Ventilator Associated Pneumonia Best Practice Amy Shay, MS, CCRN, CNS Amy Shay, MS, CCRN, CNS.

Ventilator Associated Ventilator Associated PneumoniaPneumonia

Best PracticeBest Practice

Amy Shay, MS, CCRN, CNSAmy Shay, MS, CCRN, CNS

CDC Guidelines for Preventing CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003Healthcare Associated Pneumonia, 2003

If feasible, use an endotracheal tube If feasible, use an endotracheal tube with a dorsal lumen above the ET cuff with a dorsal lumen above the ET cuff to allow drainage (by continuous or to allow drainage (by continuous or frequent intermittent suctioning) of frequent intermittent suctioning) of secretions that accumulate in the secretions that accumulate in the subglottic area.subglottic area.

Clear secretions above the ET cuff Clear secretions above the ET cuff prior to deflating the cuff for any prior to deflating the cuff for any reasonreason

CDC Guidelines for Preventing CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003Healthcare Associated Pneumonia, 2003

Gastric Alkalinization: stress ulcer Gastric Alkalinization: stress ulcer prophylaxis raises gastric pH which prophylaxis raises gastric pH which may allow for gastric colonization with may allow for gastric colonization with pathogens that can then be aspirated. pathogens that can then be aspirated.

GI prophylaxis may increase VAP risk; GI prophylaxis may increase VAP risk; Sucralfate may have less risk than H2 Sucralfate may have less risk than H2 antagonists but is associated with antagonists but is associated with increased risk of bleeding.increased risk of bleeding.

Grap MJ, Munro CLGrap MJ, Munro CLCrit Care Nurs Clin N Am, 16 2004Crit Care Nurs Clin N Am, 16 2004

CDC Guidelines for Preventing CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003Healthcare Associated Pneumonia, 2003

Analysis of ten studies of small bowel Analysis of ten studies of small bowel feeding found that small bowel feedings are feeding found that small bowel feedings are associated with reduction in associated with reduction in gastroesophageal regurgitation, increase in gastroesophageal regurgitation, increase in protein and calories delivered, and shorter protein and calories delivered, and shorter time to target dose of nutrition.time to target dose of nutrition.

Results of 7 randomized trials: small bowel Results of 7 randomized trials: small bowel feeding compared to gastric had lower feeding compared to gastric had lower incidence of pneumonia.incidence of pneumonia.

Heyland, et al. JPEN 2002;26:S51-S55.Heyland, et al. JPEN 2002;26:S51-S55. Kollef MH Crit Care Med 2004:32(6)Kollef MH Crit Care Med 2004:32(6) Heyland, el al. Crit Care Med 2001;29:1495-1501Heyland, el al. Crit Care Med 2001;29:1495-1501

CDC Guidelines for Preventing Healthcare CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003Associated Pneumonia, 2003

Elevate HOB to 30 to 45 degrees (if no Elevate HOB to 30 to 45 degrees (if no contraindications):contraindications):

Aspiration can occur even with a properly Aspiration can occur even with a properly inflated ET cuff. inflated ET cuff.

Bacterial counts higher in aspirated secretions Bacterial counts higher in aspirated secretions obtained while pts were in the supine (flat) position obtained while pts were in the supine (flat) position than in those obtained while patients were in thethan in those obtained while patients were in the semirecumbent position (45 degrees).semirecumbent position (45 degrees).

Torres et al. Torres et al. Ann Int MedAnn Int Med 1992;116:540-3. 1992;116:540-3.

■ ■ Time spent with HOB in low position on day 1 Time spent with HOB in low position on day 1 of mechanical ventilation is most predictive of of mechanical ventilation is most predictive of VAP in patients with high APACHE II scores.VAP in patients with high APACHE II scores.

Grap MJ, Munro CL, et al. 2005 Am J Crit Care 14(4)Grap MJ, Munro CL, et al. 2005 Am J Crit Care 14(4)

Shortening the duration of Shortening the duration of mechanical ventilation: mechanical ventilation: Kollef MH Kollef MH Crit Care MedCrit Care Med 2004:32(6 2004:32(6))

Studies support the use of Studies support the use of Protocols*Protocols* • • weaning days reduced by 2weaning days reduced by 2 • • 50% reduction in vent related 50% reduction in vent related complicationscomplications • • Nurse/Therapist drivenNurse/Therapist driven Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. ChestChest. 120(6). . 120(6).

2001 375S-395S.2001 375S-395S.

Targeted Sedation protocolsTargeted Sedation protocols ATS/IDSA (2004) and SCCM (2002)ATS/IDSA (2004) and SCCM (2002)

TracheostomyTracheostomyFowler Byers J, et al. Fowler Byers J, et al. Am J Crit CareAm J Crit Care Sept, 2000:9(5) Sept, 2000:9(5)

VAP twice as prevalent in patients VAP twice as prevalent in patients with tracheostomy with tracheostomy

Though not statistically significant: Though not statistically significant: Patients who had tracheostomy within Patients who had tracheostomy within one week of admission had a lower one week of admission had a lower incidence of VAP than those who had incidence of VAP than those who had the procedure more than 1 week after the procedure more than 1 week after adm. adm.

Further study needed.Further study needed.

CDC Guidelines for Preventing CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003Healthcare Associated Pneumonia, 2003

““Develop and implement a Develop and implement a comprehensive oral-hygiene comprehensive oral-hygiene program (that might include the use program (that might include the use of an antiseptic agent) for patients …of an antiseptic agent) for patients …at high risk for HAP.” at high risk for HAP.”

