Ventilator-Associated Pneumonia (VAP) · PDF file 1 Ventilator-Associated Pneumonia...

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Ventilator-Associated

Pneumonia (VAP)

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of

academic medicine, and medical author. He graduated

from Ross University School of Medicine and has

completed his clinical clerkship training in various

teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale

Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has

served as a test prep tutor and instructor for Kaplan. He has developed several medical courses

and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple

levels in the academic field including faculty member and Department Chair. Dr. Jouria

continues to serves as a Subject Matter Expert for several continuing education organizations

covering multiple basic medical sciences. He has also developed several continuing medical

education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been

contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to

develop an e-module training series for trauma patient management. Dr. Jouria is currently

authoring an academic textbook on Human Anatomy & Physiology.

ABSTRACT

Ventilators are machines that provide life-saving oxygen to patients through a

tube in the nose, mouth, or trachea. However, sometimes germs will enter

through the tube and take up residence in a patient’s lungs, developing into

ventilator-associated pneumonia, or VAP. Although most cases of VAP are

treated successfully with antibiotics, early diagnosis is critical, especially since

many VAP patients are intubated and/or heavily sedated, essentially unable to

alert medical staff to their symptoms. Nurses need to be able to recognize risk

factors and symptoms to provide these early diagnoses and allow for the best

possible outcome for their patients.


Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the policies

of NurseCe4Less.com and the continuing nursing education requirements of the

American Nurses Credentialing Center's Commission on Accreditation for

registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity,

transparency, and best practice in clinical education for all continuing nursing

education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Pharmacology content is 0.5 hours (30 minutes).

Statement of Learning Need

The principles of managing the patient on a ventilator is essential for nurses to

know in order to provide safe and appropriate care, and to avoid complications

such as ventilator-assisted pneumonia.

Course Purpose

To provide nursing professionals with knowledge of the basic skills to manage

care of the patient on a ventilator and to prevent ventilator-assisted pneumonia.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 4/4/2018

Please take time to complete a self-assessment of knowledge, on page

4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be

provided at the end of the course.


1. The primary risk factor for the development of hospital-associated

bacterial pneumonia is: a. Presence of community-acquired pneumonia during admission.

b. Mechanical ventilation.

c. Viral infection during the flu season.

d. Non-compliance with respiratory precautions among healthcare workers.

2. In critically ill, mechanically ventilated patients, signs and symptoms of VAP include the following except:

a. Fever

b. Purulent Sputum

c. Hypoxemia

d. High blood pressure

3. Early-onset pneumonia (EOP) is VAP pneumonia that develops:

a. Within 24 hours of intubation

b. Within 48 and 96 hours of intubation

c. Between 96 and 110 hours of intubation

d. After two weeks of intubation

4. Placing the patient in a semi-upright position (by elevating the

head of the bed at an angle of _______ may help prevent aspiration in patients on the ventilator.

a. 10-15 degrees

b. 30 - 45 degrees

c. 45-60 degrees

d. 90 degrees

5. In intubated patients, leakage around the endotracheal cuff allows

secretions to form: a. Below the glottis and above the endotracheal-tube cuff.

b. Underneath the tongue.

c. Below the carina.

d. In the bronchial tubes.


Introduction

The primary risk factor for the development of hospital-associated bacterial

pneumonia is mechanical ventilation (with its requisite endotracheal intubation).

In fact, patients who received continuous mechanical ventilation had 5-20 times

the risk of developing hospital-associated pneumonia compared with patients

who were not receiving mechanical ventilation.1 Because of this tremendous

risk, in the last two decades, most of the research on hospital-associated

pneumonia has been focused on Ventilator-associated pneumonia (VAP). While

patients are at risk of developing other forms of hospital and healthcare related

