Ventilator Associated Pneumonia
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Transcript of Ventilator Associated Pneumonia
The Role of the Respiratory Therapist in the Diagnosis and Prevention of
Ventilator-Associated Pneumonia
Healthcare-associated infections (HAI)
Healthcare-associated pneumonia (HCAP)Pneumonia acquired during or immediately after admission to a healthcare facility (Such as a long-term care or outpatient facility)
Hospital-acquired pneumonia (HAP)Pneumonia acquired during or immediately after admission to an acute care facility, even as an outpatient
Ventilator-associated pneumonia (VAP)During or after intubation and initiation of mechanical ventilation
Clinical Definition of Pneumonia:Signs and Symptoms
At least one of the following:
• Fever (> 38 C/100.4 F) with no other identifiable cause
• Leukopenia (< 4,000 WBC/mm³) or leukocytosis (> 12,000 WBC/mm³)
• Altered mental status with no other cause, in > 70 y.o.
At least two of the following:
• New onset of purulent sputum, or change in character of sputum, or respiratory secretions, or suctioning requirements
• New onset or worsening cough, or dyspnea, or tachypnea
• Rales or bronchial breath sounds
• Worsening gas exchange (e.g., O2 desatsurations, O2 requirements, or ventilation demand)
Centers for Disease Control and Prevention
Early onset VAP
Develops 48 hours 72 hours post ventilator
Usually caused by:
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
(Grossman, et al. Evidence-Based Assessmant of Diagnostic Tests for Ventilator-Associated Pneumonia. Chest 2000)
Late onset VAP
Develops 72 hours post ventilator
Usually caused by:
Pseudomonas aeruginosa
methicillin-resistant Staphylococcus aureus (MRSA)
Acinetobacter baumannii
Enterobacteriaceae
(Grossman, et al. Evidence-Based Assessmant of Diagnostic Tests for Ventilator-Associated Pneumonia. Chest 2000)
(Uy, Ake, Regan, Niven. Impact of mini-BAL in High Risk Patients with Suspected Ventilator Associated Pneumonia (VAP). Chest 2007)
Why should I care about VAP?
• Medicare no longer covers the costs of preventable infections and mistakes. This includes all forms of HAIs
• 10% to 20% of patients intubated for 48 hours or longer will develop VAP.
• The mortality rate for VAP ranges from 24% to 50% and can reach 76%.
How do I diagnose VAP?
• Chest X-ray
• Sputum / Endotracheal aspirates (ETA)
• Clinical Pulmonary Infection Score (CPIS)
• Bronchoscopic bronchoalveolar lavage (BAL)
• Nonbronchoscopic bronchoalveolar lavage (mini-BAL)
Chest X-ray
http://medinfo.ufl.edu/year1/rad6190/planes_section.shtml
CXR• Not a reliable tool for diagnosing
pneumonia as the reproducibility of the findings may vary significantly.
• Pulmonary infiltrates may be due to pulmonary hemorrhage, chemical aspiration, pleural effusion, congestive heart failure, atelectasis, pulmonary embolism, or tumor as well as in VAP
ETA• Easily obtainable at the bedside by any
clinical personnel
• Inexpensive compared to other procedures
• Often contaminated by oral secretions
• Often leads to over diagnosis of VAP
Clinical Pulmonary Infection Score (CPIS)
Fiberoptic Bronchoscopic BAL
http://www.prodimed.com/images_produits/58228one_g.gif
Fiberoptic Bronchoscopic BAL
Pros
Most accurate diagnostic test available
Direct visualization and sampling of specific lung area
Allows identification of accompanying disease, disorder, or lesion
Cons
Highly invasive: greater potential for adverse effects
Limited by endotracheal tube (ETT) size; not available in pediatrics
Costly
Probable delays in use, not available 24 hours / day
May actually spread infection if improperly cleaned
Mini-BAL
InnoMed Combicath mini-BAL catheter
Mini-BAL
ProsSample may may be collected quickly
by RN or RCP
Much less expensive than bronchoscopic BAL
Limited and temporary adverse effects
Sterile equipment - no risk of cross-contamination
Protected specimen means higher specificity and sensitivity than ETA
Narrow catheter usable in most patient populations
ConsBlind procedure means unknown
sample site
More expensive than ETA
Requires trained personnel
How do I treat VAP?
Antibiotic Therapy
Empiric Treatment
Quantitative / Qualitative based Treatment
Oral Care
Organism inhibition
Suction
Ventilator bundle
Empiric Antibiotic TherapyPros - Based on most likely Gram negative organisms Allows for rapid initial treatment of suspected
pneumonia
Cons - Often a hit-or-miss option May lead to resistant organisms
Quantitative & Qualitative Antibiotic Therapy
Pros -• Identifies specific organisms and the measure of
each one• Allows for focused treatment by the best choice of
antibiotic
Cons -• Slow, requires waiting on the results of cultures• Dependent on invasive tests that may or may not
be available
Oral Care
Chlorhexidine mouthwash -
Inhibits Staphylococcus aureus bacterial growth (Tad-y)
Reduces intubation time (Scannapieco)
Reduces VAP risk (Scannapieco)
(Tad-y et al. Efficacy of Chlorhexidine Oral Decontamination in the Prevention of Ventilator-Associated Pneumonia. Chest 2007)
(Scannapieco et al. A randomized Trial of Chlorhexidine Gluconate on Oral Bacterial Pathogens in Mechanically Ventilated Patients. Critical Care. 2009)
Endotracheal Tubes
Traditional Endotracheal Tube
http://img.medscape.com/fullsize/migrated/455/533/iim455533.fig2.gif
Endotracheal Tubes
As a safety mechanism, the ETT cuff does not completely seal the airway - movement of the tube, checking cuff pressure, and patient movement will allow secretions to flow past the cuff into the lower airway and lung fields.
Medication to treat stress ulcers reduces the gastric pH often leading to colonization of gastrointestinal organisms which then migrate up the esophagus because the gastric sphincter is held open by the nasogastric tube.
Endotracheal Tubes
http://www.bsac.org.uk/pyxis/RTI/Ventilator%20associated%20pneumonia/Ventilator%20associated%20pneumonia.htm
Subglottic ETT
Subglottic Suction Devices (SSD) -Uses a dedicated irrigation channel to remove pooled
secretions above the ETT cuff. Suction port becomes clogged with purulent secretions or
by subglottic tissue Much more expensive than traditional tubes May cause policy conflicts if patients are intubated with
traditional tubes prior to arrival
Subglottic Suction ETT
Subglottic Suction
http://www.zapvap.com/images/drawings/humantrachea.gif
Ventilator Bundle
http://img.medscape.com/fullsize/migrated/547/460/ajcc547460.tab1.gif
Noninvasive VentilationMay be an option to endotracheal
intubation
Best used for short-term situations:
Myasthenia Gravis
ALS / Lou Gehrig’s
Obstructive Sleep Apnea (OSA)
Congestive Hart Failure (CHF)
Allows patient to be more involved in care decisions
Handwashing
According to the CDC - Clean hands are the single most
important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings.
Hand hygiene reduces the incidence of healthcare associated infections.
CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals, and about 90,000 of these patients die as a result of their infection.
http://implantblog.files.wordpress.com/2007/12/handwashing.jpg
Conclusions
Through aggressive adherence to established protocols, effective utilization of proven policies, and critical decision making, respiratory therapists can reduce costs and improve patient outcomes.