4 CriticalCareChoices2005

entilator-associated pneumonia (VAP) in patientswho are already critically ill prolongs their hospi-

talization and recovery and significantly increases therisk of complications and death. Preventing VAP is onegoal of the Institute for Healthcare Improvement’s100,000 Lives Campaign, unveiled in December 2004.(For more information, visit http://www.ihiorg/IHI/Programs/Campaign.

In this article, we’ll describe how you can help preventVAP from developing. First, let’s review VAP and its causes.

Who let the bugs in?Ventilator-associated pneumonia is the most commonand lethal form of hospital-acquired pneumonia (alsoknown as nosocomial pneumonia). It occurs in up to28% of patients who need mechanical ventilation formore than 48 hours.

Endotracheal (ET) intubation and mechanical ventila-tion predispose patients to VAP by interfering with thenormal defense mechanisms that keep microorganismsfrom entering the lungs. Endotracheal tubes, especiallycuffed ones, interfere with the mucociliary transport sys-tem that helps clear airway secretions. Secretions thataccumulate below and above the ET tube are an idealgrowth medium for pathogens. The ET tube also pre-vents normal closure of the epiglottis, resulting in anincomplete seal of the laryngeal structures that normallyprotect the lungs. This can contribute to aspiration thatoften leads to VAP.

Ventilator-associated pneumonia is characterized bypulmonary infiltrates and fever. Other assessment find-ings include leukocytosis, purulent tracheal secretions,and pathogenic microorganisms cultured from trachealaspirate.

Who’s at risk?Patient risk factors for VAP include:• conditions that increase the risk of colonization bypathogens, such as previous antibiotic therapy or con-taminated ventilator equipment

• conditions thatincrease the risk ofaspiration, such asintubation, presenceof a nasogastric(NG) tube, ordecreased level ofconsciousness• conditions thatimpair defensemechanisms, suchas age extremes(particularly age 70or older), malnutri-tion, diabetes, renalinsufficiency, andchronic obstructivepulmonary disease(COPD).

Other risk factorsare related to poorinfection controltechnique by healthcare providers, including inadequate hand hygiene and fail-ure to wear gloves when handling respiratory secretions orequipment contaminated with respiratory secretions.

Types of VAPDetermining the type of VAP can help identify theresponsible nosocomial organisms and guide antibiot-ic therapy.• Early-onset VAP occurs during the first 3 to 4 daysof mechanical ventilation. The causative organismsoften are the same ones responsible for community-acquired pneumonia; likely to be sensitive to tradi-tional antibiotic therapy, they’re usually easier to treat.Common organisms implicated in early-onset VAPinclude Streptococcus pneumoniae, Haemophilusinfluenzae, and Moraxella catarrhalis.• Late-onset VAP, which occurs 5 or more days after

V

Learn how it develops and strategies you can use to reduceyour patient’s risk of this common complication.

By William C. Pruitt, RRT, AE-C, CPFT, MBA, and Michael Jacobs, RN, CCRN, CEN, MSN

Can you prevent

ventilator-associated

initiation of mechanical ventilation, is most common-ly due to Staphylococcus aureus, Acinetobacter bauman-nii, Pseudomonas aeruginosa, Klebsiella pneumoniae,and the Enterobacter species. Because these pathogensmay be antibiotic-resistant (for example, methicillin-resistant S. aureus), they must be treated with morepowerful antibiotics and antibiotic combinations.Late-onset VAP, which can increase mortality rates by50%, has become significantly more prevalent inrecent years.

A clinician may choose to start a patient on antibi-otics as soon as she suspects VAP or to delay treat-ment until the pathogen is identified by an invasiveprocedure (such as bronchoscopy, protected specimenbrushings, or bronchoalveolar lavage) and lab analy-sis. She’ll base the decision on the severity of disease,time of onset, and presence of risk factors.