forms of pneumonia, VAP is categorized and studied separately from these other

forms of the illness.2

Ventilator-associated pneumonia is a life-threatening illness with a mortality

rate of 35 – 50%.3 Approximately 15 – 25% of all patients who receive

respiratory support through mechanical ventilation develop VAP.4 It is most

common in patients in trauma, burn and neurosurgical centers, but it is also

present in respiratory support centers and intensive care centers.5 While

patients may experience pneumonia while they are receiving care in a

healthcare setting, VAP is specific to patients who are receiving mechanical

ventilation. It is diagnosed using specific criteria, which includes the

development of pneumonia within 48 hours of being placed on mechanical

ventilation.6 In many instances, it can be challenging to diagnose VAP, as the

patient is often experiencing a number of complications and symptoms as a

result of his or her underlying medical condition.7 In fact, many conditions

produce symptoms that mirror those found in VAP. Diagnosis depends on

confirmatory testing, which includes blood work, specimen cultures and chest

radiographs.8


Ventilator-associated pneumonia is caused by a number of different

microorganisms, which are identified using the diagnostic strategies listed

above. Early onset VAP develops within 48 and 96 hours of intubation, and it is

often caused by flora in the upper airway.9 These flora typically include

Haemophilus influenza and Streptococcus pneumonia.10

Late onset VAP, which occurs after 96 hours of intubation, is typically caused by

a different series of microorganisms, which commonly include gram-negative

bacilli.11 It is important to identify the type of VAP so that the appropriate

treatment can be administered immediately. In most instances the patient will

receive initial empiric antibiotic therapy to slow the progression of VAP.12

However, once the specific microorganism has been identified, treatment will

often be modified to provide more specific therapy.13 The goal is eradication of

the pathogen. With treatment, many patients will be able to recover fully from

VAP. Therefore, it is important for healthcare providers to be familiar with the

causes, symptoms, and treatment of VAP.

Microbiology Of VAP

Bacteria are the most common pathogen in instances of VAP. However, in some

instances, viral and fungal pathogens can be involved in cases of VAP.9 When

fungal or viral pathogens are present, it is typically in patients who are

immunocompromised.14 While the specific bacteria will differ depending on the

institution, the most common bacterial pathogens include:10

Aerobic GNB - Pseudomonas aeruginosa, Acinetobacter baumanii,

Klebsiella pneumoniae, Escherichia coli

Gram-positive organisms such as Staphylococcus aureus


The specific type of bacteria will also vary depending on when the patient

develops pneumonia. In instances of early onset pneumonia, patients will

typically be infected with antimicrobial-sensitive bacteria. These strains of

bacteria include:15

Enterobacter spp

E. coli, Klebsiella spp

Proteus spp

Serratia marcescens

Streptococcus pneumonia

Haemophilus influenza

Methicillin-sensitive S. aureus

In instances of late-onset VAP, the patient is typically infected with multidrug-

resistant pathogens. The most common pathogens include:16

P. aeruginosa

K. pneumonia (extended spectrum beta-lactamase and Klebsiella-

producing carbapanamase strains)

Acinetobacter spp

Stenotrophomonas maltophilia

Burkholderia cepacia

Methicillin-resistant S. aureus

The etiologic agents that cause VAP vary among institutions and settings

primarily because of differences in patient populations, diagnostic methods

employed, and definitions used.6 In general, however, bacteria have been the

most frequently isolated pathogens. In most studies, very few anaerobic

bacteria and viruses were reported, partly because anaerobic and viral cultures

were not performed routinely in the reporting facilities.15


Microbiology Of CAP

The majority of Community Acquired Pneumonia (CAP) cases are caused by the

Streptococcus pneumonia pathogen. There are other pathogens that are known

to cause CAP, but their prevalence varies.5 Other pathogens present in instances

of CAP include:17

Haemophilus influenza

Mycoplasma pneumonia

Influenza A

Legionella species

Chlamydophilia pneumoniae

While the pathogens listed above are commonly found in cases of CAP, a

number of CAP cases involve unidentifiable pathogens. In fact, approximately 30

– 50% of CAP cases will involve unidentifiable pathogens and/or other causes.18

Some cases of CAP are caused by pathogens that are not typically associated

with CAP. For example, some pathogens that were originally limited to health

care facilities have been found in cases of CAP. The most common health care

related pathogen is methicillin-resistant Staphlococcus aureus (MRSA).19 In

addition, some viruses can be linked to CAP.

