Transcript Document

Ventilator-Associated
Pneumonia (VAP)
An Overview for RC Students
Special thanks to:
Donald Dumford
Beth Israel Deaconess Medical Center
CDC
General Overview of Medical
Protocols
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Morbidity, mortality and cost
associated with VAP
Who gets VAP? Risk factors that
increase likelihood of developing VAP
Etiology: The bugs
Treatment: The drugs
How VAP develops (Pathogenesis)
Measures to prevent VAP
General Care & Nursing Objectives
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Review policy and procedural practice changes
for VAP prevention
Discuss BIDMC practice changes related to:
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Hand Hygiene
Oral Care
HOB elevation
Suctioning
Vent Circuits
Who is at Greatest Risk?
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Reintubation
Supine position
Impaired cough/depressed LOC
Oropharyngeal colonization
Presence of NG/OG tubes and enteral
feeding
Cross contamination by staff
Definition- “Know thy enemy”
Pneumonia that develops in someone who has been intubated
-Typically in studies, patients are only included if intubated
greater than 48 hours
-Early onset= less than 4 days
-Late onset= greater than 4 days
Endotracheal intubation increases risk of developing pneumonia
by 6 to 21 fold
Accounts for 90% of infections in mechanically ventilated
patients
American Thoracic Society, Infectious Diseases Society of America.
Guidelines for the management of adults with hospital-acquired, ventilator-associated,
and healthcare-associated pneumonia.
Why Do We Care?
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Hospital acquired pneumonia (HAP) is the
second most common hospital infection
VAP is the most common intensive care unit
(ICU) infection
VAP occurs in 10 - 65% of all ventilated
patients
Crit Care Clin (2002)
VAP is one of critical care’s quality initiatives
which can improve patient outcomes
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VAP increases:
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Medical costs
Ventilator days
ICU and hospital LOS
Estimated direct cost of excess
hospital stay due to VAP is $40,000 per
patient
Chest (2002)
Length of stay and cost
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Remember that Medicare is no longer
reimbursing for nosocomial infections
VAP increased length of stay in the ICU
by 5-7 days (mean of 6.1 days)1,2
Increase in cost
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Increase of $10,000-$40,000 per patient 1,2
Safdar N et al. Clinical and economic consequences of ventilator-associated
pneumonia: a systematic review
2 Rello et al. Epidemiology and outcomes of ventilator-associated pneumonia
in a large US database
How Do We Diagnose? 2-1-2
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Radiographic evidence x 2 consecutive days
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At least 1 of the following:
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New, progressive or persistent infiltrate
Consolidation, opacity, or cavitation
Fever (> 38 degrees C) with no other recognized cause
Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000
WBC/mm3)
At least 2 of the following:
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New onset of purulent sputum or change in character of
secretions
New onset or worsening cough, dyspnea, or tachypnea
Rales or bronchial breath sounds
Worsening gas exchange (↓ sats, P:F ratio < 240, ↑ O2 req.)
The Bugs
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Figure 1 from Park
Park DR. The microbiology of ventilator-associated pneumonia.
Etiology- select risk factors
for pathogens
Streptococcus pneumoniae
Smoking, COPD, absence of
antibiotic therapy
Haemophilus influenzae
Smoking, COPD, absence of
antibiotic therapy
MSSA
Younger age, Traumatic coma,
Neurosurgery
MRSA
COPD, steroid therapy, longer
duration of MV, prior antibiotics
Pseudomonas aeruginosa
COPD, steroid therapy, longer
duration of MV, prior antibiotics
Acinetobacter species
ARDS, head trauma,
neurosurgery, gross aspiration,
prior cephalosporin therapy
Park DR. The microbiology of ventilator-associated pneumonia.
What Are Our Practice Goals?
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Hand Hygiene
Mouth care Q 2-4 hours
HOB > 30 degrees unless contraindicated
Closed inline suction – saline only when
needed
Change vent circuits only when needed
Hand Hygiene
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Hand hygiene is the single most
important (and easiest!!!) method for
reducing the transmission of pathogens.
