PNEUMONIA

Mohammad reza rajabi

Bachelor of science in anesthesia

Master of science in critical care

Tehran university of medical sciences

1

(غیر نمادین اکتسابی از جامعه)پنومونی آتیپیک

ریه التهابی تغییرات با دار تب حاد تنفسی بیماری

ریه بینابینی بافت و آلوئولی های تیغه به محدود

:آتیپیک واژه

ریه، نسج تراکم بر دال فیزیکی های یافته فقدان ، متوسط خلط تولید بیانگر

آلوئولی اگزودای فقدان ، WBC افزایش

(تر شایع جوان بالغین و ها بچه در ) پنومونیه مایکوپالسما :علت

:زایی بیماری مکانیسم

التهابی، واکنش ، سلولی نکروز سپس و تنفسی اپیتلیوم به ارگانیسم اتصال

ساز زمینه مخاطی، های مژه جاروبی عمل مهار تنفسی، اپیتلیوم ریزش

باکتریال ثانویه عفونت

2

درمان پنومونی ویروسی

آنتی بیوتیک ها در عفونت های ویروسی بی تاثیر

:درمان حمایتی

مایع درمانی تب و تاکی پنه باعث دفع نامحسوس مایع می شود

داروی ضد تب بهبود تب و سردرد

ضد سرفه بهبود سرفه

بخور گرم کاهش التهاب مجاری تنفسی

آنتی هیستامین کاهش عطسه و آبریزش بینی

3

درمان پنومونی

تجویز آنتی بیوتیک مناسب بر حسب تعیین گرم میکروب ♠

ساعت در بیماران مشکوک به 4-8تجویز سریع آنتی بیوتیک در طی ♠

CAP کلید درمان

ساعت بعد از قطع شدن تب 72ادامه درمان : در پنومونی پنوموکوکی ♠

هفته بعد از قطع شدن تب 1-2ادامه درمان : در پنومونی با علل باکتریال ♠

.روز طول می کشد 10-21درمان : در پنومونی آتیپیک ♠

4

پنومونی آسپیراسیون

Ω ناشی از آسپیراسیون مواد آندروژن و اگزوژن به راه های هوایی تحتانی

Ω عفونت ناشی از آسپیراسیون باکتری های مستقر در راه های : شایع ترین نوع

هوایی فوقانی

Ω هم در بیمارستان و هم در جامعه اتفاق می افتد.

:عوامل دیگر: عوامل بیماری زا

استرپتوکوک پنومونیه محتویات معده

هموفیلوس آنفلونزا مواد شیمیایی اگزوژن

استافیلوکوک آرئوس

5

تظاهرات بالینی پنومونی

شروع عالیم پنومونی تدریجی، غیر اختصاصی

، تب و لرز ، سردرد ، درد پلورتیک ،درد عضالنی ، فارنژیت ، خستگی ، تعریق شبانهعالمت تاخیری :لب ها و بستر ناخن ها) چرکی ، سیانوز مرکزی –خلط موکوسی یا موکوسی

، ارتوپنه ، تاکی پنه ، سرفه( هیپوکسی

:بررسی و یافته های تشخیصی

تاریخچه

معاینات جسمی

رادیوگرافی

کشت خون

بررسی خلط

6

انواع روش های جمع آوری خلط

، چند بار نفس عمیق ، انجام ( کاهش فلور طبیعی دهان)شستن دهان با آب 1.

سرفه ، ریختی خلط در ظرف استریل

تراشه ای –ساکشن بینی 2.

تراشه ای –ساکشن دهانی 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 .شود می ایجاد میکروبی مختلف عوامل توسط که ریه پارانشیم التهابی بیماری

متحده ایاالت در عفونی های بیماری از ناشی مرگ علت ترین شایع

امریکا در مرگ علت هفتمین و میرند می بیماری این اثر در نفر 66000 ساالنه

.است

9

طبقه بندی پنومونی

:طبقه بندی چهارگانه

باکتریال یا تیپیک

آتیپیک

حفره ای –غیرهوازی

فرصت طلب

:نوع دیگر طبقه بندی

( CAP)پنومونی اکتسابی از جامعه

( HAP)پنومونی اکتسابی از بیمارستان

پنومونی در افراد مبتال به نقص سیستم ایمنی

پنومونی ناشی از آسپیراسیون

10

پنومونی اکتسابی از جامعه

باکتریال: منشا

(شروع آن ناگهانی)به دنبال عفونت ویروسی دستگاه تنفسی فوقانی

شایع ترین علت (پنوموکوک) استرپتوکوک پنومونیه: علت

: عالئم

تب باال

لرز

درد پلورتیک

چرکی -سرفه خلط دار با خلط موکوسی

11

سایر ارگانیسم های دخیل در پنومونی حاد اکتسابی از جامعه

شایع ترین ( COPD شایع ترین علت باکتریال تشدید ) هموفیلوس آنفلوانزا 1)