It is quite common for patients to develop CAP after infection with potent strains

of influenza.17 Some patients will develop CAP through other viral respiratory

infections such as:20

Parainfluenza virus

Adenovirus

Human metapneumovirus

Herpes zoster virus (HSV)

Varicella-zoster virus (VZV)

Measles


The following table provides information regarding the type of pathogen and the

prevalence of cases of CAP:21

Identified Pathogens in Community-Acquired Pneumonia

Pathogen Cases (%)

Streptococcus pneumonia 20-60

Haemophilus influenza 3-10

Staphylococcus aureus 3-5

Gram-negative bacilli 3-10

Legionella species 2-8

Mycoplasma pneumonia 1-6

Chlamydia pneumonia 4-6

Viruses 2-15

Aspiration 6-10

Others 3-5

Mechanical Ventilation

A mechanical ventilator provides a patient with respiratory support in situations

that warrant it. Mechanical ventilators are most often used when patients are

under general anesthesia, or when they are critically ill and unable to breath

independently. Mechanical ventilators provide different levels of oxygen, up to

100%, based on the specific needs of the patient.22 The oxygen and airflow can

be controlled and modified based on the changing status of the patient. In

addition, the tidal volume (volume of respirations) and the number of

respirations per minute can be adjusted so that the patient receives the

appropriate amount of support.23 The goal with all adjustments is to provide

regulated respiratory support. Some patients will only require minimal support,

while others will require full levels of oxygen to support ventilation.24


Indications

The major indication for mechanical ventilation is acute respiratory failure, of

which there are two basic causes:25

1. Ventilatory (Hypercapnic respiratory failure)

Reduced respiratory drive

Chest wall abnormalities

Respiratory muscle fatigue

2. Inefficient Gas Exchange (Hypoxic respiratory failure)

Intrapulmonary shunt

Ventilation-perfusion mismatch

Decreased FRC

The above are basic indications for mechanical ventilation. However, the

following list provides specific guidelines for the use of mechanical ventilation.

When a patient presents with one or more of the following conditions,

mechanical ventilator support may be necessary:26

Bradypnea or apnea with respiratory arrest

Acute lung injury and the acute respiratory distress syndrome

Tachypnea (respiratory rate >30 breaths per minute)

Vital capacity less than 15 mL/kg

Minute ventilation greater than 10 L/min

Arterial partial pressure of oxygen (PaO2) with a supplemental fraction of

inspired oxygen (FIO2) of less than 55 mm Hg

Alveolar-arterial gradient of oxygen tension (A-a DO2) with 100%

oxygenation of greater than 450 mm Hg

Clinical deterioration

Respiratory muscle fatigue

Obtundation or coma


Hypotension

Acute partial pressure of carbon dioxide (PaCO2) greater than 50 mm Hg

with an arterial pH less than 7.25

Neuromuscular disease

The above guidelines and recommendations are used to determine the necessity

of mechanical ventilation. In some instances, mechanical ventilation is not

required. The following is a list of the primary goals of mechanical ventilation,

which should be considered when determining whether or not to provide a

patient with respiratory support.

Goals of Mechanical Ventilation27

Relieve respiratory distress

Decrease work of breathing

Improve pulmonary gas exchange

Reverse respiratory muscle fatigue

Permit lung healing

Avoid complications

The procedure for mechanical ventilation is the same regardless of the patient’s

condition. The patient is intubated, which involves the insertion of an

endotracheal tube into the individual’s trachea. The tube is inserted through the

mouth or nose, depending on the specific needs of the patient.23 Once the tube

is inserted, the patient will begin receiving respiratory support. In some

instances, the patient will control the respiratory rate through spontaneous

breathing. In other instances, the ventilator will control respiration.28 Once the

patient begins receiving mechanical ventilation, continuous monitoring is

necessary. Monitoring includes chest X-rays, arterial blood gas measurement

and analysis, as well as frequent observation.24


VAP And Pathophysiology

Ventilator-associated pneumonia is divided into two categories, which are

defined by the duration of time between intubation and the onset of illness.