Trying noninvasive ventilationOne of the best ways to prevent VAP is to use noninva-sive ventilation if appropriate. For some patients, such asthose with acute exacerbations of COPD, noninvasivepositive-pressure ventilation (NPPV) is an alternative tointubation and mechanical ventilation.

Noninvasive positive-pressure ventilation is adminis-tered via a face mask that fits over the mouth and noseor a nasal mask that fits over the nose. The mask is con-nected to either a mechanical ventilator or a bi-level pos-itive airway pressure machine using aerosol tubing or aventilator circuit.

Noninvasive positive-pressure ventilation can providemany of the supportive measures found in traditionalmechanical ventilation, including various modes of ven-tilatory support with rate and volume settings (such asassist-control or synchronized intermittent mandatory

CriticalCareChoices2005 5

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ventilation), supplemental oxygen, positive end-expira-tory pressure, continuous positive airway pressure, andpressure support. By avoiding intubation and the associ-ated high risk of aspiration around an artificial airway,this option reduces the risk of VAP.

However, although NPPV has been used for 20 yearsby home health care patients needing temporary sup-port, the therapy has the following drawbacks when it’sused as a full-support mode instead of traditionalmechanical ventilation.• Because NPPV doesn’t secure the airway, leaks withsubsequent loss of tidal volume can be a problem. • The mask may make patients feel claustrophobic. • Suctioning, if needed, can be done nasotracheally ororotracheally because the patient lacks an artificial air-way. Passing the suction catheter though the nasophar-ynx can be traumatic, and the lower airway may not beadequately suctioned via this approach. In addition,nasotracheal suctioning can introduce pathogens intothe lungs, increasing the risk of VAP.• Eating and drinking is difficult if NPPV is being used forfull support. The mask must be removed, interrupting ven-tilation, for the patient to eat or drink by mouth. Gastricdistension is sometimes a problem, and an NG tube maybe is used to prevent this problem. Patients also may be fedthrough the NG tube to avoid discontinuing NPPV.

Because of these drawbacks, NPPV is appropriate onlyfor short-term ventilator needs. If the patient requiresfull ventilatory support for more than 24 hours, he’llneed to be intubated and be connected to a traditionalmechanical ventilator.

Ways to prevent VAP If your patient needs an artificial airway, you can takesteps during the initial insertion to reduce his risk ofdeveloping VAP.• Use meticulous hand hygiene. Wear clean gloves whenappropriate.• Use an oral artificial airway rather than a nasal one ifpossible. Nasal intubations increase the risk of nosocomi-al sinusitis and development of VAP.• Keep the ET tube cuff at minimal occluding volume. Thisavoids damage to the tracheal wall. Make sure the cuff isinflated adequately to reduce the chance that the patientwill aspirate secretions that accumulate above the cuff.Newer ET tubes now have a dorsal lumen above the cuffso you can clear tracheal secretions that accumulate inthe subglottic area with either continuous or frequentintermittent suctioning.• Consider a tracheostomy tube for patients who need long-term ventilation. This option still needs to be studied todetermine if it provides a clear benefit in reducing VAP. • Observe meticulous infection control. If oral intubation isused, the reusable laryngoscope blade (and stylet) shouldhave high-level disinfection before use (for example, withglutaraldehyde). Sterilization also can be used for these

reusable items, or single-use disposable blades and styletscan be used. Suction the patient’s oropharynx beforeinsertion. If the sterile ET tube is inadvertently passedinto the esophagus, it should be discarded and a new ster-ile one should be used for subsequent attempts.• Secure the ET tube to prevent extubation. Unplannedextubation increases the risk of aspiration and requiresreintubation, both of which raise the patient’s risk of VAP. • Take aspiration precautions. To reduce the risk of aspira-tion, elevate the patient’s head to at least 30 degrees—preferably 45 degrees if not contraindicated. Make surethe ET tube cuff is properly inflated. Suction above andbelow the cuff as needed and before ET tube removal. • Perform frequent mouth care. As oral secretions pool,pathogens colonize the teeth and oral mucosa. Contami-nated oral secretions flow to the subglottic area, wheresmall amounts may be aspirated. Oral suctioning pre-vents oral secretions from pooling and toothbrushingremoves the plaque that promotes bacterial growth. Adaily oral hygiene rinse with a chlorhexidine-based solu-tion may prevent or reduce oropharyngeal colonization.If the patient can’t expectorate during brushing or rins-ing, perform simultaneous oral suctioning.

