Purpose and Goal: CNEP # 2042

  • Describe the characteristics of ventilator-associated pneumonia.
  • Identify at least two strategies for the prevention of ventilator-associated pneumonia.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored.

Requirements for Successful Completion

  • Successfully complete the post-test.
  • Complete the evaluation form.

Date

  • September 2015 – September 2017

Learning Objectives

  • Describe the characteristics of ventilator-associated pneumonia.
  • Describe the neonatal risk factors for ventilator-associated pneumonia.
  • Describe at least two strategies for the prevention of ventilator-associated pneumonia.

Introduction

  • Ventilator-associated pneumonia is also known as VAP.
  • VAP is a healthcare-associated infection.
  • It is the second most common hospital-acquired infection.
  • VAP contributes to increased length of stay and hospital costs.

Ventilator-Associated Pneumonia

  • VAP is pneumonia that occurs in ventilated infants.
  • It occurs at or >48 hours of mechanical ventilation.
  • Occurs an average of 9 days following intubation.
  • Most common in low birthweight infants <750 grams.
  • Incidence is 7–32% of ventilated NICU infants.
  • Thought to be related to aspiration of oral secretions
    • Tracheal cultures consistent with oral bacteria
     
  • VAP contributes to increased:
    • Ventilator-dependent days
    • Length of stay
    • Morbidity and mortality
    • Widespread antibiotic use
     
  • Length of stay is increased by a minimum of 8 days.
  • Hospital costs are increased by a minimum of $51,157.

Neonatal Risk Factors

  • Neonates are at a higher risk of VAP.
  • Immature immune systems
    • Decreased complement activity
    • Abnormal granulocyte migration
    • Abnormal bacterial digestion
     
  • Immature barrier protection
    • Mucous membranes
    • Immature skin
     
  • Lack of maternal immunoglobulin protection
    • Preterm infants lack full protection.
    • Maternal protection occurs in third trimester.
     
  • Additionally VAP is associated with:
    • Low birthweight infants
    • Duration of mechanical ventilation
    • Reintubation
    • Endotracheal suctioning
    • Opiate treatment
     
  • Low-birthweight infants may require prolonged ventilation.
    • Multiple intubations
    • Multiple episodes of VAP
     
  • Additional risk factors
    • Previous bloodstream infections
    • Aspiration during intubation
    • Neuromuscular weakness
    • Transport out of NICU for procedures
     

Clinical Presentation

  • Worsening gas exchange
    • Oxygen desaturation
    • Increased oxygen requirement
    • Increased ventilatory support
     
  • Clinical signs and symptoms
    • Temperature instability
    • Leukopenia with left shift
    • Leukocytosis with left shift
    • New onset purulent sputum
    • Increased pulmonary secretions
    • Greater need for suctioning
    • Apnea
    • Tachypnea
    • Bradycardia
    • Tachycardia
    • Nasal flaring
    • Retractions
    • Grunting
    • Wheezing
    • Rales
    • Rhonchi
    • Cough
     
  • Chest radiographic evidence
    • Two or more chest radiographs with:
      • New infiltrates
      • Progressive infiltrates
      • Consolidations
      • Cavitation
      • Pneumatoceles
       
     

Diagnosis of VAP

  • There is no gold standard for diagnosis.
  • Tracheal cultures can be useful.
    • False negative can miss infection.
    • False positive can indicate colonization.
     
  • Clinical signs of VAP most important
    • More than 50% have negative cultures.
     
  • Most common organisms
    • Pseudomonas aeruginosa
      • Most common
       
    • Staphylococcus aureus
    • Enterobacter species
    • Klebsiella pneumoniae
     

Prevention of VAP

  • Several recommendations have been suggested.
  • Not all approaches are evidence-based.
  • Most studies have focused on adults.
  • VAP bundles first introduced in 2004
  • A bundle is a cohesive set of evidence-based practices.
    • Current CDC guidelines recommend use.
    • Education and team approach critical
     

Current VAP Bundle

  • Hand hygiene
    • Meticulous hand care is critical.
    • Hands should be cleansed before all cares.
    • Gloves should be worn for all cares.
     
  • Elevate head of bed.
    • Elevate 15–30 degrees.
    • Prevent aspiration of secretions.
      • Oral secretions
      • Gastrointestinal contents
       
     
  • Reduce the duration of intubation.
    • Most important strategy
    • Continually assess readiness to wean.
    • Extubate as soon as possible.
    • Avoid over-sedation and minimize opiate use.
     
  • Oral hygiene
    • Minimize colonization of oral mucosa.
    • Suction mouth before nose.
    • Use clean suction devices.
      • Avoid use of bulb syringes.
      • Replace devices every 12 hours.
       
    • Routinely perform with all cares
      • Before repositioning
      • Before planned extubation
      • Before moving or retaping ETT
      • Before changing OG or NG tubes
       
    • Sterile water or breastmilk may be used.
      • Use sterile gauze or cotton applicator.
      • Gently wipe gums, tongue, lips.
       
     
  • Endotracheal tube care
    • Use a sterile ETT for all intubations.
      • Do not set ETT on bed.
      • Do not touch lower ETT.
       
    • Use sterile intubation equipment.
    • Maintain secure ETT to avoid extubation.
    • Maintain sterile in-line suction equipment.
     
  • Prevent contamination of equipment.
    • Wear gloves when handling equipment.
    • Clean all equipment every 12 hours.
      • Use germicidal cleaning agent.
      • Clean general bed space.
        • High touch surfaces
         
      • Clean respiratory equipment.
        • Ventilator screen and knobs
         
       
    • Drain ventilator circuit condensation.
      • Maintain closed circuit.
      • Drain with all cares.
      • Drain before repositioning.
       
    • Suction only as clinically indicated.
      • No routine suctioning
      • No routine use of saline
      • Use sterile in-line suction.
        • Rinse suction catheter after use.
         
      • Use separate suction canisters.
        • Oral care canister
        • In-line suction canister
        • Change canisters every 72 hours.
         
       
    • Change ventilator circuits as needed.
      • When visibly soiled
      • With any malfunction
      • No routine changes
       
    • Store resuscitation bags outside of bed.
      • Store in a clean open plastic bag.
      • Replace when visibly soiled.
       
    • Monitor VAP bundle practices.
      • Monitor hand hygiene practices.
      • Monitor unplanned extubations.
      • Monitor all reintubations.
      • Monitor all diagnoses of VAP.
       
     

Summary

  • VAP is a common hospital-acquired infection.
  • Low-birthweight NICU infants are at highest risk.
  • Consistent approaches to prevention are critical.
  • VAP Bbundles are currently recommended.
    • Decreased incidence of VAP
    • Improved safety and NICU outcomes
     

References

  1. Stokowski, L. 2009. Ventilator Associated Pneumonia in Infants and Children. MedScape Nurses.
  2. Speer, M.E. 2004. Neonatal Pneumonia. Up-To-Date.
  3. Kollef, M.H. 2014. Clinical Presentation and Diagnosis of Ventilator-Associated Pneumonia. Up-To-Date.
  4. Foglia, E., Meier, M.D., and Elward, A. 2007. Ventilator-Associated Pneumonia in Neonatal and Pediatric Intensive Care Unit Patients. Clinical Microbiology Reviews, 20 (3), p 409-425.

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