Early onset VAP develops within 48 and 96 hours of intubation and is typically

caused by organisms that are susceptible to antibiotics. Late onset VAP develops

in patients once they have surpassed 96 hours after intubation. Late onset VAP

is typically caused by microorganisms that are resistant to antibiotics.29 The

pathophysiology of VAP includes two distinct components:5

Colonization of the respiratory and digestive tracts

Micro-aspiration of secretions of the upper and lower regions of the airway

Colonization in the lungs occurs as the result of the spread of organisms from a

variety of sources. The most common sources of bacteria include:30

Oropharynx

Sinus cavities

Nares

Dental plaque

Gastrointestinal tract

Patient-to-patient contact

Ventilator circuit

When the bacteria from these sources are inhaled, it will cause an active host

response, which can lead to the development of VAP. Bacteria can also enter the

lower respiratory tract directly through the endotracheal tube. This typically

occurs when upper airway and oral secretions line the endotracheal tube,

forming a biofilm that is composed of large quantities of bacteria, which then

enter the lungs through ventilator assisted breathing.8 In some instances the

biofilm will enter the lung through other means, including:1


Installation of saline into the tube

Coughing

Suctioning

Repositioning of the endotracheal tube

In addition to the access routes listed above, the endotracheal tube increases

the risk of infection by interrupting the regular processes of the upper and lower

airways. When an endotracheal tube is inserted, it bypasses the upper airway,

thereby affecting the body’s ability to filter and humidify air.31 The endotracheal

tube also impacts the involuntary cough reflex by eliminating or reducing it.

When the cough reflex is impacted, it can affect the patient’s ability to remove

or clear mucous from the lungs.23 In some patients, the endotracheal tube will

provide an outlet for bacteria to bind to the trachea. When this occurs, the

patient will experience an increase in the production and secretion of mucous.27

All of these factors, which are associated with the impairment of defense

mechanisms, increase the risk of the colonization of bacteria in the patient’s

lung and the subsequent development of VAP.10

Patients are also at risk of developing VAP through the aspiration of gastric

contents. The stomach is a direct source of bacteria when a patient has a

nasogastric or orgogastric tube in place for enteral feeding and pharmaceutical

administration.32 When the patient has a tube in place, it affects the regular

processes of the gastroesophageal sphincter. When this interruption occurs, the

patient will experience an increase in gastrointestinal reflux, which serves as a

route for the translocation of bacteria into the oropharynx.33 This eventually

leads to the colonization of bacteria in the upper airway. In addition to the

effects caused by the tube, enteral feeding causes changes to the gastric pH and

the gastric volume, which increases the patient’s risk of aspiration and provides

an ideal environment for bacterial colonization.34


Risk Factors

There are a number of different risk factors for VAP, which can be categorized

into patient-related and treatment-related risks. In some instances, the risk

factor can be identified and minimized to prevent infection. In other instances,

the risk factor will have occurred prior to hospitalization, but will increase the

patient’s chances of developing VAP during his or her stay. The following is a list

of the most common VAP risk factors.

Ventilation for 5+ Days

Mechanical ventilation and intubation are the direct causes of VAP. However, the

risk of developing VAP increases once a patient receives ventilator assistance for

more than five days. A number of studies have shown that the duration of

ventilation is directly correlated to the development of VAP. The longer a patient

receives mechanical ventilation, the greater his or her risk of developing VAP.