ویروس ایجاد کننده پنومونی در نوزادان و بچه ها

( COPDتشدید حاد ) موراکسال کاتارالیس 2)

(با شیوع باالی عوارض مثل آمپیم و آبسه های ریوی ) استافیلوکوک طالئی 3)

(شایع ترین عامل پنومونی باکتریال گرم منفی) کلبسیال پنومونیه 4)

پسودومونا آئروژینوزا 5)

لژیونال پنوموفیلیا6)

12

Health Care–associated Pneumonia

numerous outpatients benefit from health care

services such as dialysis, chemotherapy, or

ambulatory surgery. Similarly, in most nursing

homes and rehabilitation hospitals, patients can

receive intensive and/or invasive medical

therapies

13

Four Classes Of Pneumonia

1. Community-acquired pneumonia

2. Ventilator-associated pneumonia

3. Hospital-acquired pneumonia

4. Health care–associated pneumonia

14

Community-acquired Pneumonia

(CAP)

common infectious disease affecting about 1 per 1,000

of the adult population per year.

An intensive care unit (ICU) admission for severe

CAP is required for 2% of patients

most frequent pathogen is Streptococcus pneumoniae

Despite progress in antibiotic therapy

mortality remains elevated

15

Diagnosis Of Community-acquired Pneumonia

clinical symptoms:

1.cough 2.dyspnea

3.sputum production 4.pleuritic chest pain

5.elevated body temperature.

These symptoms can be absent or moderated in older

patients.

not specific signs of pneumonia;

a chest radiograph or computed tomography (CT) scan

revealing a new infiltrate

16

Chest Radiograph Allows

1.staging of severity

localization

number of involved lobes.

2.detect complications

pleural effusion

Cavitation

acute respiratory distress syndrome [ARDS]

17

Definition Of Severe CAP

one of two major criteria :

need for mechanical ventilation

septic shock

two 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 CAP

Four “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 radiograph

two “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 admission

2. Severe respiratory failure (PaO2/FiO2 <250 mm Hg)

3. Requirement for mechanical ventilation

4. Bilateral or multilobar or extensive (greater than or equal to 50%

within 48 hours of admission) involvement of the chest radiograph

5. 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 hours

7. Low urine output (less than 20 mL/hour or less than 80 mL/4 hours) or

acute renal failure requiring dialysis

20

Diagnostic Studies

1.Sputum stains and cultures

2.endotracheal aspiration

3.protected brush

4.bronchoalveolar lavage

5.transtracheal aspiration

6.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

ciprofloxacin

Retrospective studies have suggested that some combination regimens

24

Treatment Of Severe CAP…

pneumonia caused by S. pneumoniae Continue until the

patient has been afebrile for 72 hours

Bacteria causing necrosis of the pulmonary parenchyma (e.g.,

S. aureus, P. aeruginosa, Klebsiella, and anaerobes) should

probably be treated for no less than 2 weeks.

Pneumonia caused by intracellular organisms should probably

be treated for at least 2 weeks.

25

Treatment Of Severe CAP…

Nonantimicrobial Therapy 1.Activated Protein C

2.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 Course

Evaluation On Day 3

a decrease in fever and oxygenation requirements is not

observed in responding patients prior to day 3 or 4.

In the absence of rapid clinical deterioration, initial

therapy should not be changed prior to completion of 48

to 72 hours of the initial therapy.

27

Ventilator-associated Pneumonia

(VAP)

is defined as a pneumonia occurring in intubated or tracheotomized

patients undergoing mechanical ventilation. Although usual

guidelines suggest a delay of 48 to 72 hours between the beginning

of mechanical ventilation and the occurrence of pneumonia to

qualify 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 Pathogens

Early Onset

VAP

Pneumonia that develops

between 48-96 hours after

being placed on the ventilator

Usually include:

Staphylococcus aureus (Methicillin

sensitive-MSSA)

Haemophilus influenza

Streptococcus pneumoniae

Late Onset

VAP

Pneumonia that develops

after 96 hours )≥5 days) on

ventilator

Usually include:

Staphylococcus aureus (Methicillin

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?

1. Air failtration in nasal cavity

2. Mucociliary escalator

3. Cough mechanism

32

Bypassed

Blocked

Inhibited

Normal Clearance Mechanisms and Reflexes are:

“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 pathogens

has dramatically increased during recent years.

4. Prompt initiation of an adequate antibiotic therapy is

essential.

