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Pneumonia presentation Pneumonia presentation Presentation Transcript

  • PNEUMONIA Mohammad reza rajabiBachelor of science in anesthesiaMaster of science in critical care Tehran university of medical sciences 1
  • ‫پنومونی آتیپیک(غیر نمادین اکتسابی از جامعه)‬ ‫بیماری تنفسی حاد تب دار با تغییرات التهابی ریه‬ ‫‪‬‬ ‫محدود به تیغه های آلوئولی و بافت بینابینی ریه‬ ‫‪‬‬ ‫واژه آتیپیک:‬ ‫بیانگر تولید خلط متوسط ، فقدان یافته های فیزیکی دال بر تراکم نسج ریه،‬ ‫افزایش ‪ ، WBC‬فقدان اگزودای آلوئولی‬ ‫علت: مایکوپالسما پنومونیه ( در بچه ها و بالغین جوان شایع تر)‬ ‫مکانیسم بیماری زایی:‬ ‫اتصال ارگانیسم به اپیتلیوم تنفسی و سپس نکروز سلولی ، واکنش التهابی،‬ ‫ریزش اپیتلیوم تنفسی، مهار عمل جاروبی مژه های مخاطی، زمینه ساز‬ ‫عفونت ثانویه باکتریال‬ ‫2‬
  • ‫درمان پنومونی ویروسی‬ ‫بی تاثیر‬ ‫‪ ‬آنتی بیوتیک ها در عفونت های ویروسی‬ ‫درمان حمایتی :‬‫تب و تاکی پنه باعث دفع نامحسوس مایع می شود‬ ‫‪ ‬مایع درمانی‬ ‫بهبود تب و سردرد‬ ‫‪‬داروی ضد تب‬ ‫بهبود سرفه‬ ‫‪‬ضد سرفه‬ ‫کاهش التهاب مجاری تنفسی‬ ‫‪‬بخور گرم‬ ‫کاهش عطسه و آبریزش بینی‬ ‫‪‬آنتی هیستامین‬ ‫3‬ View slide
  • ‫درمان پنومونی‬ ‫♠ تجویز آنتی بیوتیک مناسب بر حسب تعیین گرم میکروب‬ ‫♠ تجویز سریع آنتی بیوتیک در طی 8-4 ساعت در بیماران مشکوک به‬ ‫کلید درمان‬ ‫‪CAP‬‬ ‫♠ در پنومونی پنوموکوکی: ادامه درمان 27 ساعت بعد از قطع شدن تب‬‫♠ در پنومونی با علل باکتریال : ادامه درمان 2-1 هفته بعد از قطع شدن تب‬ ‫♠ در پنومونی آتیپیک : درمان 12-01 روز طول می کشد.‬ ‫4‬ View slide
  • ‫پنومونی آسپیراسیون‬ ‫‪ Ω‬ناشی از آسپیراسیون مواد آندروژن و اگزوژن به راه های هوایی تحتانی‬‫‪ Ω‬شایع ترین نوع : عفونت ناشی از آسپیراسیون باکتری های مستقر در راه های‬ ‫هوایی فوقانی‬ ‫‪ Ω‬هم در بیمارستان و هم در جامعه اتفاق می افتد.‬ ‫عوامل دیگر:‬ ‫عوامل بیماری زا:‬ ‫محتویات معده‬ ‫استرپتوکوک پنومونیه‬ ‫مواد شیمیایی اگزوژن‬ ‫هموفیلوس آنفلونزا‬ ‫استافیلوکوک آرئوس‬ ‫5‬
  • ‫تظاهرات بالینی پنومونی‬ ‫تدریجی، غیر اختصاصی‬ ‫شروع عالیم پنومونی‬‫‪ ‬تب و لرز ، سردرد ، درد پلورتیک ،درد عضالنی ، فارنژیت ، خستگی ، تعریق شبانه ،‬‫خلط موکوسی یا موکوسی – چرکی ، سیانوز مرکزی( لب ها و بستر ناخن ها:عالمت تاخیری‬ ‫هیپوکسی) ، ارتوپنه ، تاکی پنه ، سرفه‬ ‫بررسی و یافته های تشخیصی:‬ ‫تاریخچه‬ ‫معاینات جسمی‬ ‫رادیوگرافی‬ ‫کشت خون‬ ‫بررسی خلط‬ ‫6‬
  • ‫انواع روش های جمع آوری خلط‬‫1. شستن دهان با آب (کاهش فلور طبیعی دهان) ، چند بار نفس عمیق ، انجام‬ ‫سرفه ، ریختی خلط در ظرف استریل‬ ‫ساکشن بینی – تراشه ای‬ ‫2.‬ ‫ساکشن دهانی – تراشه ای‬ ‫3.‬ ‫بوسیله برونکوسکوپی فیبراپتیک‬ ‫4.‬ ‫7‬
  • ‫پنومونی در بیماران با نقص سیستم ایمنی‬ ‫‪‬مصرف کورتیکواستروئید ها‬ ‫‪‬شیمی درمانی‬ ‫‪‬نقصان تغذیه‬ ‫‪‬آنتی بیوتیک های وسیع الطیف‬ ‫‪‬ایدز‬ ‫انواع :‬ ‫‪‬پنومونی حاصل از پنوموسیتیس کارینی(‪) PCP‬‬ ‫‪‬پنومونی قارچی‬ ‫‪‬پنومونی حاصل از مایکوباکتریوم نوبرکلوزیس‬ ‫عالئم بالینی:‬ ‫تب ، سرفه بدون خلط ، تنگی نفس‬ ‫8‬
  • ‫پنومونی‬ ‫بیماری التهابی پارانشیم ریه که توسط عوامل مختلف میکروبی ایجاد می شود.‬ ‫شایع ترین علت مرگ ناشی از بیماری های عفونی در ایاالت متحده‬‫ساالنه 00066 نفر در اثر این بیماری می میرند و هفتمین علت مرگ در امریکا‬ ‫است.‬ ‫9‬
  • ‫طبقه بندی پنومونی‬ ‫طبقه بندی چهارگانه:‬ ‫باکتریال یا تیپیک‬ ‫آتیپیک‬ ‫غیرهوازی – حفره ای‬ ‫فرصت طلب‬ ‫نوع دیگر طبقه بندی:‬ ‫پنومونی اکتسابی از جامعه(‪) CAP‬‬ ‫پنومونی اکتسابی از بیمارستان (‪) HAP‬‬‫پنومونی در افراد مبتال به نقص سیستم ایمنی‬ ‫پنومونی ناشی از آسپیراسیون‬ ‫01‬
  • ‫پنومونی اکتسابی از جامعه‬ ‫منشا : باکتریال‬ ‫به دنبال عفونت ویروسی دستگاه تنفسی فوقانی(شروع آن ناگهانی)‬‫شایع ترین علت‬ ‫علت : استرپتوکوک پنومونیه( پنوموکوک)‬ ‫عالئم :‬ ‫تب باال‬ ‫لرز‬ ‫درد پلورتیک‬ ‫سرفه خلط دار با خلط موکوسی - چرکی‬ ‫11‬
  • ‫سایر ارگانیسم های دخیل در پنومونی حاد اکتسابی از جامعه‬ ‫1( هموفیلوس آنفلوانزا( شایع ترین علت باکتریال تشدید ‪ ) COPD‬شایع ترین‬ ‫ویروس ایجاد کننده پنومونی در نوزادان و بچه ها‬ ‫موراکسال کاتارالیس ( تشدید حاد ‪) COPD‬‬ ‫2(‬‫استافیلوکوک طالئی ( با شیوع باالی عوارض مثل آمپیم و آبسه های ریوی )‬ ‫3(‬ ‫کلبسیال پنومونیه ( شایع ترین عامل پنومونی باکتریال گرم منفی)‬ ‫4(‬ ‫پسودومونا آئروژینوزا‬ ‫5(‬ ‫6( لژیونال پنوموفیلیا‬ ‫21‬
  • Health Care–associated Pneumonianumerous outpatients benefit from health careservices such as dialysis, chemotherapy, orambulatory surgery. Similarly, in most nursinghomes and rehabilitation hospitals, patients canreceive intensive and/or invasive medicaltherapies 13
  • Four Classes Of Pneumonia1. Community-acquired pneumonia2. Ventilator-associated pneumonia3. Hospital-acquired pneumonia4. Health care–associated pneumonia 14