Therefore, healthcare providers should strive to reduce the duration of

mechanical ventilation as a means of preventing the development of VAP.23

Recent Hospitalization

Patients who have recently been hospitalized have a greater risk of developing

VAP due to potential exposure to multi-drug resistant pathogens. During an

initial assessment and evaluation, the patient history should include questions

regarding recent hospitalizations. In some instances, the ventilated patient will

receive empiric antibiotics as a preventative measure to ensure that the

multidrug-resistant pathogens do not colonize and cause the patient to develop

VAP.16


Residence in Nursing Home

In long-term care facilities (LTCFs) such as nursing homes, pneumonia is the

first or second most common infection (after those of the urinary tract) acquired

by patients, and accounts for 13-48% of all nursing home-associated infections.

Its seasonal variation mirrors that of influenza, suggesting that influenza plays a

major role in the occurrence of pneumonia in the elderly. Nursing home-

associated pneumonia is associated with a high mortality rate. The case-fatality

rate of pneumonia in nursing home residents is reported to be from 6% to

23%.5

Hemodialysis Treatment

Patients who have recently received hemodialysis treatment have a greater risk

of developing VAP due to potential exposure to multi-drug resistant pathogens.

During an initial assessment and evaluation, the patient history should include

questions regarding hemodialysis. In some instances, the ventilated patient will



VAP.35

Chemotherapy

Patients who are undergoing chemotherapy are at an increased risk of

developing hospital-acquired infections, including ventilator-associated

pneumonia, due to a compromised immune system.16

Intravenous Wound Care

Patients who have recently received intravenous wound care have a greater risk

of developing VAP due to potential exposure to multi-drug resistant pathogens.

During an initial assessment and evaluation, the patient history should include


questions regarding intravenous wound care. In some instances, the ventilated

patient will receive empiric antibiotics as a preventative measure to ensure that

the multidrug-resistant pathogens do not colonize and cause the patient to

develop VAP.36

Recent Antibiotic Use

Patients who have recently used antibiotics have a greater risk of developing

VAP due to the development of multi-drug resistant pathogens. During an initial

assessment and evaluation, the patient history should include questions

regarding recent antibiotic use. In some instances, the ventilated patient will



VAP.37

Immunocompromised Patients

Immunocompromised patients have a greater risk of developing VAP due to

their increased susceptibility to infections. Patients with the following conditions

are especially susceptible to VAP:30

HIV/AIDS

Cancer

Organ transplantation

Patients on corticosteroids

Patients taking medications that suppress the immune system

Symptoms

When a patient is undergoing mechanical ventilation, it is important to

continuously monitor him or her for signs of VAP. Most patients will display

common symptoms, which make early identification and treatment easier.35 The


following symptoms, discussed below, are the most common signs of VAP. Once

symptoms have been detected, it is important to begin treatment immediately

to minimize the effects of the illness and prevent further damage.

Fever

Fever is common in instances of VAP due to the level of infection in the body.

Most patients will have an ongoing fever.38

Purulent Sputum

Purulent sputum is infected mucus that the patient produces from the lower

airways. It is comprised of the following components:39

Pus

White blood cells

Cellular debris

Dead tissue

Serous fluid

Viscous liquid

Purulent sputum is typically yellow in color, but in some instances it can be

greenish. When sputum is present, it is indicative of infection. While purulent

sputum is not unique to VAP, it is an indicator of the illness. The sputum will be

cultured to determine the bacterial composition.7

Leukocytosis

Leukocytosis, which is a higher than normal white blood cell count, is often one

of the first signs of VAP. Leukocytosis is indicative of an inflammatory response

to an infection and is most common in bacterial and viral infections.39 There are

five principal types of leukocytosis:40


Neutrophilia (the most common form)

Lymphocytosis

Monocytosis

Eosinophilia

Basophilia

Low Body Temperature

Low body temperature is a common symptom of VAP. In most instances,

patients will experience low body temperature in conjunction with other

symptoms of VAP. It is not common for patients with VAP to experience low

body temperature in the absence of other symptoms.1

Hypoxemia

Patients with VAP will often experience a lower than normal level of oxygen in

the blood. This condition is known as hypoxemia. The low respiratory levels that

occur when a patient is infected cause this lack of oxygen. The lungs are unable

to function properly, which impacts the amount of oxygen distributed to the rest

of the body.41 Hypoxemia is suspected when the patient presents with shortness

of breath, and is identified through the measurement of the patient’s blood

oxygen level. The measurement is completed using a sample of blood from the

patient’s artery. In some instances, a pulse oximeter will be used to measure

the saturation of oxygen in the patient’s blood, which is then used to determine

the patient’s blood oxygen level.14

Diagnosis

In many instances, VAP can be difficult to diagnose. Typically, providers will use