Keeping the circuit cleanThe ventilator circuit has been studied closely because ofits possible role in VAP. The American Association forRespiratory Care and the Centers for Disease Controland Prevention (CDC) each have clinical practice guide-lines regarding VAP and the ventilator circuit. Their rec-ommendations include the following.• Don’t routinely change the ventilator circuit, but dochange it if it’s visibly soiled or malfunctioning.• Drain and discard any condensation collecting in theventilator tubing, taking care to drain this fluid awayfrom the patient. Wear gloves when draining fluid andwash your hands or use an alcohol-based hand rub(unless your hands are visibly soiled) after performingthis procedure.• Don’t change closed system (in-line) suction setups forinfection control purposes. The maximum time for usingthese safely before changing is unknown. The CDCregards the choice of a multiuse closed suction systemversus single-use open suction to be an unresolved issue.

Passive humidification systems, such as heat and mois-ture exchangers, haven’t received a clear recommendationfor general use because of issues related to increased antibi-otic resistance by pathogens, increased dead space, and riskof airway occlusion. Likewise, heated humidifiers haven’treceived a clear recommendation for general use. Morestudy is needed to resolve the issue of passive humidityversus humidified delivery. More study also is needed toresolve issues connected with humidified circuits.

If passive humidifiers are used, they don’t have to bechanged more frequently than every 48 hours and mayin some cases be used for up to 1 week. Change the

6 CriticalCareChoices2005

humidifier when it’s visibly soiled or if it’s malfunction-ing. Fill heated humidifiers with sterile water only.

Patient nutrition and VAPAll critically ill patients have high calorie needs to fightcomplications and to heal. Because a mechanically venti-lated patient can’t take foods or fluids orally, he mayneed an enteral tube for feedings. Unfortunately, anenteral tube increases his risk of aspiration and VAP, sotake these preventive steps:• Advocate for an orogastric tube instead of an NG tube, ifappropriate. An NG tube increases the patient’s risk ofnosocomial sinusitis and pathogen contamination of theoropharyngeal area from the nasopharyngeal area.• Routinely verify correct feeding tube placement by more thanone method, including measuring the pH of gastric aspirate.• Monitor the patient’s tolerance of gastric feedings.Auscultate bowel sounds and measure abdominal girthfrequently. Measure residual gastric volume at least every4 hours during continuous feedings and before eachintermittent feeding, to decrease the likelihood of gastricdistension and aspiration. Less than 200 ml is generallyconsidered an acceptable amount of gastric residual vol-ume, although this can vary from institution to institu-tion. If residual volume is more than 200 ml, stop theenteral feeding for 2 hours, then reassess residual volume.• Elevate the patient’s head to at least 30 degrees at all timesfor continuous feedings or during and for 1 hour after inter-mittent feedings. This helps minimize the risk of refluxand pulmonary aspiration.

Learning to prevent VAPEducation is key to preventing VAP. A recent study foundthat VAP rates at two teaching hospitals and two communi-ty hospitals were reduced by an average 46% after respirato-ry care practitioners and intensive care unit nurses com-pleted a staff-development program about risk factors andstrategies to prevent VAP. A team approach was important;the study authors found that in one of the community hos-pitals, where few respiratory therapists completed the staff-development program, VAP rates remained unchanged.

A growing problem in health care facilities, VAP raisesthe cost of care and increases patient-care time, hospitallength of stay, and patient morbidity. Strategies to pre-vent and treat VAP are effective only if staff is educatedabout them and encouraged to follow best practiceguidelines.

