Articles, Blog

“Prevention of Ventilator-Associated Pneumonia” by Debra Morrow, RN for OPENPediatrics

October 20, 2019

The purpose of this video is to provide general
information and education about the care of a critically ill child. It is in no way a substitute for the independent
decision-making and judgment by a qualified health care professional. The information contained in this video should
not be used to make a diagnosis or to overrule the advice of a qualified health care provider,
nor should it be used to provide advice for emergency medical treatment. Prevention of Ventilator-Associated pneumonia
by Deb Morrow. Hi, I’m Deb Morrow, a Staff Nurse III and
the Infection Prevention Coordinator for the Cardiovascular Intensive Care Unit at Children’s
Hospital Boston. Today I’d like to talk to you about strategies
that we use at Children’s Hospital Boston to prevent the development of ventilator-associated
pneumonia. Epidemiology. Ventilator-associated pneumonia is a leading
cause of healthcare-associated infections. These infections are a significant source
of cost, morbidity, and mortality. Adults with ventilator-associated pneumonia
have a 40% mortality rate. And patients of all ages spend an average
of six extra days in the intensive care unit for the management of pneumonia. Ventilator-associated pneumonia is preventable. Pathogenesis. In a healthy person, the lower airway is a
sterile body site. And the endotracheal tube provides access
to the lower airway. Colonized secretions from the subglottic area,
which leak into the lower airway around the endotracheal tube is the primary mechanism
of infection. Other sources of contamination include aspiration
of fluids from the stomach, particularly when a nasal gastric tube is in place; contaminated
respiratory equipment, such as ventilator parts, water, or bronchoscopes; inhalation
of contaminated medications; the contaminated hands of health care workers, who don’t clean
their hands before manipulating the endotracheal tube during intubation or suctioning; seeding
from a remote site of infection; or biofilm buildup on the endotracheal tube. Let’s talk about biofilm for a moment. Biofilm is a thin mucous film that develops
on the inside and outside of every catheter inserted into the body. Bacteria colonize the surfaces of these catheters
and secreted mucous film, which can protect the bacteria from antibiotics. Bacterial multiplication takes place under
the biofilm. The best prevention is to remove endotracheal
tubes as soon as possible. Categories of Ventilator-Associated Pneumonia. There are two categories of ventilator-associated
pneumonia and in general, bacteria are the most frequently isolated pathogens. Early onset pneumonia is usually caused by
antibiotic susceptible organisms, and it occurs within the first four days of intubation. Late onset occurs after four days of intubation,
and it is usually caused by antibiotic resistant bacteria. And it has the highest rate of mortality. Patients who are immunocompromised are more
likely to have viral or fungal pneumonia than patients with intact immune systems. Other risk factors for the development of
ventilator-associated pneumonia are prolonged ventilation and repeated intubations, supine
position, immobilization, surgical procedures of the head, neck, thorax or upper abdomen,
and underlying chronic lung disease. Prevention Bundle. At Children’s Hospital Boston, we have developed
a bundle to prevent ventilator-associated pneumonia, which includes hand hygiene– which
is the cornerstone of every infection prevention initiative, elevating the head of the bed
30 to 40 degrees, oral hygiene, a daily sedation break, and a daily assessment of need for
the endotracheal tube. Elevating the head of the bed 30 to 40 degrees
will prevent secretions from collecting in the subglottic area and will prevent aspiration
of fluids from the stomach. Infants in isolettes should be in a reverse
Trendelenburg position. Use of a cuffed endotracheal tube will also
prevent colonized secretions from entering the lungs. The posterior pharynx should be suctioned
on a regular basis and before changing a patient’s position to remove secretions. Oral hygiene is very important. During severe illness, the predominantly gram-positive
bacteria in the mouth switch to predominantly gram-negative bacteria. Gram-negative bacteria thrive in plaque, which
can build up on teeth in as little as three days. The process of chewing facilitates the production
of saliva, which is a natural antibacterial. However, many patients in the intensive care
units are unable to eat. Saliva production can also be decreased by
the use of oxygen therapy, antihypertensives, anticholinergics, such as atropine sulfate,
sympathiomimetics, such as dopamine, antihistamines, and diuretics. Oral hygiene keeps mucosa and lips clean,
soft, moist and intact, and removes debris and plaque without damaging the mucosa. At Boston Children’s Hospital, we brush teeth
and gums with toothbrush, toothpaste and sterile water every six hours. If a patient does not have teeth, we will
use a gauze with sterile water and rub all surfaces of the gums, tongue, and mouth every
six hours. The subglottic area should be suctioned before
position change and every four hours to prevent the buildup of secretions in the posterior
pharynx. It is also important to drain the ventilator
tubing away from the patient so that contaminated fluid from the circuit does not enter the
endotracheal tube. We identify a respiratory plan at patient
rounds using a daily goal sheet. When patients are stable, sedation medications
are decreased and paralytic medications are halted to assess the patient’s stability and
respiratory status. If a patient is able to maintain adequate
ventilation and vital signs, sedation will be decreased or stopped. It is important that the bedside nurse be
part of these discussions. Conclusion. Evidence-based practices can reduce ventilator-associated
pneumonia rates. You should implement bundles for the management
of the intubated patient. Assess the need for the endotracheal tube
every day. Observe practice for compliance with policy. Feedback infection rates to staff. Establish policies for the insertion and maintenance
of endotracheal tubes. Educate doctors and nurses on ventilator-associated
pneumonia prevention. And communication training will help staff
to speak up when practice to prevent ventilator-associated pneumonia is not followed. That concludes our video on prevention of
ventilator-associated pneumonia. Thank you. Please help us improve the content by providing
us with some feedback. What did or didn’t you like about this video? Was the content too simple, just right, or
too difficult? What the length too short, just right, or
too long? Any additional comments? You can either click the Start a New Discussion
button and type in feedback, or send us an email at [email protected] Note, feedback is not required to complete
this activity in the guided learning pathway.

1 Comment

  • Reply Antonio Luiz Carvalho dos Santos April 26, 2019 at 5:59 pm

    Good video. All of the pneumonia prevention topics associated with mechanical ventilation are statistically proven to be effective? Or are some based on clinical experience? Thank you.

  • Leave a Reply