Schleder, Stott, & Lloyd, 2002Schleder, Stott, & Lloyd, 2002

Oral Care: AACNOral Care: AACN

AACN 5AACN 5thth Edition, 2005 Scott JM, Vollman KM Edition, 2005 Scott JM, Vollman KM Endotracheal Tube and Oral Care, Procedure # 4 Endotracheal Tube and Oral Care, Procedure # 4 Unit One Pulmonary SystemUnit One Pulmonary System

Perform ET suctioning only when clinically indicatedPerform ET suctioning only when clinically indicated Oral hygiene should be performed every 2-4 hours Oral hygiene should be performed every 2-4 hours

and should include:and should include: Toothbrushing at least two times a day;Toothbrushing at least two times a day; Oral swabs with 1.5% hydrogen peroxide soln every Oral swabs with 1.5% hydrogen peroxide soln every

2-4 hours;2-4 hours; Mouth moisturizer to oral mucosa and lipsMouth moisturizer to oral mucosa and lips Subglottic suctioning continuously or intermittentlySubglottic suctioning continuously or intermittently

Oral Care: plaqueOral Care: plaque

Grap MJ, Munro CL 2004:Grap MJ, Munro CL 2004:

Toothbrushing is the most effective Toothbrushing is the most effective means of mechanical removal of means of mechanical removal of plaque.plaque.

Munro CL, Grap MJ, Elswick RK, el al: 2006;Munro CL, Grap MJ, Elswick RK, el al: 2006;AmAm J CritJ Crit CareCare;15;15

Higher plaque scores confer greater Higher plaque scores confer greater risk for VAPrisk for VAP

Oral Care: use of antisepticsOral Care: use of antiseptics

Fourrier 2005 Crit Care Med 33Fourrier 2005 Crit Care Med 33

CHG – reduced colonization but not VAPCHG – reduced colonization but not VAP

Munro & Grap 2006 Crit Care Med 34Munro & Grap 2006 Crit Care Med 34

CHG – effective in reducing VAPCHG – effective in reducing VAP

Seguin 2006 Crit Care Med 34Seguin 2006 Crit Care Med 34

Povidone-Iodine - decreased prevalence of Povidone-Iodine - decreased prevalence of VAP in head traumaVAP in head trauma

Appropriate staffing levels Appropriate staffing levels in the ICU in the ICU

Inverse relationship between the Inverse relationship between the adequacy of staffing levels and adequacy of staffing levels and duration of stay and subsequent duration of stay and subsequent development of VAP.development of VAP.

Increased workloads for RNs and RTs Increased workloads for RNs and RTs lead to reliance on less trained lead to reliance on less trained personnel that may result in lapses in personnel that may result in lapses in infection controlinfection control

Kollef MH Kollef MH Crit Care MedCrit Care Med 2004:32(6) 2004:32(6)

Appropriate staffing levels Appropriate staffing levels in the ICU in the ICU

Critical Care MedicineCritical Care Medicine 2007;vol 35, No 1 2007;vol 35, No 1 Prospective cohort study 10,637 patient daysProspective cohort study 10,637 patient days Examined nurse/patient ratios and infection Examined nurse/patient ratios and infection

ratesrates Staffing is key determinant for healthcare Staffing is key determinant for healthcare

associated infections in critically ill patients associated infections in critically ill patients

Higher nursing skill mix (up to 87.5% RNs) Higher nursing skill mix (up to 87.5% RNs) lowers the incidence of adverse occuranceslowers the incidence of adverse occurances

Blegen, Goode, Reed Blegen, Goode, Reed Nurs ResNurs Res 1998;47 1998;47

Recommendation that Recommendation that everyoneeveryone can agree on can agree on

Educational programs for RNs and RTs addressing Educational programs for RNs and RTs addressing VAP etiology and infection control procedures is VAP etiology and infection control procedures is associated with decreased VAP rates in the ICU associated with decreased VAP rates in the ICU setting.setting.

Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. the occurrence of ventilator-associated pneumonia.

Critical Care Medicine. Critical Care Medicine. 2002; 30(11): 2407-2412.2002; 30(11): 2407-2412.

““Staff education….is a cornerstone for efforts to Staff education….is a cornerstone for efforts to reduce the incidence of VAP.”reduce the incidence of VAP.”

Craven,DCraven,D. Chest. Chest 2006;130 2006;130

Ventilator bundle staff educational sessions have a Ventilator bundle staff educational sessions have a significant effect on clinical practice.significant effect on clinical practice.

Tolentino-DelosReyes, Ruppert, Shyang-Yun, et al Tolentino-DelosReyes, Ruppert, Shyang-Yun, et al Am J Crit CareAm J Crit Care 2007; 16 2007; 16

VAP Rate & HOB ≥ 30VAP Rate & HOB ≥ 3000

Oral Care Compliance Oral Care Compliance & VAP Rate& VAP Rate

0%

20%

40%

60%

80%

100%

120%

Nov

'03

Feb '0

4

Apr

'04

Jun '0

4

Aug '0

4

Oct

'04

Dec

'04

Feb '0

5

Apr

'05

Jun '0

5

Aug '0

5

Oct

'05

Dec

'05

Feb '0

6

ProtocolCompliance

VAP Rate

Mouth Care Compliance and VAP Rate Trends for ICU

Issues of debate in VAP Issues of debate in VAP prevention:prevention:

Oral care interventions: CHG, 1.5% Oral care interventions: CHG, 1.5% Peroxide, Povidone Iodine, saliva Peroxide, Povidone Iodine, saliva substitutes, mechanical interventionssubstitutes, mechanical interventions

Removal of secretions: continuous vs Removal of secretions: continuous vs intermittentintermittent

Endotracheal tube Biofilm – silver coated Endotracheal tube Biofilm – silver coated ET tubes? ET tubes?

Cost of prevention measuresCost of prevention measures

[email protected]@mvh.org for questions for questions