  • Community-acquired Pneumonia (CAP) common infectious disease affecting about 1 per 1,000of the adult population per year. An intensive care unit (ICU) admission for severeCAP is required for 2% of patients most frequent pathogen is Streptococcus pneumoniae Despite progress in antibiotic therapymortality remains elevated 15
  • Diagnosis Of Community-acquired Pneumoniaclinical symptoms:1.cough 2.dyspnea3.sputum production 4.pleuritic chest pain5.elevated body temperature.These symptoms can be absent or moderated in olderpatients.not specific signs of pneumonia;a chest radiograph or computed tomography (CT) scanrevealing a new infiltrate 16
  • Chest Radiograph Allows1.staging of severity localization number of involved lobes.2.detect complications pleural effusion Cavitation acute respiratory distress syndrome [ARDS] 17
  • Definition Of Severe CAPone of two major criteria : need for mechanical ventilation septic shocktwo of three minor criteria : systolic blood pressure < 90 mm Hg multilobar involvement on chest radiograph  PaO2/FiO2 < 250 mm Hg) 18
  • Assessing The Severity Of CAPFour “core” factors )CURB score(: Confusion blood Urea nitrogen > 19 mg/dL [7 mmol/L] Respiratory rate > 30 breaths/minute Blood pressure—systolic < 90 mm Hg or diastolic <60 mm Hg)two “additional” factors : hypoxemia (SpO2 < 92% or PaO2 < 60 mm Hg [8kPa] bilateral or multilobar involvement on chest radiographtwo “pre-existing” factors : age 50 years or older the presence of coexisting disease 19
  • CAP Was Considered Severe When Any One Of The Following Criteria Was Present:1. Respiratory frequency greater than 30 breaths per minute on admission2. Severe respiratory failure (PaO2/FiO2 <250 mm Hg)3. Requirement for mechanical ventilation4. Bilateral or multilobar or extensive (greater than or equal to 50% within 48 hours of admission) involvement of the chest radiograph5. Shock (systolic blood pressure less than 90 mm Hg or diastolic blood pressure less than 60 mm Hg)6. Requirement for vasopressors for more than 4 hours7. Low urine output (less than 20 mL/hour or less than 80 mL/4 hours) or acute renal failure requiring dialysis 20
  • Diagnostic Studies1.Sputum stains and cultures2.endotracheal aspiration3.protected brush4.bronchoalveolar lavage5.transtracheal aspiration6.Blood cultures drawn before antibiotic therapy, are rarely positive (6%–20% of cases) and, when positive, are most often for S. pneumoniae, Staphylococcus aureus, and Gram-negative bacilli. 21
  • Specific Etiologies In Immunosuppressed Patients♠ Immunosuppressed patients have an increased risk of severe CAP♠ Human immunodeficiency virus (HIV) infected patients used to have a 25-fold higher risk of developing bacterial pneumonia♠ Patients with chemotherapy-induced neutropenia ( < 500 neutrophils/µL( & prolonged ) >10 days)♠ Patients with solid organ transplant♠ monoclonal antibody therapies♠ Patients treated by anti–tumor necrosis factor (TNF) - α monoclonal antibodies 22
  • Treatment Of Severe CAP Antimicrobial spectrum The ideal antibiotic should have a “kill spectrum” to cover all pathogens responsible for severe CAP Timing of initial therapy administration within 4 hours of admission 23
  • Treatment Of Severe CAP…Antimicrobial choices β-Lactam antibiotics cefotaxime ceftriaxone ampicillin sulbactam)  Macrolides erythromycin Clarithromycin azithromycin Fluoroquinolones Levofloxacin ciprofloxacinRetrospective studies have suggested that some combination regimens 24
  • Treatment Of Severe CAP… pneumonia caused by S. pneumoniae Continue until thepatient has been afebrile for 72 hours Bacteria causing necrosis of the pulmonary parenchyma (e.g.,S. aureus, P. aeruginosa, Klebsiella, and anaerobes) shouldprobably be treated for no less than 2 weeks. Pneumonia caused by intracellular organisms should probablybe treated for at least 2 weeks. 25
  • Treatment Of Severe CAP…Nonantimicrobial Therapy1.Activated Protein C2.Corticosteroids 200 mg IV bolus followed by infusion at a rate of 10 mg/hour for 7 days significant improvement in PaO2/FiO2 and chest radiograph score & decreased length of hospital stay and mortality 26
  • Expected Clinical CourseEvaluation On Day 3a decrease in fever and oxygenation requirements is notobserved in responding patients prior to day 3 or 4.In the absence of rapid clinical deterioration, initialtherapy should not be changed prior to completion of 48to 72 hours of the initial therapy. 27