a combination of symptoms (fever, leukocytosis, purulent secretions, and

hypoxemia) as the first set of criteria for diagnosis. Once symptoms have been


identified, providers will utilize blood work, lab cultures and chest radiographs to

confirm the presence of VAP. The provider will often use the Clinical Pulmonary

Infection Score, which is scoring system based on the assessment results, to

make an appropriate diagnosis.7

Blood Work

Blood work is not always necessary for the diagnosis and identification of VAP.

However, in some situations, it may be necessary to utilize blood work as a

means of determining the level of infection and the specific pathogen causing

the infection.39 The specific blood work will be determined based on the needs of

the individual patient. The following table provides descriptions of the different

types of blood work and their purpose.42

Test Description

White blood cell count High levels indicate infection

Blood cultures Cultures are done to determine the specific organism causing

the pneumonia, but they usually cannot distinguish between

harmless and dangerous organisms. They are accurate in only

10 - 30% of cases. Their use is generally limited to severe

cases.

Detection of antibodies Antibodies are immune factors that target specific foreign

invaders. Antibodies that react with mycoplasma or chlamydia

are not present early enough in the course of pneumonia to

allow for prompt diagnosis by this method.

C-reactive protein or

procolacitonin

Not generally recommended but may help identify which

patients with respiratory symptoms have pneumonia and need

to be hospitalized.


Polymerase Chain

Reaction (PCR)

In some difficult cases, PCR may be performed. The test makes

multiple copies of the genetic material (RNA) of a virus or

bacteria to make it detectable. PCR is useful for identifying

certain atypical bacteria strains, including mycoplasma and

Chlamydia pneumoniae, but it is expensive. One study found

that using a real-time PCR test may help quickly diagnose

Pneumocystis pneumonia in HIV-positive patients.

Chest X-Ray

The chest radiograph is often the first stage of VAP diagnosis. It is used to

identify the white areas in the lungs, called infiltrates, as well as any

complications caused by the pneumonia. The initial chest radiograph is used to

determine the extent of infection so that a treatment protocol can be developed.

It is important to note that other complications will cause abnormal results on

the chest radiograph, so the chest X-ray is not typically the sole diagnostic tool

used when assessing VAP.7

Culture

In many instances, practitioners will utilize sputum samples to further diagnose

VAP. The sputum sample is used to identify the specific organism causing the

infection. To acquire a sample, the patient will have to cough deeply enough to

produce mucous. The mucous is collected and tested. If the patient is unable to

produce a deep enough cough to bring up mucous from the lungs, the sample

will be collected using a tube that is inserted through the nose.41 The tube will

cause the patient to cough deeply, thereby producing an adequate sample. The

sputum sample is examined for:43

Blood, which suggests an infection is present

Color and consistency (if it is gray, green, or brown, an infection is likely)


Once the sample has been examined, it will be sent to a laboratory for further

analysis. In the laboratory, it will be analyzed to determine if bacteria is present

and if that bacteria is gram-positive or gram-negative.6

Bronchoscopy

A bronchoscopy is often used when a thorough examination of respiratory

secretions is necessary. It is quite invasive, so it is not always appropriate. It is

commonly used to diagnose patients who require immediate diagnosis, such as

those who are immunocompromised or those who show signs of a worsening

condition.44 The following is the standard procedure for the bronchoscopy:42

The patient is given a local anesthetic, oxygen, and sedatives.

The physician inserts a fiber optic tube into the lower respiratory tract

through the nose or mouth.

The tube acts like a telescope into the body, allowing the physician to view

the windpipe and major airways and look for pus, abnormal mucus, or

other problems.

