Ventilator Associated Pneumonia


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Ventilator Associated Pneumonia and the role of the Respiratory Therapist

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Ventilator Associated Pneumonia

  1. 1. The Role of the Respiratory Therapist in the Diagnosis and Prevention of Ventilator-Associated Pneumonia
  2. 2. Healthcare-associated infections (HAI) <ul><li>Healthcare-associated pneumonia (HCAP) </li></ul><ul><li>Pneumonia acquired during or immediately after admission to a healthcare facility (Such as a long-term care or outpatient facility) </li></ul><ul><li>Hospital-acquired pneumonia (HAP) </li></ul><ul><li>Pneumonia acquired during or immediately after admission to an acute care facility, even as an outpatient </li></ul><ul><li>Ventilator-associated pneumonia (VAP) </li></ul><ul><li>During or after intubation and initiation of mechanical ventilation </li></ul>
  3. 3. Clinical Definition of Pneumonia: Signs and Symptoms <ul><li>At least one of the following: </li></ul><ul><li>Fever (> 38 C/100.4 F) with no other identifiable cause </li></ul><ul><li>Leukopenia (< 4,000 WBC/mm³) or leukocytosis (> 12,000 WBC/mm³) </li></ul><ul><li>Altered mental status with no other cause, in > 70 y.o. </li></ul><ul><li>At least two of the following: </li></ul><ul><li>New onset of purulent sputum, or change in character of sputum, or  respiratory secretions, or  suctioning requirements </li></ul><ul><li>New onset or worsening cough, or dyspnea, or tachypnea </li></ul><ul><li>Rales or bronchial breath sounds </li></ul><ul><li>Worsening gas exchange (e.g., O2 desatsurations,  O2 requirements, or  ventilation demand) </li></ul>
  4. 4. Early onset VAP <ul><li>Develops  48 hours  72 hours post ventilator </li></ul><ul><li>Usually caused by: </li></ul><ul><li>Streptococcus pneumoniae </li></ul><ul><li>Haemophilus influenzae </li></ul><ul><li>Moraxella catarrhalis </li></ul><ul><li>(Grossman, et al. Evidence-Based Assessmant of Diagnostic Tests for Ventilator-Associated Pneumonia. Chest 2000) </li></ul>
  5. 5. Late onset VAP <ul><li>Develops  72 hours post ventilator </li></ul><ul><li>Usually caused by: </li></ul><ul><li>Pseudomonas aeruginosa </li></ul><ul><li>methicillin-resistant Staphylococcus aureus (MRSA) </li></ul><ul><li>Acinetobacter baumannii </li></ul><ul><li>Enterobacteriaceae </li></ul><ul><li>(Grossman, et al. Evidence-Based Assessmant of Diagnostic Tests for Ventilator-Associated Pneumonia. Chest 2000) </li></ul><ul><li>(Uy, Ake, Regan, Niven. Impact of mini-BAL in High Risk Patients with Suspected Ventilator Associated Pneumonia (VAP). Chest 2007) </li></ul>
  6. 6. <ul><li>Medicare no longer covers the costs of preventable infections and mistakes. This includes all forms of HAIs </li></ul><ul><li>10% to 20% of patients intubated for 48 hours or longer will develop VAP. </li></ul><ul><li>The mortality rate for VAP ranges from 24% to 50% and can reach 76%. </li></ul>
  7. 7. How do I diagnose VAP? <ul><li>Chest X-ray </li></ul><ul><li>Sputum / Endotracheal aspirates (ETA) </li></ul><ul><li>Clinical Pulmonary Infection Score (CPIS) </li></ul><ul><li>Bronchoscopic bronchoalveolar lavage (BAL) </li></ul><ul><li>Nonbronchoscopic bronchoalveolar lavage (mini-BAL) </li></ul>
  8. 8. Chest X-ray <ul><li> </li></ul>
  9. 9. CXR <ul><li>Not a reliable tool for diagnosing pneumonia as the reproducibility of the findings may vary significantly. </li></ul><ul><li>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 </li></ul>
  10. 10. ETA <ul><li>Easily obtainable at the bedside by any clinical personnel </li></ul><ul><li>Inexpensive compared to other procedures </li></ul><ul><li>Often contaminated by oral secretions </li></ul><ul><li>Often leads to over diagnosis of VAP </li></ul>
  11. 11. Clinical Pulmonary Infection Score (CPIS)
  12. 12. Fiberoptic Bronchoscopic BAL <ul><li>http://www. prodimed .com/images_ produits /58228one_g. gif </li></ul>
  13. 13. Fiberoptic Bronchoscopic BAL <ul><li>Pros </li></ul><ul><li>Most accurate diagnostic test available </li></ul><ul><li>Direct visualization and sampling of specific lung area </li></ul><ul><li>Allows identification of accompanying disease, disorder, or lesion </li></ul><ul><li>Cons </li></ul><ul><li>Highly invasive: greater potential for adverse effects </li></ul><ul><li>Limited by endotracheal tube (ETT) size; not available in pediatrics </li></ul><ul><li>Costly </li></ul><ul><li>Probable delays in use, not available 24 hours / day </li></ul><ul><li>May actually spread infection if improperly cleaned </li></ul>