SELECTED REFERENCESBabcock H, et al. An educational intervention to reduce ventilator-associatedpneumonia in an integrated health system: A comparison of effects. Chest.125(6):2224-2231, June 2004.

Kollef M. Prevention of hospital-associated pneumonia and ventilator-associatedpneumonia. Critical Care Medicine. 32(6):1396-1405, June 2004.

Tablan O, et al. Guidelines for preventing health-care associated pneumonia,2003: Recommendations of the Centers for Disease Control and Prevention andthe Healthcare Infection Control Practices Advisory Committee. Morbidity andMortality Weekly Report. 53(RR-3):1-36, March 26, 2004.http://www.cdc.gov/ncidod/hip/pneumonia. Accessed September 25, 2004.

William C. Pruitt is an instructor in the department of cardiorespiratory sciences at theUniversity of South Alabama in Mobile and a p.r.n. respiratory therapist at SpringhillMedical Center in Mobile. Michael Jacobs is a clinical assistant professor in the adult healthdepartment at the University of South Alabama’s College of Nursing and a p.r.n. nursingsupervisor and emergency department staff nurse at Ocean Springs (Miss.) Hospital.

The authors have disclosed that they have no significant relationship with or financial interestin any commercial companies that pertain to this educational activity.

CriticalCareChoices2005 7

CE Test

Can you prevent ventilator-associated pneumonia?

Instructions:• Read the article beginning on page 4.• Take the test, recording your answers in the test answers section(Section B) of the CE enrollment form. Each question has only one correct answer.• Complete registration information (Section A) and courseevaluation (Section C).• Mail completed test with registration fee to: Lippincott Williams& Wilkins, CE Group, 333 7th Avenue, 19th Floor, New York, NY10001.• Within 3 to 4 weeks after your CE enrollment form is received, youwill be notified of your test results.• If you pass, you will receive a certificate of earned contact hoursand an answer key. If you fail, you have the option of taking the testagain at no additional cost.• A passing score for this test is 11 correct answers.• Need CE STAT? Visit http://www.nursingcenter.com for immedi-ate results, other CE activities, and your personalized CE planner tool. • No Internet access? Call 1-800-933-6525, ext. 6617 or ext. 6621,for other rush service options.• Questions? Contact Lippincott Williams & Wilkins: 646-674-6617 or646-674-6621.

Registration Deadline: May 30, 2007

Provider Accreditation:This Continuing Nursing Education (CNE) activity for 2.0 contact hours is pro-vided by Lippincott Williams & Wilkins, which is accredited as a provider of con-tinuing education in nursing by the American Nurses Credentialing Center’sCommission on Accreditation and by the American Association of Critical-CareNurses (AACN 00012278, CERP Category A). This activity is also providerapproved by the California Board of Registered Nursing, Provider Number CEP11749 for 2.0 contact hours. LWW is also an approved provider of CNE inAlabama, Florida, and Iowa and holds the following provider numbers: AL#ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classifiedfor Texas nursing continuing education requirements as Type I.

Your certificate is valid in all states. This means that your certificate of earnedcontact hours is valid no matter where you live.

Payment and Discounts:• The registration fee for this test is $13.95.• If you take two or more tests in any nursing journal published by LWW andsend in your CE enrollment forms together, you may deduct $0.75 from theprice of each test.• We offer special discounts for as few as six tests and institutional bulk dis-counts for multiple tests. Call 1-800-933-6525, ext. 6617 or ext. 6621, for moreinformation.

To take this test online, visit http://www.nursingcenter.com/ce/nursing.

1. Which statement is correct about VAP?a. More patients die from VAP than any other noso-

comial pneumonia.b. VAP occurs in up to 48% of patients who need

mechanical ventilation.c. VAP is the least common type of nosocomial

pneumonia.d. VAP is characterized by bilateral pleural effusions.