  • Ventilator-associated Pneumonia (VAP)is defined as a pneumonia occurring in intubated or tracheotomizedpatients undergoing mechanical ventilation. Although usualguidelines suggest a delay of 48 to 72 hours between the beginningof mechanical ventilation and the occurrence of pneumonia toqualify for this diagnosis 28
  • Ventilator-associated Pneumonia (VAP) Defined: hospital-acquired pneumonia occurring within 48 h after initiation of mechanical ventilation with trachael intubation Diagnosis: Presence of a new, persistent, or progressive infiltrate on a chest X-ray 29
  • Early And Late VAP Time PathogensEarly Onset Pneumonia that develops Usually include: VAP between 48-96 hours after Staphylococcus aureus (Methicillin being placed on the ventilator sensitive-MSSA) Haemophilus influenza Streptococcus pneumoniaeLate Onset Pneumonia that develops Usually include: VAP after 96 hours )≥5 days) on Staphylococcus aureus (Methicillin ventilator resistant – MRSA) Pseudomonas aeruginosa Acinetobacter or Enterobacter 30
  • Clinical Presentation Of Pneumonia •Purulent secretions •Densities on Chest x-ray •Fever •Leukocytosis (high wbc)
  • Why Are Ventilated Patients More Susceptible To Pneumonia?Normal Clearance Mechanisms and Reflexes are: 1. Air failtration in nasal cavityBypassedBlocked 2. Mucociliary escalatorInhibited 3. Cough mechanism 32
  • “Aspiration of oropharyngeal pathogens or leakage of bacteria around the endotracheal tube cuff is the primary route of bacterial entry into the trachea.” 33
  • Ventilator-associated Pneumonia (VAP)major dilemmas regarding VAP :1. Prevention remains a challenge.2. There is no gold standard for diagnosis.3. The rate of multidrug-resistant causative pathogenshas dramatically increased during recent years.4. Prompt initiation of an adequate antibiotic therapy isessential. 34
  • Pathogenesis…rarely associated with VAP :1. Inhalation of gastric material2. direct inoculation of bacteria into the lower respiratory tractthrough contaminated “devices” Aerosol Bronchoscopes ventilator circuit Nebulizer tracheal suctioning 36
  • Pathogenesis… main routeAspiration of bacteria colonizing the oropharynx is the main route ofentry into the lower respiratory tract.Colonization of the oropharyngeal airways by pathogenic micro-organisms occurs during the first hospital week in most critically illpatientsThe stomach, sinuses, and dental plaque may be potential reservoirsfor pathogens colonizing the oropharynx 37
  • Ventilator-associated Pneumonia (VAP) Risk Factors♠ male gender♠ pre-existing pulmonary disease♠ coma♠ AIDS♠ head trauma♠ age older than 60 years♠neurosurgical procedures♠ multiorgan system failure♠ mechanical ventilation impairs ciliary clearance and cough limits the draining of secretions that leak around the cuff♠ other devices nebulizers or humidifiers 38
  • Increases The Risk Of VAP1. Accidental extubation, rather than reintubation2. administered by a nasogastric (rather than a postpyloric ) The nasogastric tube might increase the risk of reflux and subsequent colonization of the airways3. H2 blockers or antacids favors gastric colonization and may contribute to VAP.4. intracuff pressure less than 20 cm H2O5.Tracheostomy6.aerosol treatment7.supine position8.patient transportation out of the ICU9.sedation10.failed subglottic aspiration 39
  • Diagnostic Strategies And Diagnostic Testing (VAP)(a) the diagnosis of pneumonia must be established fever or hypothermia leukocytosis or leucopenia Tachycardia Purulent sputum decline in oxygenation pulmonary infiltrates on chest radiograph 40
  • Diagnostic Strategies And Diagnostic Testing )VAP(…b) the etiologic pathogen of this pulmonary parenchymalinfection must be identifiedBlood cultures (rarely positive)bronchoalveolar lavage (BAL)endotracheal aspirationprotected specimen brush (PSB) 41
  • ‫درجهبندي شدت پنوموني و نیاز به درمان سرپایي یا بستري کردن بیمار و‬ ‫پیشبیني مرگ ومیر معیار )‪)PORT‬‬‫‪PNEUMONIA PATIENT OUTCOMES RESEARCH TEAM‬‬ ‫34‬
  • ‫‪Pneumonia Patient Outcomes Research Team‬‬ ‫میزان درجه بندی‬ ‫مشخصات بیمار‬‫برابر سن بر حسب سال‬ ‫سن‬ ‫01 سال منهای سن‬ ‫مرد‬ ‫01 سال بعالوه سن‬ ‫زن‬ ‫مدتی که در خانه تحت پرستاری بوده است‬ ‫بیماری های همراه‬ ‫03‬ ‫بیماری های سرطانی‬ ‫02‬ ‫بیماری های کبدی‬ ‫01‬ ‫بیماری های کلیوی،‪CVA ، CHF‬‬ ‫یافته های بالینی‬ ‫02‬ ‫اختالل هوشیاری،03>‪SBP<90 ، RR‬‬ ‫51‬ ‫‪T<35OC,T>40OC‬‬ ‫01‬ ‫521<‪PR‬‬ ‫یافته های رادیوگرافیک یا آزمایشگاهی‬ ‫03‬ ‫53/7<‪PH‬‬ ‫02‬ ‫03>‪Na<130,BUN‬‬ ‫01‬ ‫052>‪ ,PO2<60,Hct<30,BS‬پلورال افیوژن‬ ‫44‬
  • ‫براساس معیار:‪PORT‬‬ ‫نمرهي زیر 07 به طور سرپایي‬ ‫باالي 09 باید بستري شوند‬‫آنها که 07 تا 09 ميباشند باید مدتي در اورژانس تحتنظر و راجع به بستري و‬ ‫ترخیص بعداً تصمیمگیري شود.‬ ‫54‬
