, as the VAP rate droppeThe results were immediate and startling, as the VAP rate dropped to zero d to zero d to zero d to zero within a week of beginning the everywithin a week of beginning the everywithin a week of beginning the everywithin a week of beginning the every----8888----hours toothbrushing regimen in hours toothbrushing regimen in hours toothbrushing regimen in hours toothbrushing regimen in the intervention group. The study was so successful that the conthe intervention group. The study was so successful that the conthe intervention group. The study was so successful that the conthe intervention group. The study was so successful that the control group trol group trol group trol group was dropped after 6 months, and all intubated patients' teeth wewas dropped after 6 months, and all intubated patients' teeth wewas dropped after 6 months, and all intubated patients' teeth wewas dropped after 6 months, and all intubated patients' teeth were re re re brushed every 8 hours, maintaining the zero rate until the end obrushed every 8 hours, maintaining the zero rate until the end obrushed every 8 hours, maintaining the zero rate until the end obrushed every 8 hours, maintaining the zero rate until the end of the f the f the f the study.study.study.study.

� The patients were randomized to receive oral decontamination witThe patients were randomized to receive oral decontamination witThe patients were randomized to receive oral decontamination witThe patients were randomized to receive oral decontamination with 2% h 2% h 2% h 2% chlorhexidine solution or normal saline solution chlorhexidine solution or normal saline solution chlorhexidine solution or normal saline solution chlorhexidine solution or normal saline solution 4 times per day4 times per day4 times per day4 times per day until their until their until their until their endotracheal tubes were removed. The outcome measures were the dendotracheal tubes were removed. The outcome measures were the dendotracheal tubes were removed. The outcome measures were the dendotracheal tubes were removed. The outcome measures were the development of evelopment of evelopment of evelopment of VAP and oropharyngeal colonization with gramVAP and oropharyngeal colonization with gramVAP and oropharyngeal colonization with gramVAP and oropharyngeal colonization with gram----negative bacilli. negative bacilli. negative bacilli. negative bacilli. MetaMetaMetaMeta----analysisanalysisanalysisanalysis was was was was performed by combining the results of the present study with thoperformed by combining the results of the present study with thoperformed by combining the results of the present study with thoperformed by combining the results of the present study with those from another se from another se from another se from another randomized controlled trial that also used a 2% chlorhexidine forandomized controlled trial that also used a 2% chlorhexidine forandomized controlled trial that also used a 2% chlorhexidine forandomized controlled trial that also used a 2% chlorhexidine formulation for oral rmulation for oral rmulation for oral rmulation for oral decontamination. decontamination. decontamination. decontamination.

� RESULTS: The characteristics of the patients in the chlorhexidinRESULTS: The characteristics of the patients in the chlorhexidinRESULTS: The characteristics of the patients in the chlorhexidinRESULTS: The characteristics of the patients in the chlorhexidine group and the e group and the e group and the e group and the normal saline group were not significantly different. The incidenormal saline group were not significantly different. The incidenormal saline group were not significantly different. The incidenormal saline group were not significantly different. The incidence of VAP in the nce of VAP in the nce of VAP in the nce of VAP in the chlorhexidine group was 4.9%chlorhexidine group was 4.9%chlorhexidine group was 4.9%chlorhexidine group was 4.9% (5 of 102), and the incidence in (5 of 102), and the incidence in (5 of 102), and the incidence in (5 of 102), and the incidence in the normal the normal the normal the normal saline group was 11.4%saline group was 11.4%saline group was 11.4%saline group was 11.4% (12 of 105). The rate of VAP in the chlorhexidine group (12 of 105). The rate of VAP in the chlorhexidine group (12 of 105). The rate of VAP in the chlorhexidine group (12 of 105). The rate of VAP in the chlorhexidine group was 7 episodes per 1,000 ventilatorwas 7 episodes per 1,000 ventilatorwas 7 episodes per 1,000 ventilatorwas 7 episodes per 1,000 ventilator----days, and the rate in the normal saline group days, and the rate in the normal saline group days, and the rate in the normal saline group days, and the rate in the normal saline group was 21 episodes per 1,000 ventilatorwas 21 episodes per 1,000 ventilatorwas 21 episodes per 1,000 ventilatorwas 21 episodes per 1,000 ventilator----days. Irritation of the oral mucosa was days. Irritation of the oral mucosa was days. Irritation of the oral mucosa was days. Irritation of the oral mucosa was observed in 10 (9.8%) of the patients in the chlorhexidine groupobserved in 10 (9.8%) of the patients in the chlorhexidine groupobserved in 10 (9.8%) of the patients in the chlorhexidine groupobserved in 10 (9.8%) of the patients in the chlorhexidine group and in 1 (0.9%) of and in 1 (0.9%) of and in 1 (0.9%) of and in 1 (0.9%) of the patients in the normal saline group. the patients in the normal saline group. the patients in the normal saline group. the patients in the normal saline group. Oropharyngeal colonization with gramOropharyngeal colonization with gramOropharyngeal colonization with gramOropharyngeal colonization with gram----negative bacilli was either reduced or delayednegative bacilli was either reduced or delayednegative bacilli was either reduced or delayednegative bacilli was either reduced or delayed in the chlorhexidine group. in the chlorhexidine group. in the chlorhexidine group. in the chlorhexidine group. Overall mortality of the patients did not differ significantly bOverall mortality of the patients did not differ significantly bOverall mortality of the patients did not differ significantly bOverall mortality of the patients did not differ significantly between the groups. Metaetween the groups. Metaetween the groups. Metaetween the groups. Meta----analysis of 2 randomized controlled trials revealed an overall analysis of 2 randomized controlled trials revealed an overall analysis of 2 randomized controlled trials revealed an overall analysis of 2 randomized controlled trials revealed an overall relative risk of VAP relative risk of VAP relative risk of VAP relative risk of VAP for patients in the chlorhexidine group of 0.53for patients in the chlorhexidine group of 0.53for patients in the chlorhexidine group of 0.53for patients in the chlorhexidine group of 0.53 (95% confidence interval, 0.31(95% confidence interval, 0.31(95% confidence interval, 0.31(95% confidence interval, 0.31----0.90.0.90.0.90.0.90.

