EVIDENCE-BASED CARESHEET

ICD-9997.31

ICD-10J18.9

AuthorsGilberto Cabrera, MD

Cinahl Information Systems, Glendale, CA

Tanja Schub, BSCinahl Information Systems, Glendale, CA

ReviewersRosalyn McFarland, DNP, RN, APNP,

FNP-BC

Teresa-Lynn Spears, RN, BSN, PHN, AE-C

Cinahl Information Systems, Glendale, CA

Nursing Executive Practice CouncilGlendale Adventist Medical Center,

Glendale, CA

EditorDiane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

October 30, 2015

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2015, Cinahl Information Systems. All rightsreserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or byany information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for adviceor information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcareprofessional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Pneumonia, Ventilator-Associated: Prevention

What We Know› Ventilator-associated pneumonia (VAP) is a life-threatening infection of the lower

airways that may develop in patients who are intubated and receiving mechanicalventilation.(1,2,6,7,10,11,13,14)(For more information on VAP, see Quick Lesson About …Pneumonia, Ventilator-Associated )• VAP is defined as pneumonia that occurs 48 hours or longer after endotracheal

intubation(1,2,7,11)

• Between 10% and 20% of patients requiring mechanical ventilation for more than48 hours develop VAP, with consequences including prolonged hospitalization andmechanical ventilation, high mortality rates, and increased hospital costs(1,9,11,13)

• VAP results from pathogenic invasion of the otherwise sterile lower respiratory tract incritically ill and, therefore, immunocompromised individuals. It is caused by microbialcolonization of the aerodigestive tract and aspiration of colonized oropharyngeal and/orgastric secretions into the lower airways(2,6,7,9,10,11)

–Factors associated with increased risk for developing VAP include longer duration ofintubation, altered neurologic status, advanced age, malnutrition, suppressed immunesystem, and use of acid-suppressing medications (e.g., proton pump inhibitors [PPIs;e.g., omeprazole], H2 blockers [e.g., ranitidine])(11)

› Strategies for prevention of VAP may include(1,2,3,5,6,9,10,11,12,13)

• good hand hygiene and use of gloves(11)

• elevating the head of the bed to 30–45° after enteral feedings to prevent aspiration,unless contraindicated(1,2,6,11,12)

• regular or continuous suctioning of oropharyngeal secretions(11,12)

• use of endotracheal tubes with subglottic secretion drainage(1,9,11)

–Authors of a systematic review and meta-analysis published in 2011 concluded that theuse of endotracheal tubes with subglottic secretion drainage can reduce the incidenceof VAP by ~ 50%(9)

• maintenance of appropriate endotracheal cuff pressures to minimize aspiration risk(2,6,11)

• daily sedation breaks and spontaneous breathing trials as appropriate to wean frommechanical ventilation(2,11)

• prophylactic antibiotic treatment to reduce the incidence of VAP in areas where theincidence is unacceptably higher(1,13)

–Researchers in a study of 129 comatose ICU patients reported that a single dose ofantibiotic prophylaxis at the time of intubation significantly reduced the incidence ofearly-onset VAP (i.e., VAP that develops within the first 4 days of intubation) but didnot affect rates of late-onsetVAP(13)

• use of silver-impregnated endotracheal tubes, antiseptic-impregnatedtubes, andendotracheal tubes that allow subglottic suctioning may reduce the risk of VAP(3)

• implementation of high-quality intensive oral hygiene, including oral swabbing,thorough toothbrushing, use of antiseptic mouthwash such as chlorhexidine gluconate

(CHX; a broad spectrum antibacterial solution) rinse 0.12%, and regular suctioning oforal secretions(1,2,5,10,11,12)

–The American Association of Critical-Care Nurses recommends providing mouth care every 2–4 hours in mechanicallyventilated patients(2)

–Cochrane reviewers evaluated 17 randomized trials including 2,402 patients and concluded that routine oral careincluding CHX rinse or gel is associated with a 40% reduction in VAP risk compared with placebo or usual care. Theyfound no significant differences in mortality, duration of mechanical ventilation, and duration of ICU stay(10)

- Some experts have noted limitations in the evidence supporting the efficacy of CHX oral care. Among these is thefact that the body of evidence is heavily influenced by 3 large studies including cardiac surgery patients who tend toexperience only short duration of intubation. Additional limitations include variations in the CHX treatment regimensused and failure to disclose other VAP prevention strategies employed in the studies(1,5)

- Investigators who conducted a systematic review of 16 randomized trials including 3,630 patients found evidence thatCHX-based oral care reduces risk of VAP in cardiac surgery patients, but not in other patients in the ICU(5)

• administration of probiotics(4)

–Investigators who undertook a recent meta-analysis concluded the administration of probiotics is associated with a 41%reduction in the incidence of VAP in trauma patients. Probiotics also reduced the incidence of other healthcare-associatedinfections and the length of ICU stay, but did not affect mortality rates(4)

• staff education, careful monitoring of respiratory status, and meticulous patient care using aseptic technique for invasiveprocedures and other infection-control strategies(12)

› Tracheostomy has been associated with a lower incidence of VAP than endotracheal intubation among critically ill patientsrequiring intubation. However, the evidence is inconclusive, and researchers in some studies have reported that tracheostomymay even increase the risk of VAP by disrupting airway integrity or by increasing the risk of bacterial contamination(8,14)

› Although it is known that individual interventions can significantly reduce VAP incidence, evidence on the efficacy ofa “ventilator care bundle,” a set of evidence-based practices used in combination to further improve outcomes, has beenmixed(6,11)

• Recent evidence, however, suggests that increased compliance with the ventilator care bundle including head of bedelevation, daily sedation breaks, gastric ulcer prevention, and deep vein thrombosis prophylaxis from 50% to 82%, resultedin a 42% reduction in the incidence of VAP(6)