  • Antibiotic TreatmentPrinciples of Initial Empiric Treatment1. Prompt initiation of adequate antimicrobial treatment is a cornerstone of therapy for VAP2. Iregui et al. studied 107 patients suffering from VAP 33 received delayed appropriate antibiotic treatment—defined as a period greater than or equal to 24 hours between the time VAP was suspected and the administration of adequate treatment. These patients exhibited a significantly higher mortality than those receiving nondelayed treatment (69.7% vs. 28.4%; p <0.001). 46
  • Guidelines For Initial Empiric Antibiotic TherapyOn the basis of the time of onset of VAP and the presenceor absence of risks for multidrug-resistant pathogens In patients with no risk factors for multidrug-resistantpathogens and an early-onset VAP (duration ofhospitalization less than 5 days), limited-spectrumantibiotic therapy based on monotherapy seemsappropriate In patients with late-onset VAP (greater than or equalto 5 days) or exhibiting risk factors for multidrug-resistant pathogens, a broad-spectrum antibiotic regimenbased on two or three combined antibiotics is usuallyrequired 47
  • Guidelines For Initial Empiric Antibiotic Therapy1. Early-onset VAP and no risk factors for multidrug-resistantpathogens •Ceftriaxone (1–2 g/24 h) or •Levofloxacin (750 mg/24 h), moxifloxacin (400 mg/24 h), or ciprofloxacin (400 mg/8 h) or •Ampicillin (1–2 g) plus sulbactam (0.5–1 g)/6 h or •Ertapenem (1 g/24 h) 48
  • Guidelines For Initial Empiric Antibiotic Therapy…2. Late-onset VAP or risk factors for multidrug-resistant pathogens•Antipseudomonal cephalosporin: Cefepime (1–2 g/8–12 h) or ceftazidime (2 g/8h)or•Antipseudomonal carbapenem: Imipenem (500 mg/6 h or 1 g/8 h) or meropenem(1 g/8 h)or•β-Lactam/β-lactamase inhibitor: Piperacillin-tazobactam (4.5 g/6 h)plus•Antipseudomonal fluoroquinolone: Levofloxacin (750 mg/24 h) or ciprofloxacin(400 mg/8 h)or•Aminoglycosidea: Gentamicin (7 mg/kg/24 h) or tobramycin (7 mg/kg/24 h) oramikacin (20 mg/kg/24 h)plus•Vancomycin (15 mg/kg/12 h)aor•Linezolid (600 mg/12 h) 49
  • Duration Of Therapy optimal duration was unknown experts empirically recommended a 14- to 21-day treatmentduration ATS/IDSA guidelines suggest shortening the duration of therapyto 7 days 8 - 15 days of antibiotic treatment were equally effective A prospective, multicenter, randomized, double-blind trial was performedRecent studies demonstrated that empiric antibiotic therapy couldbe safely discontinued after 72 hours when a noninfectious etiologyfor the pulmonary infiltrates is discovered or when signs andsymptoms of active infections resolve 50
  • Prognosis Of Ventilator-associated Pneumonia crude mortality rates : vary from 24% to 76% *malignancy *immunosuppression*ASA grade 3 or more *age older than 64 years*anticipated death within 5 years severity of disease justifying ICU admission high APACHE II score Simplify Acute Physiology Score greater than 37 51
  • Prognosis Of Ventilator-associated Pneumonia… initial severity of VAPchest radiographic involvement of more than one lobeplatelet count <150,000 cells/µLLogistic Organ Dysfunction score > 4time of onset of VAP > 3 daysSurgeryHypotension initial therapeutic approach (delayed initialappropriate antibiotic treatment) 52
  • Prevention Of Ventilator-associated Pneumonia£ hand washing£ glove use£ sterile equipment£ Adequate staffing£ When intubation is necessary, the orotracheal route is preferred£ Use of Noninvasive positive pressure ventilation£ reduce the duration of mechanical ventilation£ Ventilator circuit management£ optimized sedation and weaning protocols£ semirecumbent (45-degree) patient position£ Postpyloric feeding£ Continuous aspiration of subglottic secretions 53
  • Measures Recommended By The Centers For Disease Control And Prevention To Reduce The Incidence Of Ventilator-associated Pneumonia Changing the breathing circuits of ventilators only when theymalfunction or are visibly contaminated Preferential use of orotracheal rather than nasotracheal tubes Use of noninvasive ventilation Use of an endotracheal tube with a dorsal lumen to allowdrainage of respiratory secretions 54
  • 55
  • Hospital-acquired Pneumoniahospital-acquired pneumonia (HAP) : a pneumonia occurring less than 2 days from hospitaladmission, but without any criteria defining ventilator-associatedpneumonia Mortality rate 18.8% and 53% 56
