Transcript Ventilator Associated Pneumonia

Ventilator Associated
Pneumonia
Best Practice
Amy Shay, MS, CCRN, CNS
CDC Guidelines for Preventing Healthcare
Associated Pneumonia, 2003
 If feasible, use an endotracheal tube
with a dorsal lumen above the ET cuff
to allow drainage (by continuous or
frequent intermittent suctioning) of
secretions that accumulate in the
subglottic area.
 Clear secretions above the ET cuff
prior to deflating the cuff for any
reason
CDC Guidelines for Preventing Healthcare
Associated Pneumonia, 2003
 Gastric Alkalinization: stress ulcer
prophylaxis raises gastric pH which
may allow for gastric colonization with
pathogens that can then be aspirated.
 GI prophylaxis may increase VAP risk;
Sucralfate may have less risk than H2
antagonists but is associated with
increased risk of bleeding.
 Grap MJ, Munro CL
Crit Care Nurs Clin N Am, 16 2004
CDC Guidelines for Preventing Healthcare
Associated Pneumonia, 2003
 Analysis of ten studies of small bowel
feeding found that small bowel feedings are
associated with reduction in
gastroesophageal regurgitation, increase in
protein and calories delivered, and shorter
time to target dose of nutrition.
 Results of 7 randomized trials: small bowel
feeding compared to gastric had lower
incidence of pneumonia.
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Heyland, et al. JPEN 2002;26:S51-S55.
Kollef MH Crit Care Med 2004:32(6)
Heyland, el al. Crit Care Med 2001;29:1495-1501
CDC Guidelines for Preventing Healthcare
Associated Pneumonia, 2003
 Elevate HOB to 30 to 45 degrees (if no
contraindications):
 Aspiration can occur even with a properly
inflated ET cuff.
Bacterial counts higher in aspirated secretions
obtained while pts were in the supine (flat) position
than in those obtained while patients were in the
semirecumbent position (45 degrees).
Torres et al. Ann Int Med 1992;116:540-3.
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Time spent with HOB in low position on day 1
of mechanical ventilation is most predictive of
VAP in patients with high APACHE II scores.
Grap MJ, Munro CL, et al. 2005 Am J Crit Care 14(4)
Shortening the duration of
mechanical ventilation:
Kollef MH Crit Care Med 2004:32(6)
 Studies support the use of Protocols*
• weaning days reduced by 2
• 50% reduction in vent related
complications
• Nurse/Therapist driven
Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. Chest.
120(6). 2001 375S-395S.
 Targeted Sedation protocols
ATS/IDSA (2004) and SCCM (2002)
Tracheostomy
Fowler Byers J, et al. Am J Crit Care Sept, 2000:9(5)
 VAP twice as prevalent in patients with
tracheostomy
 Though not statistically significant:
Patients who had tracheostomy within
one week of admission had a lower
incidence of VAP than those who had
the procedure more than 1 week after
adm.
 Further study needed.
CDC Guidelines for Preventing Healthcare
Associated Pneumonia, 2003
 “Develop and implement a
comprehensive oral-hygiene
program (that might include the use
of an antiseptic agent) for patients
…at high risk for HAP.”
Schleder, Stott, & Lloyd, 2002
Oral Care: AACN
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AACN 5th Edition, 2005 Scott JM, Vollman KM
Endotracheal Tube and Oral Care, Procedure # 4
Unit One Pulmonary System
 Perform ET suctioning only when clinically indicated
 Oral hygiene should be performed every 2-4 hours
and should include:
 Toothbrushing at least two times a day;
 Oral swabs with 1.5% hydrogen peroxide soln every
2-4 hours;
 Mouth moisturizer to oral mucosa and lips
 Subglottic suctioning continuously or intermittently
Oral Care: plaque
Grap MJ, Munro CL 2004:
 Toothbrushing is the most effective
means of mechanical removal of
plaque.
Munro CL, Grap MJ, Elswick RK, el al: 2006;Am J Crit Care;15
 Higher plaque scores confer greater
risk for VAP
Oral Care: use of antiseptics
Fourrier 2005 Crit Care Med 33
 CHG – reduced colonization but not VAP
Munro & Grap 2006 Crit Care Med 34
 CHG – effective in reducing VAP
Seguin 2006 Crit Care Med 34
 Povidone-Iodine - decreased prevalence of
VAP in head trauma
Appropriate staffing levels in the
ICU
 Inverse relationship between the
adequacy of staffing levels and
duration of stay and subsequent
development of VAP.
 Increased workloads for RNs and RTs
lead to reliance on less trained
personnel that may result in lapses in
infection control
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Kollef MH Crit Care Med 2004:32(6)
Appropriate staffing levels in the
ICU
 Critical Care Medicine 2007;vol 35, No 1
 Prospective cohort study 10,637 patient days
Examined nurse/patient ratios and infection
rates
 Staffing is key determinant for healthcare
associated infections in critically ill patients
 Higher nursing skill mix (up to 87.5% RNs)
lowers the incidence of adverse occurances
Blegen, Goode, Reed Nurs Res 1998;47
Recommendation that
everyone can agree on
 Educational programs for RNs and RTs addressing
VAP etiology and infection control procedures is
associated with decreased VAP rates in the ICU
setting.
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Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing
the occurrence of ventilator-associated pneumonia.
Critical Care Medicine. 2002; 30(11): 2407-2412.
 “Staff education….is a cornerstone for efforts to
reduce the incidence of VAP.”
Craven,D. Chest 2006;130
 Ventilator bundle staff educational sessions have a
significant effect on clinical practice.
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Tolentino-DelosReyes, Ruppert, Shyang-Yun, et al Am J Crit Care 2007; 16
VAP Rate & HOB ≥ 300
Oral Care Compliance
& VAP Rate
Mouth Care Compliance and VAP Rate Trends for ICU
120%
100%
80%
Protocol
Compliance
60%
VAP Rate
40%
20%
Feb '06
Dec '05
Oct '05
Aug '05
Jun '05
Apr '05
Feb '05
Dec '04
Oct '04
Aug '04
Jun '04
Apr '04
Feb '04
Nov '03
0%
Issues of debate in VAP
prevention:
 Oral care interventions: CHG, 1.5%
Peroxide, Povidone Iodine, saliva
substitutes, mechanical interventions
 Removal of secretions: continuous vs
intermittent
 Endotracheal tube Biofilm – silver coated
ET tubes?
 Cost of prevention measures
 [email protected] for questions