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

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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

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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

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Ventilator Bundle

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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.

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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.