  • ‫پنومونی بیمارستانی (‪) HAP‬‬‫‪‬عالئم آن 84 ساعت بعد از بستری شدن در بیمارستان تظاهر می یابد.‬ ‫‪ % 15‬عفونت های بیمارستانی را به خود اختصاص می دهد.‬ ‫‪‬کشنده ترین عفونت بیمارستانی‬ ‫تظاهرات بالینی:‬‫تب ، عالئم تنفسی ، خلط چرکی ، لکوسیتوز ، تاکی کاردی ، افیوژن پلور‬ ‫شرایط مستعد کننده :‬ ‫‪‬افراد دارای بیماری زمینه ای شدید‬ ‫‪‬مصرف داروهای سرکوب کننده ایمنی‬ ‫‪‬درمان آنتی بیوتیکی طوالنی مدت‬ ‫‪‬تهویه مکانیکی‬ ‫75‬
  • Health Care–associated Pneumonia And Nursing Home PneumoniaHCAN patients who : was hospitalized in an acute care hospital for 2 or more dayswithin 90 days of the infection resides in a nursing home or long-term care facility (LTCF) received recent intravenous antibiotic therapy, chemotherapy, orwound care within 30 days of the current infection attends a hospital or hemodialysis clinic 58
  • Risk Factors In Nursing Home functional status diminished ability to clear airways underlying comorbidities (such as chronic obstructivepulmonary disease and heart disease) swallowing disorders use of sedatives. 59
  • Etiology Of Nursing Home–acquired Pneumonia♠ S. pneumoniae♠ H. influenzae♠ Gram-negative bacilli♠ S. aureus 60
  • CDC DEFINITION OF PNEUMONIAHoran TC, Andrus M, Dudreck MA. CDC/NHSN surveillance definition of health-care associated infection and criteria for specific types of infection in the acute care 61
  • Etiology- Select Risk Factors ForPathogensStreptococcus pneumoniae Smoking, COPD, absence of antibiotic therapyHaemophilus influenzae Smoking, COPD, absence of antibiotic therapyMSSA Younger age, Traumatic coma, NeurosurgeryMRSA COPD, steroid therapy, longer duration of MV, prior antibioticsPseudomonas aeruginosa COPD, steroid therapy, longer duration of MV, prior antibioticsAcinetobacter species ARDS, head trauma, neurosurgery, gross aspiration, prior cephalosporin therapy Park DR. The microbiology of ventilator-associated pneumonia. 62
  • Objectives State the definition for ventilator associated pneumonia (VAP) Define who is at greatest risk for the development of VAP Describe effective strategies for reducing the incidence of VAP 63
  • How Do We Diagnose? 2-1-2 Radiographic evidence x 2 consecutive days … New, progressive or persistent infiltrate … Consolidation, opacity, or cavitation At least 1 of the following: … Fever (> 38 degrees C) with no other recognized cause … Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000 WBC/mm3) At least 2 of the following: … New onset of purulent sputum or change in character of secretions … New onset or worsening cough, dyspnea, or tachypnea … Rales or bronchial breath sounds … Worsening gas exchange )↓ sats, P:F ratio < 240, ↑ O2 req.) 64
  • HOB Elevation > 30 Degrees On All Mechanically Ventilated Patients Contraindications  Hypotension MAP <70  Tachycardia >150  CI <2.0  Central line procedure  Posterior circulation strokes  Cervical spine instability use reverse trendelenburg  Some femoral lines ie: IABP no higher than 30 degrees use reverse trendelenburg  Increased ICP, No higher than 30 degrees avoid hip flexion  Proning 65
  • Continuous Infusions: Daily Wake Up All infusions should be at the lowest rate to achieve effect IV bolus therapy should be used to supplement infusion when necessary Every patient must be awakened daily unless contraindicated! 66
  • Daily Wake Up Wean infusion to off in increments of 10-25% daily in order to perform a clinical assessment Rebolus and restart infusion if the patient becomes symptomatic. Your new continuous IV dose should be lower than what you began with Goal is to decrease sedation 67
  • Why? Sedation Vacation Has been demonstrated to reduce overall patient sedation Promotes early weaningIdentified Issues and Concerns Increases potential for self-extubation Increases potential for patient pain and anxiety Increases episodes of desaturationAnecdotal Experience Promotes early extubation No significant increase in patient self-extubation 68
  • Endotracheal Intubation Contributes to the development of VAP: … Causes mucosal injury, producing decreased mucociliary clearance … Decreases effectiveness of cough … Increases binding sites for bacteria … Increases mucus secretion … Provides a reservoir for bacteria Reintubation is a significant risk factor for VAP 69
  • Airway Management Mechanical ventilation … Avoidance  Mask ventilation trials … Orotracheal intubation  Nasotracheal intubation may slightly increase the risk for VAP … Ventilator circuitry changes  Change only when soiled or malfunctioning … Cuff management  Maintain at 25-30 cm H2O 70
