Elevation of the head of the bed 30 to 45 degrees has been shown to decrease the rate and risk of aspiration and hospital-acquired pneumonia. Feeding tube placement does not decrease the risk of aspiration. In order to prevent tissue trauma and unwarranted oxygen desaturation, patients should be only suctioned when clinically indicated by the presence of secretions. Enteral feedings appropriately delivered have been shown to decrease mortality and morbidity when compared with hyperalimentation.
An endotracheal tube cuff leak allows oral secretions above the cuff to leak into the bronchial tree, placing the patient at high risk of developing ventilator-associated pneumonia. Enteral feedings place the patient at risk of VAP if a semirecumbent position is not maintained or if residual volumes are increased. A diminished level of consciousness and obtundation are risk factors for hospital-acquired pneumonia (HAP) in a nonintubated patient. Nasogastric tubes place the nonintubated patient at risk of HAP.
The best approach to establishing a comprehensive program of oral care should begin with forming a multidisciplinary team that can review supporting scientific literature and develop a policy or protocol, provide hospital wide education, and measure outcomes of the intervention.
Option A is incorrect because placing kits at the bedside does not ensure their use. Merely obtaining staff input does not designate any accountability for the project as Option B does.
Option D is of very limited help because the nature of those oral care orders needs to coincide with a best-practices approach to care before outcomes could be expected to improve.
HOB elevation of 30-45 degrees is associated with a lower incidence of aspiration of gastric contents. The current best practices for preventing VAP call for daily sedation vacations to avoid oversedation, frequent oral care, and early enteral rather than parenteral nutrition.
Sputum aspirate with quantitative or semiquantitative cultures is a more sensitive test for diagnosing HAP than expectorated samples with Gram's stain. Chest x-rays are useful in determining the location of a pneumonia. Blood cultures are a key component of distinguishing primary from secondary infections, particularly in pneumococcal pneumonia. Al cultures should be drawn prior to antibiotic administration to avoid masking organisms.
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The Scope of the Problem
Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections and can impact more than 20% of mechanically ventilated patients. It is associated with:
- Increased morbidity and mortality — Mortality rates vary but may exceed 10%
- Prolonged mechanical ventilation
- Increased hospital length of stay — by 2 days
- Extended use of antimicrobial medication
- Increased costs — $40,000 per patient or $1.2 billion annually in the United States.
VAP occurs as a result of a bacterial infection of the pulmonary parenchyma of mechanically ventilated patients. Infection can occur as a result of some bacterial invasion of the sterile lower respiratory tract such as aspiration, use of contaminated equipment, ingestion of contaminated medications, or colonization of the aerodigestive tract. Consequently the development of a standard, reliable, and valid definition for VAP has been difficult to identify.
Recently, AACN was invited to participate in the CDC's National Healthcare Safety Network development of a new approach for defining VAP. A surveillance definition and algorithm for the detection of ventilator-associated events has been proposed and is designed to detect a wide variety of conditions associated with mechanically ventilated adult patients. This is expected to be implemented in January 2013. For more information visit the Critical Care Societies Collaborative information page.
Prevention Strategies
Prevention strategies are aimed at eliminating the most common VAP development mechanisms.
- Perform daily spontaneous awakening trials and spontaneous breathing trials
- Maintain head of bed at 30 - 45 degrees as long as tolerated
- Use an endotracheal tube (ETT) with a dorsal lumen above the cuff to allow drainage by continuous suctioning of tracheal secretions that accumulate in the subglottic area
- Perform regular oral care
- Remove condensation from the ventilator circuit, and keep the circuit closed during removal
Test Your Knowledge
Source: AACN Certification and Core Review for High Acuity and Critical Care, Sixth Edition
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