Transcript Ventilator Acquired Pneumonia: Introduction: Ventilator

Ventilator Associated Pneumonia
Overview
• Ventilator-associated pneumonia (VAP) occurs in 10-20% of
intubated patients.
• It is one of the most important nosocomial infections
encountered in the intensive care unit (ICU).
• VAP is an airway infection that has developed >48 hours after
the intubation.
• Mortality rates range from 24-50%, depending on individual
comorbidities and the pathogen involved.
• VAP increases ICU length of stay to 6.1 days & hospital length
of stay to 10.5 days.
• Each VAP is adds an estimated $40,000 to patient care costs.
Ventilator Associated Pneumonia
Pathophysiology
• After a period of hospitalization, patients’ oral
cavity becomes colonized with microorganisms.
• Impairment of host defenses predispose
patients to infection with colonizing organisms.
• Organisms enter upper respiratory system
around the cuff of the endotracheal tube.
• Infection of the lower respiratory track results
from organism migration.
Ventilator Bundle
Ventilator Bundle Defined:
a group of interventions related to ventilator care that, when all
interventions are applied simultaneously, there is enhanced
reduction in incidence of VAP than when each intervention is
implemented separately (Institution of health care improvement,
2011).
Ventilator Bundle Component Elements:
1.
Head of bed elevation at least 30 degrees.
2.
Daily sedation interruption with readiness to wean
assessment.
Peptic ulcer disease prophylaxis.
Deep vein thrombosis prophylaxis.
Thorough daily oral care with subglottic suctioning.
3.
4.
5.
Subglottic Suctioning
Removing secretions that have accumulated above
the ETT is a significant strategy for VAP prevention.
A meta-analysis found that ETTs with continuous or
intermittent subglottic suction decreased the
incidence of VAP in patients expected to be
mechanically ventilated longer than 72 hr (Rewa &
Muscedere, 2011).
Recent additional randomized controlled trials have
confirmed that VAP incidence is decreased when
continuous or intermittent subglottic suctioning is
used.
TaperguardTM Subglottic Endotracheal Tube
Connect in-line suction here
Subglottic port is
suctioning secretions
off the top of the ETT
cuff.
Connect second continuous suction here
• Found in Pyxis and on top of
crash carts.
• Prefer to use this ETT rather
than traditional ETT.
• Use in-line suction.
• Connect an additional suction
at low continuous suction (6080 mm) to subglottic port.
• If unable to connect two
suctions, leave connected to
subglottic port and switch to
ETT when needing to ET
suction.
Oral Care
Tooth brushing has been recommended as an
important intervention in critically ill patients to
remove the plaque biofilm that is a potential risk
of infection.
Not brushing for four days causes bacteria to
accumulate in sub-gingival crevices of the teeth,
causing gingival inflammation and bleeding, and
increase the risk for aspiration of the bacteria.
Studies Describing Oral Care for
Prevention of VAP
Citation
Trial
Design
Size Of
Sample
Place
Result
Munro et
al, 2009
Randomize
d
controlled
trial
471 adults
3 critical care
units:
medical,
surgical/
trauma,
neuroscience
Chlorhexidine and oral
care significantly reduced
the incidence
of ventilator-associated
pneumonia.
Mori et al,
2006
Case
control
1666 adults medicalsurgical unit
Sona et
al, 2009
Pre/post
1648 adults surgical
Rates of VAP decreased
intervention
intensive care in study period from 5.2
observation
unit
to 2.4 infections/1000
al study
ventilator days
Decreased incidence of
VAP in the oral care
Group
Oral Care Kits in Pyxis Stock
Quick Review: Mouth Care For Intubated/
Unconscious Patients
Perform mouth care every 4 hours.
Brush teeth using suction toothbrush and accompanying anti-plaque solution q
12 hours.
Brush for approximately one to two minutes by exerting gentle pressure while
moving in short horizontal or circular strokes.
Gently brush the surface of the tongue.
If brushing causes discomfort or bleeding uses suction swab side of toothbrush to
clean the teeth and tongue.
Post brushing, utilize the oropharyngeal suction catheter from the oral care kit to
remove the oropharyngeal secretion.
Apply mouth moisture inside mouth and on lips with accompanying swab q 4
hours.
Utilize accompanying Yankauer suction as needed to remove oral secretions
throughout the shift.
See appendix C in the policy of management of adult patient requiring mechanical ventilation
Recommendations
• Oral care should be provided every four hours, but that does not
mean oral brushing only. It also means oral rinsing 3 times a day
with suctioning, and providing moisture to the lips and oral
mucosa every six hours.
• When a patient is admitted to a critical care unit, an oral history
should be collected because prexisting gingivitis and
periodontitis increase the risk of bacteremia.
• Nurses should perform baseline and ongoing oral examinations
to evaluate the oral health of the patients.
• Use closed suction method to decrease the incidence of
reintroducing bacteria into the airway.
• Proper sterile endotracheal and subglottic suction techniques
help reduce the migration of bacteria into the lower airway.
Selected References
• Ames, N. J. (2011). Evidence to support tooth brushing in
critically ill patients . Pulmonary Critical Care, 20 (3), 242-250.
doi: 10.4037/ajcc2011120.
• Lalla, R. V., Sonis, S. T., & Peterson, D. E. (2007). Management of
oral mucositis in patients with cancer . Dent Clin North Am, 52(1).
doi: 10.1016/j.cden.2007.10.002
• Young,P., Carroll, M., Farber, M,, et al. (2007). Implementing a
ventilator bundle in a community hospital. The Joint Commission
Journal on Quality and Patient Safety, 33(4),219-225.
• Rewa,O. , Muscedere, J. (2011). Ventilator-Associated
Pneumonia: Update on Etiology, Prevention, and Management.
Curr Infect Dis Rep, 13, 287–295.
Selected References
• Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M.
Oral care reduces incidence of ventilator-associated
pneumonia in ICU populations. Intensive Care Med. 2006;
32(2):230-236.
• Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN.
Chlorhexidine, toothbrushing, and preventing ventilator
associated pneumonia in critically ill adults. Am J Crit Care.
2009; 18(5):428-437; quiz 438.
• Sona CS, Zack JE, Schallom ME, et al, The impact of a simple,
low cost oral care protocol on ventilator associated
pneumonia rates in a surgical intensive care uint. Journal
intensive care medicine. 2009; 24 (1):54-62