34

Pathogenesis…

rarely associated with VAP :

1. Inhalation of gastric material

2. direct inoculation of bacteria into the lower respiratory tract

through contaminated “devices”

Aerosol

Bronchoscopes

ventilator circuit

Nebulizer

tracheal suctioning

36

Pathogenesis…

main route

Aspiration of bacteria colonizing the oropharynx is the main route of

entry into the lower respiratory tract.

Colonization of the oropharyngeal airways by pathogenic micro-

organisms occurs during the first hospital week in most critically ill

patients

The stomach, sinuses, and dental plaque may be potential reservoirs

for 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 VAP

1. Accidental extubation, rather than reintubation

2. administered by a nasogastric (rather than a postpyloric )

The nasogastric tube might increase the risk of reflux and subsequent

colonization of the airways

3. H2 blockers or antacids

favors gastric colonization and may contribute to VAP.

4. intracuff pressure less than 20 cm H2O

5.Tracheostomy

6.aerosol treatment

7.supine position

8.patient transportation out of the ICU

9.sedation

10.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 parenchymal

infection must be identified

Blood cultures (rarely positive)

bronchoalveolar lavage (BAL)

endotracheal aspiration

protected specimen brush (PSB)

41

و درجه بندي شدت پنوموني و نیاز به درمان سرپایي یا بستري کردن بیمار

( (PORTپیش بیني مرگ و میر معیار PNEUMONIA PATIENT OUTCOMES RESEARCH TEAM

43

Pneumonia Patient Outcomes Research Team

مشخصات بیمار میزان درجه بندی

سن برابر سن بر حسب سال

مرد سال منهای سن 10

زن سال بعالوه سن 10

مدتی که در خانه تحت پرستاری بوده است

بیماری های همراه

بیماری های سرطانی 30

بیماری های کبدی 20

CHF ،CVAبیماری های کلیوی، 10

یافته های بالینی

RR>30 ،SBP<90اختالل هوشیاری، 20

15 T<35OC,T>40OC

10 PR<125

یافته های رادیوگرافیک یا آزمایشگاهی

30 PH<7/35

20 Na<130,BUN>30

10 ,PO2<60,Hct<30,BS>250 44 پلورال افیوژن

:PORTبراساس معیار

به طور سرپایي 70نمره ي زیر

باید بستري شوند 90باالي

مي باشند باید مدتي در اورژانس تحت نظر و راجع به بستري و 90تا 70آنها که

.ترخیص بعدا تصمیم گیري شود

45

Antibiotic Treatment

Principles of Initial Empiric Treatment

1. Prompt initiation of adequate antimicrobial treatment

is a cornerstone of therapy for VAP

2. 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 Therapy

On the basis of the time of onset of VAP and the presence or absence of risks for multidrug-resistant pathogens

In patients with no risk factors for multidrug-resistant pathogens and an early-onset VAP (duration of hospitalization less than 5 days), limited-spectrum antibiotic therapy based on monotherapy seems appropriate

In patients with late-onset VAP (greater than or equal to 5 days) or exhibiting risk factors for multidrug-resistant pathogens, a broad-spectrum antibiotic regimen based on two or three combined antibiotics is usually required

47

Guidelines For Initial Empiric Antibiotic Therapy

1. Early-onset VAP and no risk factors for multidrug-resistant

pathogens

•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/8 h) 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) or amikacin (20 mg/kg/24 h) plus •Vancomycin (15 mg/kg/12 h)a or •Linezolid (600 mg/12 h)

49

Duration Of Therapy

optimal duration was unknown

experts empirically recommended a 14- to 21-day treatment

duration

ATS/IDSA guidelines suggest shortening the duration of therapy

to 7 days

8 - 15 days of antibiotic treatment were equally effective

A prospective, multicenter, randomized, double-blind trial was performed

Recent studies demonstrated that empiric antibiotic therapy could

be safely discontinued after 72 hours when a noninfectious etiology

for the pulmonary infiltrates is discovered or when signs and

symptoms 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 VAP

chest radiographic involvement of more than one lobe

platelet count <150,000 cells/µL

Logistic Organ Dysfunction score > 4

time of onset of VAP > 3 days

Surgery

Hypotension

initial therapeutic approach (delayed initial

appropriate 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 they

malfunction 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 allow

drainage of respiratory secretions

54

55

Hospital-acquired Pneumonia

hospital-acquired pneumonia (HAP) :

a pneumonia occurring less than 2 days from hospital

admission, but without any criteria defining ventilator-associated

pneumonia

Mortality rate 18.8% and 53%

56

( HAP)پنومونی بیمارستانی

ساعت بعد از بستری شدن در بیمارستان تظاهر می یابد 48عالئم آن.