  • Suctioning Oral suction devices (Yankauer) … Policies for use and storage not written … Harbor potentially pathogenic bacteria within 24 hours … 71% of nurses store the device in its packaging (STAMP) … Best practice???  Change q day  Rinse with sterile water or NS  Allow to air dry 71
  • Subglottal Suctioning Should be done using a 14 Fr sterile suction catheter: … Prior to ETT rotation … Prior to lying patient supine … Prior to extubation Continuous subglottic suctioning … ETT with dedicated lumen to continuously or intermittently suction above the cuff may reduce the risk of VAP 72
  • Continuous Removal Of Subglottic Secretions Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation. 73
  • Drainage Of Subglottic Secretions 74
  • Primary Route Of Bacterial Entry Into Lower Respiratory Tract Micro or macro aspiration of oropharyngeal pathogens Leakage of secretions containing bacteria around the ET cuff 75
  • Risks For MDRAmerican Thoracic Society, Infectious Diseases Society of America. Guidelines forthe management of adults with hospital-acquired, ventilator-associated, andhealthcare-associated pneumonia. 76
  • Pathophysiology Of Ventilator-associated Pneumonia (VAP) Hospital-acquired (nosocomial) pneumonia: pneumonia that occurs 48 hr or more after admission to the hospital, and was not incubating at the time of admission Healthcare associated pneumonia: pneumonia associated with 2 or more days of hospitalization within previous 90 days, residence in a nursing home or long-term care facility, receipt of intravenous antibiotic, chemotherapy, or wound care within the previous 30 days, or attendance at a hospital or hemodialysis clinic Ventilator-associated pneumonia: pneumonia that develops more than 48-72 hr after endotracheal intubation 77
  • Pathophysiology Of Ventilator-associated Pneumonia (VAP) Sources of pathogens include the environment (water and equipment) and bacteria transferred between patients by staff Severity of underlying disease, prior surgery, exposure to antibiotics, and use of invasive respiratory equipment major risk factors Intubation and mechanical ventilation increase the risk of hospital-acquired pneumonia 6- to 21-fold 78
  • Pathophysiology Of Ventilator-associated Pneumonia (VAP) Aspiration of oropharyngeal pathogens (aerobic gram-negative bacilli, Staphylococcus aureus) by leakage around the endotracheal tube cuff major route of entry for bacteria into lower respiratory tract Infected biofilm in the endotracheal tube with subsequent embolization to distal airways may be important Complications: drug-resistant pneumonia, polymicrobial pneumonia, superinfection with Pseudomonas aeruginosa or Acinetobacter with high mortality, empyema, lung abscess, Clostridium difficile colitis, occult infection, bacteremic sepsis with multiple organ involvement 79
  • Pathophysiology Of Tuberculosis (Chronic Pneumonia) Source of Mycobacterium tuberculosis an infected patient with active pulmonary disease M. tuberculosis transmitted by coughing, sneezing, or talking with release of infected respiratory secretion as aerosols (droplet nuclei) Droplet nuclei (1-5 µm) penetrate deep alveolar spaces and M. tuberculosis infects non-immune macrophages as facultative intracellular pathogens 80
  • Clinical Signs And Symptoms Of Atypical Pneumonia Syndrome Sore throat and hoarseness initially Fever, malaise, coryza, headache, and cough with variable sputum production Leukocyte >10,000/mm3 in ~20% of cases Chest X-ray usually indicates more extensive pulmonary involvement than clinical findings suggest, with unilateral or bilateral patchy infiltrates in a bronchial or peribronchial distribution Extrapulmonary findings with Legionella pneumophila: mental status changes, loose stools or diarrhea, bradycardia, elevated liver enzymes, hypophosphatemia, hyponatremia, elevated serum lactate dehydrogenase, and elevated serum creatinine levels 81
  • Clinical Signs And Symptoms Of Chronic Pneumonia Initially fever, chills, and malaise Progressive anorexia and weight loss Pulmonary symptoms appear later with worsening cough productive of sputum, dyspnea, hemoptysis, and/or pleuritic chest pain Leukocyte count often normal (exceptions: pancytopenia in miliary tuberculosis, neutrophilic leukocytosis in pulmonary actinomycosis) X-ray findings: nodular or rounded lesions, cavities, with characteristic involvement of upper lobes (tuberculosis, histoplasmosis) 82