2. Which statement is correct about an ET tube?a. It keeps microorganisms from entering the lungs.b. It helps the mucociliary transport system.c. It facilitates normal epiglottis closure.d. It predisposes patients to VAP.

3. Which statement is correct about late-onsetVAP?a. It occurs during the first 4 to 7 days of mechanical

ventilation.b. It can increase patient mortality rates by 50%.c. It’s usually easier to treat than early-onset VAP.d. It’s become significantly less prevalent recently.

4. Compared with intubation and mechanicalventilation, NPPVa. is inappropriate for use in home care.b. requires an oral or nasal ET tube.c. increases the risk of VAP.d. can provide assist-control ventilation.

5. Which statement is correct about NPPV?a. Copious bronchial secretions are easily removed

with NPPV.b. Full ventilatory support must be temporarily sus-

pended during oral nutrition.c. Loss of tidal volume is less likely with NPPV than

with an ET tube.d. A nasogastric tube can’t be used with NPPV.

6. Which statement is correct about an ET tubecuff?a. It should be inflated enough to keep the patient

from aspirating secretions that accumulate abovethe cuff.

b. It should be inflated to maximum volume once inthe trachea.

c. An inflated cuff can’t injure the wall of the trachea.d. Use a cuffless ET tube to decrease the risk of VAP.

7. Proper infection control practices for oralintubation includea. discarding an ET tube if esophageal intubation

occurs more than twice.b. disinfecting reusable laryngoscopes with alcohol

after each use.c. suctioning the oropharynx before intubation.d. avoiding the use of disposable stylets.

8. Which of the following is least likely to causeVAP?a. a properly secured ET tube b. unplanned extubationc. self-extubationd. reintubation

9. Aspiration precautions for an intubatedpatient includea. elevating the head of the bed no more than 20

degrees.b. suctioning above and below the cuff just before

extubation.c. suctioning through the ET tube only. d. deflating the cuff to prevent pooling of oral secre-

tions.

10. Which statement is correct about mouthcare for an intubated patient?a. Mouth care is contraindicated in a patient with an

ET tube.b. An alcohol-based oral rinse is recommended to

lower bacterial growth.c. Oral suctioning is needed during mouth care if the

patient can’t expectorate.d. Mouth care doesn’t affect the VAP rate.

11. Recommended guidelines for mechanicalventilation includea. routinely changing the ventilator circuit.b. changing in-line suction setups every 8 hours.c. changing passive humidifiers every 24 hours. d. changing the ventilator circuit when it’s visibly

soiled.

12. Which statement is correct about drainingventilator tubing condensation?a. Drain the fluid in the tubing toward the patient.b. Use an alcohol-based hand rub if your hands are

visibly soiled.c. Wearing gloves isn’t necessary.d. Discard any liquid that collects in the tubing.

13. Which statement is correct about passivehumidification systems?a. Heat and moisture exchangers (HMEs) have

received a clear recommendation for general use.b. Heated humidifiers should be filled with distilled,

nonsterile water.c. HMEs may increase microbial antibiotic resistance.d. HMEs decrease dead space.

14. To prevent aspiration during enteral feed-ings,a. use an orogastric tube instead of a nasogastric

tube if possible.b. elevate the patient’s head to at least 20 degrees

during continuous feedings.c. measure residual gastric volume at least every 12

hours during continuous feedings.d. stop the feeding for 4 hours if residual volume is

100 ml.

15. Common organisms implicated in early-onset VAP includea. Staphylococcus aureus.b. Acinetobacter baumannii.c. Pseudomonas aeruginosa.d. Moraxella catarrhalis.

Can you prevent ventilator-associated pneumonia?GENERAL PURPOSE To familiarize nurses with the latest recommendations for preventing ventilator-associated pneumonia (VAP). LEARNING OBJECTIVES Afterreading the preceding article and taking this test, you should be able to: 1. Identify the risk factors for and significance of VAP. 2. Describe prevention strategies for VAP.3. Identify the two types of VAP.

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