Ventilator Associated Pneumonia (VAP) Noor Tamari NUR 4216L

Objective Prevalence of VAP Understand the pathophysiology of VAP Know the S/S of VAP How VAP is Diagnosed Understand the prevention methods of VAP CASE STUDY

Why is it important 10-20% of patients requiring mechanical ventilation will develop VAP. Between 250,000 and 300,000 cases per year occur in the United States alone Increased morbidity and mortality VAP is associated with 15% of all nosocomial infections and 25% of the deaths associated with nosocomial infections. Higher costs – 40,000 dollars to 57,000 dollars more than a patient that does not develop VAP (Koeing, Truwit, 2006)

What is VAP? “VAP( Ventilator-Associated Pneumonia) is defined as a pneumonia occurring in patients requiring a device intermittently or continuously to assist respiration through a tracheostomy or endotracheal tube.” (“Safe Health Care”, 2007) “Further, the device must have been in place within the 48 hour period before onset of infection and for at least 2 consecutive days.” (“Safe Health Care”, 2007)

Signs and Symptoms Most common Fever (>38°C or >100.4°F) Rales or bronchial breath sounds Tachycardia New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements Worsening gas exchange (e.g., O2 desaturations increased oxygen requirements, or increased ventilator demand) (CDC, 2013)

Diagnosis Commonly used VAP criteria include new or progressive pulmonary infiltrate on chest radiograph fever (greater than 38.3ºC) leukocytosis purulent tracheobronchial secretions

Prevention is Key!!! Head of Bed Elevation >30 Prophylaxis to reduce DVT and PUD Daily interruptions of sedation and daily assessment of readiness for extubation Subglottic Suctioning CHX Swab

Early, single chlorhexidine application Randomized controlled clinical trial Purpose: investigate the effect of a single application of chlorhexidine (CHX) by swab on the development of (VAP) 55.6% of the control patients developed pneumonia compared to 33.3% of the intervention patients. Early, single application of CHX was found to reduce VAP (Grap, M, Munro, Hamilton, Elswick,, Sessler,, & Ward, 2011)

Treatment Prompt initiation of antibiotic therapy is a cornerstone of treatment of VAP However, when VAP is first suspected, the bacteria causing infection is typically not known Broad-spectrum antibiotics are given until the particular bacterium and its sensitivities are determined.

CASE STUDY Admitting Note Patient ID# Diagnosis: Coronary Atherosclerosis 78-year old male (DOB: 12/03/28) who after evaluation by cardiovascular surgery service on 4/29, was diagnosed with coronary artery disease. Admitted on 5/18 for elective surgery after an extensive pre-hospital multi- system work up. He has lost 30 pounds in the last 3 months. Cefazolin ordered on call to the operating room. (L) peripheral IV inserted PMH: Hyperlipidemia, renal insufficiency, myocardial infarction, obesity, pneumonia and urinary tract infection, bilateral cataracts, 10 years ago, unstable angina.

Case Study (Con) Admission Vital Signs & Labs: BP 130/70, P 88, R 20, Temp 37.1, Na 135, K 3.8, BUN 15, Cr 1.5, WBC 8.7, HCT 36 Surgical Procedure: Coronary Artery Bypass Graft using (L) was performed on 5/18 while the patient was under general anesthesia. Duration: 4 hours and 10 minutes. Admitted to CTICU on 5/18

5/18Afebrile, Lungs clear; intubated. (RIJ) internal jugular IV access device inserted. Foley catheter draining clear yellow urine. 5/19 – Temp 36.5; Bilateral rhonchi; Thin yellow blood-tinged secretions. Chest x-ray shows slight congestion with infiltrate in RLL 5/20 – Temp 38.6, Incision dressings clean and dry; Labored respirations (R=36), BP-96/50. Decreased O2 saturation, CXR-opacity in RLL. Bilateral rales on rhonchi. Suctioned for thick tan secretions. Sputum and blood cultures sent for C&S. Sputum culture- gram positive cocci

Does this patient meet the criteria for VAP?

YES, fever, purulent sputum The Facts: Had been on a vent. within the last 48 hours Febrile (38.6) New onset of purulent sputum Respiratory Distress (Rate= 36) 2 CXRs with RLL consolidation

What are some possible Nursing DX?

Ineffective Airway Clearance related to inflammation, the accumulation of secretions Impaired Gas Exchange related to alveolar capillary membrane changes Hyperthermia related to inflammatory processes Imbalanced Nutrition Less than body requirements Outcomes: -Afebrile; Effective Airway clearance; Optimal gas exchange, adequate oxygenation to the tissue; Meet the needs of adequate nutrition

Prognosis Late-onset VAP has poor prognosis in terms of mortality (66%) as compared to the early-onset type (20%) (Hina, Arun, Akhya, 2010) Case Study continued Started on IV antibiotics q6h on 5/21 Began weaning trials. Patient alert. Respiratory secretions decreased. Improved respiratory status. Extubated on 5/22 and transferred to 3 east next day.

NCLEX You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotraceal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics as scheduled 2. Hyperoxygenate the patient before suctioning 3. Maintain the head of the bed at a 30 - to 45-degree angle 4. All of the Above

Conclusion Prevention is Key! Treatment: Prompt initiation of antibiotic therapy S/S: Fever (>38°C or >100.4°F), Rales or bronchial breath sounds, Tachycardia, worsening gas exchange Prognosis: Late-onset VAP has poor prognosis in terms of mortality (66%) as compared to the early- onset type (20%)

References Safer Healthcare Now; Campaign, How –to guide: Prevention Ventilation-Associated Pneumonia. May 2007 p1-40. Grap, M., Munro, C., Hamilton, V., Elswick, R., Sessler, C., & Ward, K. (2011). Early, single chlorhexidine application reduces ventilator- associated pneumonia in trauma patients. Heart & Lung: The Journal Of Critical Care, 40(5), e115-e122 Gadani H, Vyas A, Kar AK. A study of ventilator-associated pneumonia: Incidence, outcome, risk factors and measures to be taken for prevention. Indian J Anaesth 2010;54: Centers for Disease Control and Prevention. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR 2004;53(No. RR-3). s.pdf