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

57

Health Care–associated Pneumonia And Nursing

Home Pneumonia

HCAN patients who :

was hospitalized in an acute care hospital for 2 or more days

within 90 days of the infection

resides in a nursing home or long-term care facility (LTCF)

received recent intravenous antibiotic therapy, chemotherapy, or

wound 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 obstructive

pulmonary 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 PNEUMONIA

61

Horan 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

setting

Etiology- Select Risk Factors For Pathogens

Streptococcus pneumoniae Smoking, COPD, absence of

antibiotic therapy

Haemophilus influenzae Smoking, COPD, absence of

antibiotic therapy

MSSA Younger age, Traumatic coma,

Neurosurgery

MRSA COPD, steroid therapy, longer

duration of MV, prior antibiotics

Pseudomonas aeruginosa COPD, steroid therapy, longer

duration of MV, prior antibiotics

Acinetobacter species ARDS, head trauma,

neurosurgery, gross aspiration,

prior cephalosporin therapy

62 Park DR. The microbiology of ventilator-associated pneumonia.

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

Sedation Vacation

Why?

Has been demonstrated to reduce overall patient sedation

Promotes early weaning

Identified Issues and Concerns

Increases potential for self-extubation

Increases potential for patient pain and anxiety

Increases episodes of desaturation

Anecdotal 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 MDR

76

American Thoracic Society, Infectious Diseases Society of America. Guidelines for

the management of adults with hospital-acquired, ventilator-associated, and

healthcare-associated pneumonia.

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

84

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 ventilation

Tablan 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

Problem Identification

A recent, 9,080-patient study found that the average VAP

patient spends 9.6 additional days on mechanical ventilation, 6.1 extra days in the ICU, and 11.5 more days in the hospital

And VAP costs over $40,000 per case to treat—all paid for by the facility

Rello, Chest, 2002

85

VAP . . .WHAT IS IT?

Ventilator-Associated Pneumonia

Most common nosocomial bacterial

infection among patients requiring

mechanical ventilation

86

Rello, Chest, 2002

VAP

Increased mortality in critically ill

patients (20% - 70%)

Increased cost of care:

$40,000 additional cost per patient

87

CDC guidelines from Preventing Healthcare Pneumonias, 2003

AACN Practice alert

Risk Factors For Developing VAP

Patients at extreme of age spectrum; malnutrition; severe underlying conditions

Artificial airway

Colonization of dental plaque with respiratory pathogens

Bacterial colonization of the oropharyngeal area

Aspiration of subglottic secretions

Head 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 pharynx

Nursing Mgt., Vol. 34, Supplement 3, May 2003

90

Recommended Best Practice

91

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 cavity

Nursing Mgt., Vol. 34, Supplement 3, May 2003

Albert, NEJM 1981; Preston, AJM 1981; Tablan, 1994 92

CDC Guideline for Prevention of Healthcare Associated Pneumonias, 2003 Drakulovic et al, Lancet, 1999,354:1851

In the absence of medical contraindication(s).

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

…Semi-recumbent

…Noninvasive

ventilation

…Continuous lateral

rotation

…Subglottic

suctioning

Some evidence

… Avoid over sedation

… Avoid paralytics

… Closed suctioning

… Orotracheal

intubation

… Maintain adequate

cuff pressures

… Avoid H2

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

99 Langer M. et al. Intensive Care Med 1987;13:342-6

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

Objective 2

Objective 1

Avoid

overtreatment

without VAP Immediate

treatment of

patients with

VAP

Diagnosis And Treatment Of Ventilator-associated Pneumonia

101

How To Diagnosis Of VAP?

1. Clinical approach : CPIS

2. Bacteriological approach : quatitative culture with or without bronchoscope

102

103

Mandell Principles and Practice of Infectious Disease 6th ed.2005,3362-70

104

Clinical diagnosis

105 Am J Respir Crit Care Med 2000;162:505-11

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 The

Oropharynx

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 Elevation

HOB at 30-45º

118

Handwashing

119

What role does handwashing play

in nosocomial pneumonias?

VAP Prevention

Wash 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

Reference

1. U. Lucangelo, P. Pelosi, W.A. Zin, A. Aliverti (eds.) Respiratory

System and Artificial Ventilation. ©Springer 2008

2. Infectious Diseases in Critical Care Medicine.third edition.

Edited by Burke A. Cunha, # 2010 by Informa Healthcare USA,

Inc. Informa Healthcare is an Informa business

3. Gabrielli, Andrea; Layon, A. Joseph; Yu, Mihae ,Civetta, Taylor,

& Kirby's: Critical Care, 4th Edition Copyright ©2009

Lippincott Williams & Wilkins, Chapter 111 ,Respiratory

Infections in the ICU

122