The doctor removes specimens for analysis and can also treat the patient

by removing any foreign bodies or infected tissue encountered during the

process.

Bronchoalveolar Lavage

A bronchoalveolar lavage is used to detect the specific organisms that cause

VAP. This procedure is often used in conjunction with a bronchoscopy, though it

may be used independently in some situations.

During the procedure, the patient receives an injection of saline through a

bronchoscope, which is inserted in the lung. The saline is immediately suctioned

out of the lung, and the fluid is analyzed for specific pathogens.44


While the procedure is relatively safe, it can cause some complications. They

include:42

Allergic reactions to the sedatives or anesthetics

Asthma attacks in susceptible patients

Bleeding

Fever

CDC Recommendations

The CDC provides the following guidelines for the threshold levels for cultures:45

Threshold values for cultured specimens used in the diagnosis of pneumonia

Specimen collection/technique Values

Lung parenchyma* >104 CFU/g tissue

Bronchoscopically (B) obtained specimens

Bronchoalveolar lavage (B-BAL) >104 CFU/ml

Protected BAL (B-PBAL) >104 CFU/ml

Protected specimen brushing (B-PSB) >103 CFU/ml

Nonbronchoscopically (NB) obtained (blind) specimens

NB-BAL >104 CFU/ml

NB-PSB >103 CFU/ml

CFU = colony forming units; g = gram; ml = milliliter

* Open-lung biopsy specimens and immediate post-mortem specimens obtained by

transthoracic or transbronchial biopsy

Clinical Pulmonary Infection Score

The Clinical Pulmonary Infection Score (CPIS) scores the patient based on the

findings from each assessment. However, there is some controversy regarding

the accuracy of the score and its correlation to VAP.46


The following is the Clinical Pulmonary Infection Score criteria:46

A score > 6 at baseline or at 72 h is considered suggestive of pneumonia. If <= 6 at 72

hours patient probably doesn't have pneumonia and antibiotics probably can be stopped.

Temperature (C)

>= to 36.5 and, or equal to 38.4 ................ 0 point

>= to 38.5 and, or equal to 38.9................. 1 point

>= to 39 and, or equal to 36...................... 2 points

Blood leukocytes, mm3

>= 4,000 and, <= to 11,000...................... 0 point

<4,000 or > 11,000.................................. 1 point

and, if band forms >= to 50%.................... 1 point

Tracheal secretions

Absence of tracheal secretions...................... 0 point

Presence of nonpurulent tracheal secretions ... 1 point

Presence of purulent tracheal secretions......... 2 points

Oxygenation

PaO2/FIO2, mm Hg >240 or ARDS (ARDS defined as PaO2/FIO2 <= equal to 200,

pulmonary artery wedge pressure <= to 18 mm Hg and acute bilateral

infiltrates).................................................... 0 point

<= equal to 240 and no ARDS........................ 2 points

Pulmonary radiography

No infiltrate................................................ 0 point

Diffuse (or patchy) infiltrate.......................... 1 point

Localized infiltrate........................................ 2 points

Progression of pulmonary infiltrate

No radiographic progression ........................ 0 point

Radiographic progression (no CHF or ARDS).. 2 points


Culture of tracheal aspirate

Pathogenic bacteria cultured in rare or light quantity or no growth.. 0 points

Pathogenic bacteria cultured in moderate or heavy quantity............ 1 point

Same pathogenic bacteria seen on Gram stain, add 1 point............. 1 point

-------------------------------------------------------------------------------------

Notes:

CPIS at baseline is assessed on the basis of the first five variables, i.e., temperature, blood

leukocyte count, tracheal secretions, oxygenation, and character of pulmonary infiltrate.

CPIS at 72 h is calculated based on all seven variables and took into consideration the

progression of the infiltrate and culture results of the tracheal aspirate.

A score > 6 at baseline or at 72 h is considered suggestive of pneumonia.

VAP Treatment

Ventilator-associated pneumonia treatment is administered in one of two ways.