What We Can Do› Learn more about VAP so you can accurately assess your patients’ personal characteristics and health education needs; share

this knowledge with your colleagues› Implement strategies to prevent VAP in your patients who are being mechanically ventilated(2,6,11,12)

• Elevate the head of the bed 30–45° (unless contraindicated), especially during and for 3 hours after enteral feedings, toreduce risk of aspiration–Frequently reposition and turn the patient from side to side since the patient may slide down in bed

• Follow facility protocol for tracheal suctioning and airway clearance–If possible, advocate for use of a silver-impregnatedendotracheal tube that allows continuous drainage of subglottic

secretions and may prevent infection• Provide antiseptic oral care to prevent colonization of the upper airways

–Perform comprehensive oral hygiene including daily oral assessment, and frequent toothbrushing, use of mouth swabs,use of mouthwash (e.g., CHX), and suctioning of oral secretions

• Closely monitor cuff pressure, ensuring that it is 20–30 cm H2O to prevent descent of microbes into the lower airway andaspiration

• Follow facility protocol for breaks from sedation, spontaneous breathing trials, and assessment of readiness to wean frommechanical ventilation

• Follow facility protocol for venous thromboembolism and pressure ulcer prophylaxis due to the patient’s sedentary state• Change ventilator circuits weekly, when broken, or according to facility protocol to minimize introduction of contaminants

to the circuit• Adhere to facility infection control protocols for hand hygiene, contact barrier precautions, and preventing contamination

from respiratory therapy equipment to help prevent VAP

Coding MatrixReferences are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations orother such materials

CP Conference proceedings, abstracts, presentation

References1. Buckley, M. S., Dzierba, A. L., Smithburger, P. L., McAllen, K. J., Jordan, C. J., & Kane-Gill, S. L. (2013). Chlorhexidine for the prevention of ventilator associated pneumonia in

critically ill adults. Journal of Infection Prevention, 14(5), 162-169. doi:10.1177/1757177413490814 (RV)

2. Curtin, L. J. (2011). Preventing ventilator-associated pneumonia: A nursing-intervention bundle. American Nurse Today, 6(3), 9-11. (GI)

3. Gentile, M. A., & Siobal, M. S. (2010). Are specialized endotracheal tubes and heat-and-moisture exchangers cost-effective in preventing ventilator associated pneumonia?Respiratory Care, 55(2), 184-197. (R)

4. Gu, W. J., Deng, T., Gong, Y. Z., Jing, R., & Liu, J. C. (2013). The effects of probiotics in early enteral nutrition on the outcomes of trauma: A meta-analysis of randomizedcontrolled trials. JPEN: Journal of Parenteral and Enteral Nutrition, 37(3), 310-317. doi:10.1177/0148607112463245 (M)

5. Klompas, M., Speck, K., Howell, M. D., Greene, L. R., & Berenholtz, S. M. (2014). Reappraisal of routine oral care with chlorhexidine gluconate for patients receivingmechanical ventilation: Systematic review and meta-analysis. JAMA Internal Medicine, 174(5), 751-761. doi:10.1001/jamainternmed.2014.359 (M)

6. Lawrence, P., & Fulbrook, P. (2011). The ventilator care bundle and its impact on ventilator-associated pneumonia: A review of the evidence. Nursing in Critical Care, 16(5),222-234. doi:10.1111/j.1478-5153.2010.00430.x (RV)

7. Mietto, C., Pinciroli, R., Patel, N., & Berra, L. (2013). Ventilator-associated pneumonia: Evolving definitions and preventive strategies. Respiratory Care, 58(6), 990-1003.doi:10.4187/respcare.02380 (GI)

8. Mosier, M. J., & Pham, T. N. (2009). American Burn Association practice guidelines for prevention, diagnosis, and treatment of ventilator-associated pneumonia (VAP) in burnpatients. Journal of Burn Care & Research, 30(6), 910-928. doi:10.1097/BCR.0b013e3181bfb68f (G)

9. Muscedere, J., Rewa, O., Mckechnie, K., Jiang, X., Laporta, D., & Heyland, D. K. (2011). Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: Asystematic review and meta-analysis. Critical Care Medicine, 39(8), 1985-1991. doi:10.1097/CCM.0b013e318218a4d9 (M)

10. Shi, Z., Xie, H., Wang, P., Zhang, Q., Wu, Y., Chen, E., ... Furness, S. (2013). Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. CochraneDatabase of Systematic Reviews, Issue 8. doi:10.1002/14651858.CD008367.pub2 (SR)

11. Strandring, D., & Oddie, D. (2011). Prevention of ventilator-associated pneumonia. British Journal of Cardiac Nursing, 6(6), 286-290. (RV)

12. Tablan, O. C., Anderson, L. J., Besser, R., Bridges, C., & Hajjeh, R. (2005). Guidelines for preventing health-care-associated pneumonia, 2003: Recommendations of CDC andthe Healthcare Infection Control Practices Advisory Committee. MMWR Recommendations and Reports, 53(RR-3), 1-36. doi:10.2174/157339810790820476 (G)

13. Valles, J., Peredo, R., Burgueno, M. J., Rodrigues de Freitas, A. P., Millan, S., Espasa, M., ... Artigas, A. (2013). Efficacy of single-dose antibiotic against early-onsetpneumonia in comatose patients who are ventilated. Chest, 143(5), 1219-1225. doi:10.1378/chest.12-1361 (R)

14. Veelo, D. P., Binnekade, J. M., & Schultz, M. J. (2010). Tracheostomy - causative or preventive for ventilator-associated pneumonia? Current Respiratory Medicine Reviews,6(1), 52-57. doi:10.2174/157339810790820476 (RV)