Waterless antiseptic preparations are
more effective than soap and water and
may increase compliance.
Oral Care
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Daily inspection and assessment of oral
cavity
Brush teeth q 12 hours
Swab mouth with antiseptic agent q 2-4
hours between brushing
Moisturize mouth prn
HOB > 30 Degrees
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HOB > 30 degrees at all times including
transport unless contraindicated.
Aspiration of oral secretions is a
presumed step in the development of VAP
Pulmonary aspiration is increased by
supine positioning
Positioning the HOB to 30 degrees or
higher significantly reduces gastric reflux
and VAP
Stryker beds display Fowler angle at foot of
bed
Keep patient at 30-45 degrees while intubated
HOB Elevation > 30 Degrees on all
Intubated Ventilated Patients
Contraindications
 Hypotension MAP <70
 Tachycardia >150
 CI <2.0
 Central line procedure
 Posterior circulation strokes
 Cervical spine instability use
reverse trendelenburg
 Some femoral lines ie: IABP
no higher than 30 degrees
use reverse trendelenburg
 Increased ICP, No higher
than 30 degrees avoid hip
flexion
 Proning
Reverse Trendelenburg
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In full reverse Trendelenburg the foot
of bed will read -12 degrees.
Angle of head elevation is approximately
20 degrees not 30 degrees when at -12.
Evaluate the individual clinical situation
to assess if the patient can tolerate the
addition of a small amount of Fowlers
angle which may flex the hip.
Suctioning
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In line suction:
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Maintain closed system
Use separate suction tubing for inline & yankauer
Normal saline:
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Should not be routinely used to suction pts
Causes desaturation
Does not increase removal of secretions
Can potentially dislodge bacteria
Should be used to rinse the suction catheter after
suctioning
Subglottal Suctioning
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Should be done using a 14 Fr sterile
suction catheter:
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Prior to ETT rotation
Prior to lying patient supine
Prior to extubation
Suctioning
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Yankauer:
 Use separate suction tubing
 Change q 24 hours – unless visibly soiled
date and time when changed
 Clean after each use with NS or sterile H2O
 Wipe with clean 4 X 4 gauze, place in package
 Store in original package, taped to vent
Suctioning
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SET UP
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YANKAUER STORAGE
Pathogenesis- Through the
tube
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Condensate in tubing
Development of ETT biofilm
Condensate
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Condensate in ventilator tubing becomes
rapidly contaminated with bacteria from
patient’s oropharynx
Craven et al showed that 33% of
inspiratory circuits were colonized
within 2 hours and 80% within 24 hours
ET tube biofilm (RT’s should know
this…)
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Exopolysaccharide outer layer with
quiescent bacteria within
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Difficult for bacteria to penetrate outer
layer and bacteria within resistant to
bactericidal effects of bacteria
Adair et al study
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“Microorganisms of high pathogenic
potential were isolated from all ETs
collected from patients with VAP compared
with 30% of ETs from the control group.”
Around the tube
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Oral decontamination and selective
decontamination of the digestive tract
Aspiraton of subglottic secretions
including continuous aspiration of
subglottic secretions
Semi-recumbent positioning
Sucralfate for stress ulcer
prophylaxis
Condensate management
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Heat-moisture exchanger
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Theoretical advantage=prevents bacterial
colonization of tubing
Studies= Mixed results
Disadvantage=increases dead space and resistance
to breathing
Heated wire to elevate temp of inspired air
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Advantage=Decreases condensate formation
Disadvantage=Blockage of ET tube by dried
secretions
CDC.gov. Guidelines for preventing health-care-associated pneumonia, 2003.
Ventilator Circuits
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Vent circuits (including inline suction
systems) will be in place for the
duration of ventilation unless:
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Defective
Damaged
Visibly soiled
The humidification system requires
changing
What Is Next?
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Standardization of oral care
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Sedation
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Products being trialed
Improve practice regarding weaning sedation
and daily wake up
Vent weaning
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Improve practice around weaning and
extubation
Stay Tuned…
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More to come!