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

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.

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 requirements Centers for Disease Control and prevention.(2011). Retrieved fromhttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

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.

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

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

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.

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.

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

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 .

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

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

INSTITUTE FOR HEALTHCARE IMPROVEMENT The key components of the IHI Ventilator Bundle are: Elevation of the Head of the Bed Daily "Sedation Vacations" and Assessment 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

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.

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

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.

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

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.

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).

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.

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.