  • Specimen Collection, Staining, Evaluation, And Culture Pharyngitis: throat swab Acute pneumonia: sputum Ventilator-associated pneumonia: bronchoalveolar lavage (BAL), bronchial brushings Chronic pneumonia: sputum, BAL 83
  • Problem Identification Patients that are receiving continuous mechanical ventilation have 6 to 21 times greater risk of developing hospital-associated pneumonia than patients not on mechanical ventilationTablan OC, “Guidelines for preventing health-care--associated pneumonia, 2003,” Recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC), 2003. According to an AJCC study, VAP occurs in 10 to 65% of ventilated critical care patients mortality rates between 20 and 70%Sole ML, Am J Crit Care, 2002 84
  • Problem Identification A recent, 9,080-patient study found that the average VAPpatient spends 9.6 additional days on mechanicalventilation, 6.1 extra days in the ICU, and11.5 more days in the hospital And VAP costs over $40,000 per case totreat—all paid for by the facilityRello, Chest, 2002 85
  • VAP . . .WHAT IS IT?Ventilator-Associated PneumoniaMost common nosocomial bacterialinfection among patients requiringmechanical ventilationRello, Chest, 2002 86
  • VAPIncreased mortality in critically illpatients (20% - 70%)Increased cost of care:$40,000 additional cost per patientCDC guidelines from Preventing Healthcare Pneumonias, 2003 AACN Practice alert 87
  • Risk Factors For Developing VAPPatients at extreme of age spectrum; malnutrition; severeunderlying conditionsArtificial airwayColonization of dental plaque with respiratory pathogensBacterial colonization of the oropharyngeal areaAspiration of subglottic secretionsHead of bed < 30 degrees 88
  • Risk Factors For Developing VAP Colonization of Dental Plaque with respiratory pathogens Bacterial Colonization of the oropharyngeal area Aspiration of subglottic secretions 89
  • Recommended Best Practice Water based moisturizers provide hydration Non-alcoholic oral rinses Mouthwash with hydrogen peroxide actives naturally occurring peroxidase which resists bacterial colonization in the oral pharynxNursing Mgt., Vol. 34, Supplement 3, May 2003 90
  • Recommended Best Practice Soft bristle toothbrush removes plaque and stimulates the mucosa Sodium bicarbonate toothpaste overcomes odor, dissolves mucous, eliminates breeding ground for bacteria, and reduces acidity Mouthwash with an antiseptic agent has an antimicrobial effect on the oral cavityNursing Mgt., Vol. 34, Supplement 3, May 2003 91
  • Albert, NEJM 1981; Preston, AJM 1981; Tablan, 1994 92
  • In the absence of medical contraindication(s).CDC Guideline for Prevention of Healthcare Associated Pneumonias, 2003Drakulovic et al, Lancet, 1999,354:1851 93
  • Oral Cavity Suction the oral cavity Swab the oral cavity every 4 hours and PRN to cleanse and maintain oral mucosal integrity Moisturize oral cavity every 4 hours 94
  • Brush Teeth Brush teeth 2 times per day to remove dental plaque 95
  • Oropharyngeal Suctioning Suction every 12 hours to remove secretions from the oropharyngeal area above the vocal cords. 96
  • Nosocomial Pneumonia Second most common nosocomial infection in US … 15% of all hospital-associated infections … incidence range from 4.2 to 7.7/1000 discharges Associated with substantial morbidity and mortality: VAP mortality can reach 60% in ICU Risk Factors for nosocomial pneumonia … extremes of age … severe underlying disease … immunosuppression … depressed sensorium … cardiopulmonary disease … thoracic-abdominal surgery … mechanically assisted ventilation 97
  • Nosocomial Infections Lower Respiratory Infections Modifiable Risk Factors Strong evidence  Some evidence … Avoid over sedation … Semi-recumbent … Avoid paralytics … Noninvasive … Closed suctioning ventilation … Orotracheal … Continuous lateral intubation rotation … Maintain adequate cuff pressures … Subglottic … Avoid H2 suctioning antagonists 98
  • What Is VAP? A nosocomial pneumonia associated with mechanical ventilation that develops within 48 hours or more of hospital admission and which was not developing at the time of admission - early onset VAP - late onset VAP Langer M. et al. Intensive Care Med 1987;13:342-6 99
  • Why Do We Care? Hospital acquired pneumonia (HAP) is the second most common hospital infection VAP is the most common intensive care unit (ICU) infection (10-20%) 90% of all nosocomial infections occurring in ventilated patients are pneumonias 100