  14. 14. Mini-BAL <ul><li>InnoMed Combicath mini-BAL catheter </li></ul>
  15. 15. Mini-BAL <ul><li>Pros </li></ul><ul><li>Sample may may be collected quickly by RN or RCP </li></ul><ul><li>Much less expensive than bronchoscopic BAL </li></ul><ul><li>Limited and temporary adverse effects </li></ul><ul><li>Sterile equipment - no risk of cross-contamination </li></ul><ul><li>Protected specimen means higher specificity and sensitivity than ETA </li></ul><ul><li>Narrow catheter usable in most patient populations </li></ul><ul><li>Cons </li></ul><ul><li>Blind procedure means unknown sample site </li></ul><ul><li>More expensive than ETA </li></ul><ul><li>Requires trained personnel </li></ul>
  16. 16. How do I treat VAP? <ul><li>Antibiotic Therapy </li></ul><ul><li>Empiric Treatment </li></ul><ul><li>Quantitative / Qualitative based Treatment </li></ul><ul><li>Oral Care </li></ul><ul><li>Organism inhibition </li></ul><ul><li>Suction </li></ul><ul><li>Ventilator bundle </li></ul>
  17. 17. Empiric Antibiotic Therapy <ul><li>Pros - </li></ul><ul><li>Based on most likely Gram negative organisms </li></ul><ul><li>Allows for rapid initial treatment of suspected pneumonia </li></ul><ul><li>Cons - </li></ul><ul><li>Often a hit-or-miss option </li></ul><ul><li>May lead to resistant organisms </li></ul>
  18. 18. Quantitative & Qualitative Antibiotic Therapy <ul><li>Pros - </li></ul><ul><li>Identifies specific organisms and the measure of each one </li></ul><ul><li>Allows for focused treatment by the best choice of antibiotic </li></ul><ul><li>Cons - </li></ul><ul><li>Slow, requires waiting on the results of cultures </li></ul><ul><li>Dependent on invasive tests that may or may not be available </li></ul>
  19. 19. Oral Care <ul><li>Chlorhexidine mouthwash - </li></ul><ul><li>Inhibits Staphylococcus aureus bacterial growth (Tad-y) </li></ul><ul><li>Reduces intubation time (Scannapieco) </li></ul><ul><li>Reduces VAP risk (Scannapieco) </li></ul><ul><li>(Tad-y et al. Efficacy of Chlorhexidine Oral Decontamination in the Prevention of Ventilator-Associated Pneumonia. Chest 2007) </li></ul><ul><li>(Scannapieco et al. A randomized Trial of Chlorhexidine Gluconate on Oral Bacterial Pathogens in Mechanically Ventilated Patients. Critical Care. 2009) </li></ul>
  20. 20. Endotracheal Tubes <ul><li>Traditional Endotracheal Tube </li></ul>
  21. 21. Endotracheal Tubes <ul><li>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. </li></ul><ul><li>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. </li></ul>
  22. 22. Endotracheal Tubes
  23. 23. Subglottic ETT <ul><li>Subglottic Suction Devices (SSD) - </li></ul><ul><li>Uses a dedicated irrigation channel to remove pooled secretions above the ETT cuff. </li></ul><ul><li>Suction port becomes clogged with purulent secretions or by subglottic tissue </li></ul><ul><li>Much more expensive than traditional tubes </li></ul><ul><li>May cause policy conflicts if patients are intubated with traditional tubes prior to arrival </li></ul>
  24. 24. Subglottic Suction ETT Subglottic Suction
  25. 25. Ventilator Bundle <ul><li>http:// img . medscape .com/ fullsize /migrated/547/460/ajcc547460.tab1. gif </li></ul>
  26. 26. Noninvasive Ventilation <ul><li>May be an option to endotracheal intubation </li></ul><ul><li>Best used for short-term situations: </li></ul><ul><li>Myasthenia Gravis </li></ul><ul><li>ALS / Lou Gehrig’s </li></ul><ul><li>Obstructive Sleep Apnea (OSA) </li></ul><ul><li>Congestive Hart Failure (CHF) </li></ul><ul><li>Allows patient to be more involved in care decisions </li></ul>
  27. 27. Handwashing <ul><li>According to the CDC - </li></ul><ul><li>Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings. </li></ul><ul><li>Hand hygiene reduces the incidence of healthcare associated infections. </li></ul><ul><li>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. </li></ul>
  28. 28. Conclusions <ul><li>Through aggressive adherence to established protocols, effective utilization of proven policies, and critical decision making, respiratory therapists can reduce costs and improve patient outcomes. </li></ul>