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Ventilator-Associated Pneumonia 506 Advanced Pathophysiology Jenny Holloway Liberty University December 11, 2011

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Ventilator-Associated Pneumonia. 506 Advanced Pathophysiology Jenny Holloway Liberty University December 11, 2011. OBJECTIVES. - PowerPoint PPT Presentation

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Page 1: Ventilator-Associated Pneumonia

Ventilator-Associated Pneumonia506 Advanced Pathophysiology

Jenny HollowayLiberty University

December 11, 2011

Page 2: Ventilator-Associated Pneumonia

OBJECTIVES

The objectives of this presentation is to: Provide the learner with the

knowledge necessary to accurately define ventilator- associated pneumonia, including the ability to describe the pathophysiology process,

Identify the risk factors associated with VAP

Correctly apply appropriate nursing interventions to prevent VAP.

Page 3: Ventilator-Associated Pneumonia

Ventilator-Associated Pneumonia

According to the Centers for Disease Control VAP is diagnosed:– Patients must be mechanically ventilated

for > 48 hours and exhibit 3 out of the 5 symptoms:• Fever• Leukocytosis• Change in sputum (color and/or amount)• Radiographic evidence of new or worsening

infiltrates• Increase in oxygen requirementsCenters for Disease Control and prevention.(2011). Retrieved

fromhttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

VGCC
Page 4: Ventilator-Associated Pneumonia

Ventilator Associated Pneumonia

Second most common nosocomial infection Leading cause of death due to hospital acquired infections

Evans, B. (2005). Best-practice protocols: VAP prevention. Nursing Management, 36(12), 10-16

.

Brashers, V. (2006). Clinical applications of pathophysiology: An evidence-based approach (3rd ed.) St. Louis, MO: Mosby.

Page 5: Ventilator-Associated Pneumonia

Ventilator-Associated Pneumonia

Once viewed among health care providers as something that happens when a patient is on a ventilator

Now viewed as an error and is reportable to– Institute of Medicine– Leapfrog Group

Page 6: Ventilator-Associated Pneumonia

JOINT COMMISION MEASURES TO REDUCE VAP

JCAHO – hospitals required to show VAP prevention/reduction measures– 2011Standard:

NPSG.07.03.01 “Measure and monitor multidrug-resistant organism prevention processes and outcomes, including the following:- Multidrug-resistant organism infection rates using evidence- based metrics- Compliance with evidence-based guidelines or best practices- Evaluation of the education program provided to staff …”

http://www.jointcommission.org/assets/1/6/NPSG_EPs_Scoring_HAP_20110706.pdf

Page 7: Ventilator-Associated Pneumonia

VAP STATISTICS

Incidence = 9% to 70% of patients on ventilators

Increased ICU stay by several days

Increased avg. hospital stay 1 to 3 weeks

Mortality = 13% to 55%

Added costs of $40,000 - $50,000 per stay

Evans, B. (2005). Best-practice protocols: VAP prevention. Nursing Management, 36(12), 10-16.

Page 8: Ventilator-Associated Pneumonia

Hospital-acquired pneumonia (HAPs), including ventilator-associated pneumonia (VAP), often start in the oral cavity. Bacteria can colonize in the oropharyngeal area, and these pathogens can be aspirated into the lungs, causing infection. VAP is the most common infectious complication among ICU patients and accounts for over 47% of all infections.

Page 9: Ventilator-Associated Pneumonia

ASPIRATION OF BACTERIA IN VAP

“Dental plaque biofilm: Normal oral flora and their glue-like properties attach exogenous pathogens to the surface of the teeth, forming a multi-organism biofilm. This biofilm can fragment and travel in oral secretions. If aspirated, it may lead to infection (pneumonia).”

http://www.sageproducts.com/products/oral-hygiene/source-of-hap.cfm

Page 10: Ventilator-Associated Pneumonia

RISK FACTORS FOR VAP

Major risk factor = mechanical intubation

Factors that enhance colonization of the oropharynx &/or stomach:–Administration of antibiotics–Admission to ICU–Underlying chronic lung disease

Cook, D. J., & Walter, S. D. (1998). Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Annals Of Internal Medicine, 129(6), 433-440

.

