Ventilator Associated Pneumonia Best Practice

1. Ventilator Associated PneumoniaBest Practice Amy Shay, MS, CCRN, CNS

2. CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003 • If feasible, use an endotracheal tube with a dorsal lumen above the ET cuff to allow drainage (by continuous or frequent intermittent suctioning) of secretions that accumulate in the subglottic area. • Clear secretions above the ET cuff prior to deflating the cuff for any reason

3. CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003 • Gastric Alkalinization: stress ulcer prophylaxis raises gastric pH which may allow for gastric colonization with pathogens that can then be aspirated. • GI prophylaxis may increase VAP risk; Sucralfate may have less risk than H2 antagonists but is associated with increased risk of bleeding. • Grap MJ, Munro CLCrit Care Nurs Clin N Am, 16 2004

4. CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003 • Analysis of ten studies of small bowel feeding found that small bowel feedings are associated with reduction in gastroesophageal regurgitation, increase in protein and calories delivered, and shorter time to target dose of nutrition. • Results of 7 randomized trials: small bowel feeding compared to gastric had lower incidence of pneumonia. • Heyland, et al. JPEN 2002;26:S51-S55. • Kollef MH Crit Care Med 2004:32(6) • Heyland, el al. Crit Care Med 2001;29:1495-1501

5. CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003 • Elevate HOB to 30 to 45 degrees (if no contraindications): • Aspiration can occur even with a properly inflated ET cuff. Bacterial counts higher in aspirated secretions obtained while pts were in the supine (flat) position than in those obtained while patients were in thesemirecumbent position (45 degrees). Torres et al. Ann Int Med 1992;116:540-3. ■ Time spent with HOB in low position on day 1 of mechanical ventilation is most predictive of VAP in patients with high APACHE II scores. Grap MJ, Munro CL, et al. 2005 Am J Crit Care 14(4)

6. Shortening the duration of mechanical ventilation: Kollef MH Crit Care Med 2004:32(6) • Studies support the use of Protocols* • weaning days reduced by 2 • 50% reduction in vent related complications • Nurse/Therapist driven Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. Chest. 120(6). 2001 375S-395S. • Targeted Sedation protocols ATS/IDSA (2004) and SCCM (2002)

7. TracheostomyFowler Byers J, et al. Am J Crit Care Sept, 2000:9(5) • VAP twice as prevalent in patients with tracheostomy • Though not statistically significant: Patients who had tracheostomy within one week of admission had a lower incidence of VAP than those who had the procedure more than 1 week after adm. • Further study needed.

8. CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003 • “Develop and implement a comprehensive oral-hygiene program (that might include the use of an antiseptic agent) for patients …at high risk for HAP.” Schleder, Stott, & Lloyd, 2002

9. Oral Care: AACN • AACN 5th Edition, 2005 Scott JM, Vollman KM • Endotracheal Tube and Oral Care, Procedure # 4 • Unit One Pulmonary System • Perform ET suctioning only when clinically indicated • Oral hygiene should be performed every 2-4 hours and should include: • Toothbrushing at least two times a day; • Oral swabs with 1.5% hydrogen peroxide soln every 2-4 hours; • Mouth moisturizer to oral mucosa and lips • Subglottic suctioning continuously or intermittently

10. Oral Care: plaque Grap MJ, Munro CL 2004: • Toothbrushing is the most effective means of mechanical removal of plaque. Munro CL, Grap MJ, Elswick RK, el al: 2006;AmJ CritCare;15 • Higher plaque scores confer greater risk for VAP

11. Oral Care: use of antiseptics Fourrier 2005 Crit Care Med 33 • CHG – reduced colonization but not VAP Munro & Grap 2006 Crit Care Med 34 • CHG – effective in reducing VAP Seguin 2006 Crit Care Med 34 • Povidone-Iodine - decreased prevalence of VAP in head trauma

12. Appropriate staffing levels in the ICU • Inverse relationship between the adequacy of staffing levels and duration of stay and subsequent development of VAP. • Increased workloads for RNs and RTs lead to reliance on less trained personnel that may result in lapses in infection control • Kollef MH Crit Care Med 2004:32(6)

13. Appropriate staffing levels in the ICU • Critical Care Medicine 2007;vol 35, No 1 • Prospective cohort study 10,637 patient days Examined nurse/patient ratios and infection rates • Staffing is key determinant for healthcare associated infections in critically ill patients • Higher nursing skill mix (up to 87.5% RNs) lowers the incidence of adverse occurances Blegen, Goode, Reed Nurs Res 1998;47

14. Recommendation that everyone can agree on • Educational programs for RNs and RTs addressing VAP etiology and infection control procedures is associated with decreased VAP rates in the ICU setting. • Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Critical Care Medicine. 2002; 30(11): 2407-2412. • “Staff education….is a cornerstone for efforts to reduce the incidence of VAP.” Craven,D. Chest 2006;130 • Ventilator bundle staff educational sessions have a significant effect on clinical practice. • Tolentino-DelosReyes, Ruppert, Shyang-Yun, et al Am J Crit Care 2007; 16

15. VAP Rate & HOB ≥ 300

16. Oral Care Compliance & VAP Rate

17. Issues of debate in VAP prevention: • Oral care interventions: CHG, 1.5% Peroxide, Povidone Iodine, saliva substitutes, mechanical interventions • Removal of secretions: continuous vs intermittent • Endotracheal tube Biofilm – silver coated ET tubes? • Cost of prevention measures • acshay@mvh.org for questions