Every year, patients across the UK are diagnosed with Hospital Acquired Pneumonia (HAP)- an infection of the lung tissue that develops as a result of being admitted to a hospital. Those patients with HAP have both an increased length of stay, and a higher mortality risk. Patients especially at risk for HAP are those who are on mechanical ventilation. These infections are known as Ventilator Associated Pneumonia (VAP) and are one of the leading mortality causes from infection in the intensive care unit¹. According to NHS, 10,000-20,000 patients are diagnosed with VAP annually².

It is important for caregivers, patients, and family members to understand the risks of VAP, as well as possible care techniques for reducing the likelihood of infection. Resources on the impact, risk factors for VAP, and education are available.

Who is at Risk of Acquiring VAP?

Main Cause

Ventilator Associated Pneumonia (VAP) can develop when a patient has been intubated with an endotracheal or tracheostomy tube for at least 48 hours. When intubated, protective reflexes are diminished and without actions like coughing, micro-organisms can grow quickly and pool above the tracheal tube cuff. Micro-aspiration can then occur, allowing bacteria into the respiratory tract, which can ultimately develop into pneumonia.

VAP is a common complication of mechanical ventilation and the most common infection in the ICU¹. Statistics show 10-20% of patients ventilated for more than 48 hours will develop VAP and that those who do are twice as likely to die of the infection compared to similar patients without VAP.

Who is at Risk of Acquiring VAP?

There are certain traits, conditions or habits that may raise the risk for VAP, these conditions are known as risk factors. An increased number of risk factors may increase the likelihood of VAP.

Risk factors for the development of VAP can be based on the patient themselves or their other diagnoses and circumstances. Risk factors can include older age, chronic lung disease, prolonged mechanical ventilation and other injuries like burns or trauma. Patients have the highest risk of developing VAP during days 1-5 of ventilation and the risk is reduced each day following¹.




References
¹ NICE, PneuX for preventing ventilator-associated pneumonia in intensive care, June 2016, Available at: www.nice.org.uk

VAP Education and Prevention

Changes in the Strategy of Mechanical Ventilation

Approaches to patients with respiratory insufficiency include using bi-level, non-invasive ventilation when feasible to prevent the tracheal intubation and subsequent use of sedation. This requires health care team members to recognise signs of respiratory insufficiency and apply the therapy before failure occurs.

Standard Precautions

Hand washing, gloving and extra care given to any respiratory or suction devices that are used in conjunction with mechanical ventilation should be maximised with any ventilated patient. Extra attention should be given to any aerosol medication delivery devices to maintain asepsis and inline suction catheters should be used to avoid disconnecting the ventilator circuit¹. Circuit changes should only be done if the tubing becomes soiled or damaged. Lavaging the patients endotracheal tube with normal saline to help clear thick secretions should be avoided if possible. A biofilm with possibly contaminated secretions builds up on the inside of the endotracheal tube and can be washed down to the lung tissue by the normal saline rinse.

Ventilator Bundles

Due to the high prevalence of ventilator associated pneumonia (VAP) a care process has been outlined for mechanically ventilated patients based on high-risk complications that are common. The protocol is triggered when the patient is intubated and placed on the ventilator. Not one single thing can prevent VAP but a combination and total adherence to the protocol can dramatically reduce the risk. There are an assortment of variations of the VAP care bundle but each touch on the main points of: preventing aspiration, preventing contamination of equipment and preventing colonization of the areodigestive tract.

  1. Elevation of the Head of the Bed
    It is imperative for the patient to be in the recumbent position with the head of the bed elevated thirty to forty-five degrees, unless otherwise contradicted by a doctor for medical reasons such as low blood pressure. This position encourages the collection of secretions from the upper airway to pool posterior to the glottis opening and towards the esophagus. The gastric reflux now has to fight gravity and is less likely to pool in the glottis area². It is important to educate the family on the significance of head elevation and use of visual cues to help identify when the head of the bed is in proper position in order to help reduce the risk of VAP.

  2. Daily Sedative Interruption
    It is important to implement a protocol to lighten sedation daily allowing the patient to regain a higher level of consciousness for a period of time each day. Most ventilated patients are placed on sedatives to allow them to tolerate the invasive endotracheal tube and positive pressure ventilation. Weaning trials should be scheduled to coincide with the time off medication to assess neurological readiness to extubate. Since the sedatives are usually given in dosages that suppress spontaneous respiration a sedation vacation allows a more comprehensive assessment of the patient’s ability to come off of the ventilator. Rapid weaning is a proven method to decrease time on ventilation and speed up the removal of the airway¹.

