Ventilator Associated Pneumonia Best Practice

1
Ventilator Associated PneumoniaBest Practice

• Amy Shay, MS, CCRN, CNS

2
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

3
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 CLCrit Care Nurs Clin N Am, 16
  2004

4
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.
• Heyland, et al. JPEN 200226S51-S55.
• Kollef MH Crit Care Med 200432(6)
• Heyland, el al. Crit Care Med 2001291495-1501

5
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 1992116540-3.
• 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)

6
Shortening the duration of mechanical
ventilation Kollef MH Crit Care Med 200432(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)

7
TracheostomyFowler Byers J, et al. Am J Crit
Care Sept, 20009(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.

8
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

9
Oral Care AACN

• 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

10
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
  2006Am J Crit Care15
• Higher plaque scores confer greater risk for VAP

11
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

12
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
• Kollef MH Crit Care Med 200432(6)

13
Appropriate staffing levels in the ICU

• Critical Care Medicine 2007vol 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 199847

14
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.
• 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 2006130
• Ventilator bundle staff educational sessions have
  a significant effect on clinical practice.
• Tolentino-DelosReyes, Ruppert, Shyang-Yun, et al
  Am J Crit Care 2007 16

15
VAP Rate HOB 300
16
Oral Care Compliance VAP Rate
17
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
• acshay_at_mvh.org for questions