� # # # # poloha pacienta 30st elevace horní -VAP IHI Bundle

� # # # # analgosedace- 1x denně probuzenípacienta= dailly stop sedation návrh –dělat denně u každého v 10 00 hodin

� # # # # prevence TEN heparinem -mechanismus ?

� # # # # punkční TS místo chirurgické TS =

tracheostomie

� RESULTS: Among patients intubated for 24 hours or longer, rates RESULTS: Among patients intubated for 24 hours or longer, rates RESULTS: Among patients intubated for 24 hours or longer, rates RESULTS: Among patients intubated for 24 hours or longer, rates of of of of microbiologically confirmed VAP were microbiologically confirmed VAP were microbiologically confirmed VAP were microbiologically confirmed VAP were 4.8%4.8%4.8%4.8% (37/766 patients; 95% (37/766 patients; 95% (37/766 patients; 95% (37/766 patients; 95% confidence interval [CI], 3.4%confidence interval [CI], 3.4%confidence interval [CI], 3.4%confidence interval [CI], 3.4%----6.6%) in the group receiving the silver6.6%) in the group receiving the silver6.6%) in the group receiving the silver6.6%) in the group receiving the silver----coated coated coated coated tube and tube and tube and tube and 7.5%7.5%7.5%7.5% (56/743; 95% CI, 5.7%(56/743; 95% CI, 5.7%(56/743; 95% CI, 5.7%(56/743; 95% CI, 5.7%----9.7%) (P = .03) in the group 9.7%) (P = .03) in the group 9.7%) (P = .03) in the group 9.7%) (P = .03) in the group receiving the uncoated tube (all intubated patients, 3.8% [37/96receiving the uncoated tube (all intubated patients, 3.8% [37/96receiving the uncoated tube (all intubated patients, 3.8% [37/96receiving the uncoated tube (all intubated patients, 3.8% [37/968; 95% CI, 8; 95% CI, 8; 95% CI, 8; 95% CI, 2.7%2.7%2.7%2.7%----5.2%] and 5.8% [56/964; 95% CI, 4.4%5.2%] and 5.8% [56/964; 95% CI, 4.4%5.2%] and 5.8% [56/964; 95% CI, 4.4%5.2%] and 5.8% [56/964; 95% CI, 4.4%----7.5%] [P = .04]), with a 7.5%] [P = .04]), with a 7.5%] [P = .04]), with a 7.5%] [P = .04]), with a relative risk reduction of 35.9% (95% CI, 3.6%relative risk reduction of 35.9% (95% CI, 3.6%relative risk reduction of 35.9% (95% CI, 3.6%relative risk reduction of 35.9% (95% CI, 3.6%----69.0%; all intubated patients, 69.0%; all intubated patients, 69.0%; all intubated patients, 69.0%; all intubated patients, 34.2% [95% CI, 1.2%34.2% [95% CI, 1.2%34.2% [95% CI, 1.2%34.2% [95% CI, 1.2%----67.9%]). The silver67.9%]). The silver67.9%]). The silver67.9%]). The silver----coated endotracheal tube was coated endotracheal tube was coated endotracheal tube was coated endotracheal tube was associated with delayed occurrence of VAP (P = .005). No statistassociated with delayed occurrence of VAP (P = .005). No statistassociated with delayed occurrence of VAP (P = .005). No statistassociated with delayed occurrence of VAP (P = .005). No statistically ically ically ically significant betweensignificant betweensignificant betweensignificant between----group differences were observed in durations of group differences were observed in durations of group differences were observed in durations of group differences were observed in durations of intubation, intensive care unit stay, and hospital stay; mortaliintubation, intensive care unit stay, and hospital stay; mortaliintubation, intensive care unit stay, and hospital stay; mortaliintubation, intensive care unit stay, and hospital stay; mortality; and ty; and ty; and ty; and frequency and severity of adverse events. frequency and severity of adverse events. frequency and severity of adverse events. frequency and severity of adverse events.

� CONCLUSION: Patients receiving a CONCLUSION: Patients receiving a CONCLUSION: Patients receiving a CONCLUSION: Patients receiving a silversilversilversilver----coated endotracheal coated endotracheal coated endotracheal coated endotracheal tubetubetubetube had a statistically significant reduction in the incidence of Vhad a statistically significant reduction in the incidence of Vhad a statistically significant reduction in the incidence of Vhad a statistically significant reduction in the incidence of VAP and AP and AP and AP and delayed time to VAP occurrence compared with those receiving a sdelayed time to VAP occurrence compared with those receiving a sdelayed time to VAP occurrence compared with those receiving a sdelayed time to VAP occurrence compared with those receiving a similar, imilar, imilar, imilar, uncoated tube.uncoated tube.uncoated tube.uncoated tube.

� Incidenci VAP lze prevencí redukovat� Mít na ICU guidelines prevence VAP� Edukovat personál a dbát na dodržování

guidelines � Nové OTK s polyuretanovou manžetou a

ods.nad balonkem � Opět otevřený systém odsávání?� www.vapaway.eu� www.LoTrach.com