  • Diagnosis And Treatment Of Ventilator-associated Pneumonia Avoidovertreatment Immediate without VAP treatment of patients with VAP Objective 1 Objective 2 101
  • How To Diagnosis Of VAP?1. Clinical approach : CPIS2. Bacteriological approach : quatitative culture with or without bronchoscope 102
  • Mandell Principles and Practice of Infectious Disease 6th ed.2005,3362-70 103
  • Clinical diagnosis 104
  • Am J Respir Crit Care Med 2000;162:505-11 105
  • GRAM STAIN Sputum or tracheal suction gram stain NO ORGANISMS in non-neutropenic pts. NO HAP/VAP 94% 106
  • Bacterial Culture Of Tracheal Secretion Qualitative culture - non specific Semi-quantitative culture - low specificity Quantitative culture : TS, BAL, PSB - increase specificity 107
  • Identification Of The Problem VAP Statistics … leading cause of death due to nosocomial infection in ICUs. … Mechanically-ventilated patients: 9% to 28% … Mortality rate: 40% - 80%. … Hospital length of stay: 4-9 days. … Hospital cost: $29,000 - $40,000 per patient. 108
  • Current Guidelines Oral care with antiseptic agents can decrease the incidence of VAP.  No optimal concentration or formulation is specified. Oral hygiene (removal of plaque from teeth and gums) is recommended every 12 hours. Oral care (removal of secretions from oropharynx and moisturizing the mouth and lips) is recommended every 4 hours. 109
  •  Nosocomial pneumonia ranks second in morbidity and first in mortality among nosocomial infections mortality rate of VAP : 54% -71% VAP occurs : 9% to 24% of patients The treatment of nosocomial pneumonia adds 5 to 7 days to the hospital stay of surviving patients mortality is particularly high in pneumonia attributed to Pseudomonas or Acinetobacter. 110
  • Risk Factors For Ventilator-associated Pneumonia (VAP) presence of an endotracheal tube and continuous ventilatory support enteral nutrition therapy lack of elevation of the head of the bed and the patient’s position dental plaque 111
  • Presence Of An Endotracheal Tube Allows : direct entry of bacteria into the pulmonary tract impairs the cough reflex slows the action of the mucociliary escalator slows promotes excessive secretion of mucus 112
  • Significance Of Nosocomial Pneumonias Increases ventilatory support requirements and ICU stay by 4.3 days Increases hospital LOS by 4 to 9 days Increases cost - > $11,000 per episode Estimates of VAP cost / year for nation > $ 1.2 billion 113
  •  One of the most critical risk factors for the development of nosocomial pneumonia in patients who are receiving continuous ventilatory support (ie, VAP) is colonization of the oropharynx 114
  • Factors Increase Bacterial Colonization Of TheOropharynx mechanical ventilation Within 48 hours of hospital admission, the composition of the oropharyngeal flora of critically ill patients undergoes a change to predominantly gram- negative organisms, constituting a more virulent flora that includes potential VAP pathogens. dental plaque dental plaque of patients in the ICU is colonized by potential respiratory pathogens such as “methicillin-resistant Staphylococcus aureus” and “Pseudomonas aeruginosa”. 115
  • Prevention Strategies  Head elevation  Ventilator equipment changes  Continuous removal of subglottic secretions  Handwashing 116
  • Continuous Removal Of Subglottic Secretions Use an ET tube with continuous suction through a dorsal lumen above the cuff to prevent drainage accumulation. 117
  • HOB ElevationHOB at 30-45º 118
  • HandwashingWhat role does handwashing play in nosocomial pneumonias? 119
  • VAP PreventionWash hands or use an alcohol-based waterless antiseptic agent before and after suctioning, touching ventilator equipment, and/or coming into contact with respiratory secretions. 120
  • No Data To Support These Strategies Use of small bore versus large bore gastric tubes Continuous versus bolus feeding Gastric versus small intestine tubes Closed versus open suctioning methods Kinetic beds 121
  • Reference1. U. Lucangelo, P. Pelosi, W.A. Zin, A. Aliverti (eds.) Respiratory System and Artificial Ventilation. ©Springer 20082. Infectious Diseases in Critical Care Medicine.third edition. Edited by Burke A. Cunha, # 2010 by Informa Healthcare USA, Inc. Informa Healthcare is an Informa business3. Gabrielli, Andrea; Layon, A. Joseph; Yu, Mihae ,Civetta, Taylor, & Kirbys: Critical Care, 4th Edition Copyright ©2009 Lippincott Williams & Wilkins, Chapter 111 ,Respiratory Infections in the ICU 122