  3. Peptic Ulcer Disease (PUD) Prophlaxis
    Patients who are on mechanical ventilation are much more predisposed to gastric stress ulcers then ICU patients not being mechanically ventilated. Stress ulceration can raise gastric pH and promote growth of bacteria in the stomach, which can cause problems if a ventilated patient aspirates any reflux of gastric contents¹. Although the gastric ulcer treatment itself is not related to VAP, it does have an impact on the possible occurrence of VAP. Stress ulcer prophylaxis has historically been treated with antacids or an H2 proton pump inhibitors. When an antacid or proton pump inhibitor is used to prevent ulceration of the stomach the normally low pH (acidic) environment of the stomach is changed and bacterial growth can proliferate¹.This results in a higher incidence of VAP in these patients who are more prone to gastric reflux accumulating in the area above the glottis. H2 inhibitors such as cimetidine and ranitidine block the secretion of gastric acid. Sucralfate does not significantly alter gastric pH since its action is to bind to the proteins of an ulcer site.

  4. Deep Vein Thrombosis Prophlaxis
    Prevention of deep vein thrombosis (DVT) is not targeted directly at the prevention of VAP but VAP rates decreased dramatically in hospitals where all elements of the bundle, including DVT prophlaxis were used.

    Ventilated patients are confined to a bed and in many cases have blood pressure or circulatory problems. The lack of mobility combined with age, circulatory problems and comorbidity such as trauma or COPD place them at high risk for deep vein thrombosis. Prevention of deep vein thrombosis includes empiric anticoagulant therapy such as heparin or low molecular weight heparin and warfarin¹. Patients at risk for bleeding difficulties such as post surgical procedures or trauma where anticoagulant therapy is contraindicated can benefit from physical manipulation of the muscles of the leg to enhance efficient venous drainage. Pneumatic stockings, sometimes known as squeezers continuously milk the muscles and vasculature of the legs improving blood flow and preventing clot formation. Any patient confined to an ICU bed and especially mechanically ventilated patients should be maintained on prophylactic therapy for DVT prevention.

  5. Daily Oral Care with Chlorhexidine
    A biofilm consisting of bacteria and other mouth and upper airway flora forms in the oral cavity and teeth in a relatively short period of time unless good hygiene is maintained. Regular cleaning of the oral cavity and teeth prevent the buildup of the biofilm and decrease the chances of any leakage past the endotracheal tube cuff being contaminated with a heavy bacterial load. Dental plaque can be a significant reservoir for potential respiratory pathogens that cause VAP. Biofilms and bacteria can form an oral mucosa, creating the potential for bacterial colonisation in the upper respiratory tract². Using a preparation of chlorhexidine rinse inhibits the formation of dental plaque and helps stimulate saliva flow thus reducing the risk of VAP. Scheduling CHG as a medication so that reminder will appear on the nurses’ chart and trigger oral care is a great way to ensure the patient is getting the necessary treatment in VAP prevention².




References
¹ Medline University, eCourse "Recognizing and Preventing Ventilator Acquired Pneumonia (VAP)", available at www.medlineuniversity.com
² Medline University, eCourse "5 Five Step Approach forAvoiding VAP", available at www.medlineuniversity.com

Impacts & Outcomes of VAP

Ventilator Associated Pneumonia (VAP) is a major problem in intensive care units with a critical impact on the hospital and on the patients. VAP is the leading cause of death among hospital acquired infections.

Impact on the Patient

According to the NHS, VAP is a critical issue in intensive care units (ICU) and causes on average 10 to 20% of patients to develop infections while they are under mechanical ventilation each year. VAP is the most common and fatal infection in the ICU, increasing the mortality risk by 30% for affected patients.

Impact on the Hospital

VAP has important consequences on the hospital and the hospital staff. The incidence of VAP prolongs the length of patient stay in the ICU and hospital, which is estimated to be an extra 6.1 days¹, and means that more staff is needed to care for those patients. Longer stays and increased staff increases finncial costs, adding thousands of pounds to the typical hospital stay. It is estimated that each patient developing VAP costs the NHS between £10k and £20k².




References
¹ Guide to the Elimination of Ventilator-Associated Pneumonia, 2009, Available at: www.apic.org
² NHS England, NHS Chief launches new fast track funding so NHS patients get treatment innovations faster, June 2016, Available at: www.england.nhs.uk

Medline VAPrevent Solutions


DenTips

DenTips Oral Swabs are used for removing mucus build up in a patient's mouth. They can be used for oral cleaning and combined with a mouthwash, oral moisturizer or other solution.

Suction Components

Medline Suction Components aid in mechanical debridement of the mouth and gums. The tools connect to standard suction tubing and allow for suctioning of secretions from the oral cavity.

VAPrevent Kits

VAPrevent Kits contain everything needed for 1 oral cleaning. The built in medicine cup allows caregivers to pour mouthwash directly into the packaging, and the thumb valve is easy to use to suction oral secretions.




References
¹ British Journal of Medical Practitioners, Ventilator Associated Pneumonia – an Overview, 2009, Available at: www.bjmp.org
² NHS England, NHS Chief launches new fast track funding so NHS patients get treatment innovations faster, June 2016, Available at: www.england.nhs.uk

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