Page 11: Ventilator-Associated Pneumonia

RISK FACTORS FOR VAP con’t

Conditions favoring aspiration into the respiratory tract or reflux from GI tract:–Supine position–History of GERD–NGT placement– Intubation and self-extubation– Immobilization–Surgery of head/neck/thorax/upper

abdomen

Cook, D. J., & Walter, S. D. (1998). Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Annals Of Internal Medicine, 129(6), 433-440

Page 12: Ventilator-Associated Pneumonia

RISK FACTORS FOR VAP con’t

Conditions requiring prolonged use of mechanical ventilatory support with potential exposure to contaminated respiratory devices &/or contact with contaminated hands

Host Factors:– Extremes of age

• very young and the very old– Malnutrition

• Even obese clients can be malnourished– Immunocompromised

• Cook, D. J., & Walter, S. D. (1998). Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Annals Of Internal Medicine, 129(6), 433-440

Page 13: Ventilator-Associated Pneumonia

INSTITUTE FOR HEALTHCARE IMPROVEMENT

The key components of the IHI Ventilator Bundle are:– Elevation of the Head of the Bed – Daily "Sedation Vacations" and Assessme

nt of Readiness to Extubate

– Peptic Ulcer Disease Prophylaxis – Deep Venous Thrombosis Prophylaxis – Daily Oral Care with Chlorhexidine

• http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilatorBundle.aspx

Page 14: Ventilator-Associated Pneumonia

VENTILATOR BUNDLE

Head of bed (HOB) elevation ≥30 degrees reduces the frequency and risk for nosocomial pneumonia compared to supine position by up to 34%

Augustyn, B. (2007). Ventilator-associated pneumonia: Risk factors and prevention. Critical Care Nurse, 27, 32-39.

Page 15: Ventilator-Associated Pneumonia

VENTILATOR BUNDLE

Implement a protocol to lighten sedation daily at an appropriate time to assess for neurological readiness to extubate.  Include precautions to prevent self-extubation such as increased monitoring and vigilance during the trial.

Include a sedation vacation strategy in your overall plan to wean the patient from the ventilator; if you have a weaning protocol, add "sedation vacation" to that strategy. http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilatorBundle.aspx

Page 16: Ventilator-Associated Pneumonia

VENTILATOR BUNDLE

A study in the 1980’s showed that using Ranitidine to reduce stress ulcers in ventilated patients did not decrease the risk of VAP, but reduced the risk of GI bleeding associated with stress ulcers

Augustyn, B. (2007). Ventilator-associated pneumonia: Risk factors and prevention. Critical Care Nurse, 27, 32-39.

Page 17: Ventilator-Associated Pneumonia

VENTILATOR BUNDLE

While it is unclear if there is a specific association between DVT prophylaxis and decreasing rates of ventilator-associated pneumonia, pt’s that are immobile have an increased risk of developing DVTs and PEs http://www.ihi.org/knowledge/Pages/Changes/ImplementtheVentilatorBundle.aspx

Page 18: Ventilator-Associated Pneumonia

VENTILATOR BUNDLE

Oral decontamination by pharmacological (Chlorhexidine) and mechanical (toothettes) means decrease the colonization of bacterial in the oropharynx

Augustyn, B. (2007). Ventilator-associated pneumonia: Risk factors and prevention. Critical Care Nurse, 27, 32-39.

Page 19: Ventilator-Associated Pneumonia

VENTILATOR BUNDLE

Although not a specific part

of the Ventilator bundle,

removing oral secretions

prior to position changes

was shown to reduce the

incidence of VAP in a study

conducted by Chao, et al

(2008).

Page 20: Ventilator-Associated Pneumonia

CONCLUSION

The ventilator bundle is a cost-effective program that when implemented and followed by nurses can directly impact the ventilated client in a positive manner.

Evans, B. (2005). Best-practice protocols: VAP prevention. Nursing Management, 36(12), 10-16.

Page 21: Ventilator-Associated Pneumonia

REFERENCES

References

Joint Commission. (2011). http://www.jointcommission.org/assets/1/6/NPSG_EPs_Scoring_HAP_20110706.pdf

Centers for Disease Control and Prevention Guidelines for Preventing Healthcare-Associated Pneumonia, 2003,

[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm]

Brashers, V. (2006). Clinical applications of pathophysiology: An evidence-based approach (3rd ed.) St. Louis, MO:

Mosby.

Chao, Y., Yin-Yin, C., Wang, K., Ru-Pin, L., & Hweifar, T. (2009). Removal of oral secretion prior to position

change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: a clinical controlled

trial study. Journal Of Clinical Nursing, 18(1), 22-28. doi:10.1111/j.1365-2702.2007.02193.x

Cook, D. J., & Walter, S. D. (1998). Incidence of and risk factors for ventilator-associated pneumonia in critically ill

patients. Annals Of Internal Medicine, 129(6), 433-440.

Evans, B. (2005). Best-practice protocols: VAP prevention. Nursing Management, 36(12), 10-16.

Augustyn, B. (2007). Ventilator-associated pneumonia: Risk factors and prevention. Critical Care Nurse, 27, 32-39.

Sage products. Retrieved from http://www.sageproducts.com/products/oral-hygiene/source-of-hap.cfm.