The initial, and frequently used approach, is empiric treatment. With this

approach, patients are given broad-spectrum antibiotics without the

identification of the pathogen that is causing the infection. The second method

of treatment involves targeted antibiotic therapy, which is used when the

specific infection-causing organism has been identified. In many instances, both

methods of treatment will be used.

The ultimate goal with therapy is to balance the use of broad-spectrum

treatment with more specific therapy once the infection-causing agent has been

identified.8

Empiric Therapy

Empiric treatment is typically administered before the infection-causing

organism has been identified. With this approach, the patient receives broad


spectrum antibiotic therapy with the goal of reducing or eliminating the primary

infectious agent.47

The following antibiotics are frequently used when providing empiric treatment

to the patient:

Early Onset (< 5 days since admission)

Ceftriaxone 2 g IV or IM q 24 h or

Levofloxacin 750 mg IV or PO q 24 h or

Moxifloxacin 400 mg IV or PO q 24 h or

Ciprofloxacin 400 mg IV q 8 h or

Ampicillin-sulbactam 3 g IV or IM q 6 h or

Ertapenem 1 g IV or IM q 24 h

Duration of therapy: 8 days

Late onset (≥ 5d since admission), MDR risk factors present, or diagnosis of

HCAP:5,6,

Cefepime 2 g IV q 8 h or

Ceftazidime 2 g IV q 8 h or

Imipenem 500 mg IV q6h or 1 g IV q 8 h or

Meropenem 1 g IV q 8 h or

Piperacillin-tazobactam 4.5 g IV q 8 h PLUS

Vancomycin 15 mg/kg IV q 12 h or

Linezolid 600 mg IV q 12 h PLUS

Ciprofloxacin 400 mg IV q 8 h or

Levofloxacin 750 mg IV q 24 h

Duration of therapy: Depends on specific needs of patient.48


Once the patient begins receiving empiric treatment, he or she will be

continuously monitored to assess the impact the medicine is having on the

infection. The following guidelines are used during the assessment of empiric

treatment:49

If clinical improvement is noted in 48 -72 h and cultures are negative,

consider stopping antibiotics

If clinical improvement is noted in 48 – 72 h and cultures are positive,

adjust regimen per susceptibilities and continue antibiotics for 7 – 8 days

If there is no clinical improvement and cultures are negative, look for

alternative diagnoses

If there is no clinical improvement and cultures are positive, adjust

regimen per susceptibilities

Targeted Drug Therapy

While empiric treatment is successful in many instances of VAP, it is often

necessary to employ targeted antibiotic therapy that is tailored to the specific

pathogen causing the infection. Targeted drug therapy is used in situations

where empiric treatment is not effective or not appropriate, or in situations that

require treatment that will attack a specific organism.50

Patient Care During Treatment

It is important to utilize proper methods for patient care while administering

treatment for VAP. These care strategies will help prevent further infection,

while reducing the risk of the patient developing additional complications. The

most important care strategies include feeding and body positioning, intubation

considerations, and oral hygiene.


Feeding and Body Positioning

It is important to ensure that the patient receives proper feeding and body

positioning while receiving mechanical ventilation and treatment for VAP.

Feeding

1. Acidified enteral feeding:

Because enteral feeding can increase gastric pH and result in gastric

colonization, acidification of enteral solutions has been advocated to

prevent gastric and tracheal colonization in patients receiving such

treatment.32

2. Continuous versus intermittent enteral feeding:

Continuous enteral feeding of mechanically ventilated patients, a common

practice in ICUs, has been associated with increased gastric pH,

subsequent gastric colonization with Gram-negative bacilli, and a high

incidence of pneumonia; whereas intermittent enteral feeding has been

associated with lower gastric pH and lower rates of pneumonia.33

Body Positioning

Placing the patient in a semi-upright position (by elevating the head of the bed

at an angle of 30 - 45 degrees) is beneficial in preventing aspiration. The

increased risk for pneumonia in intubated, mechanically ventilated patients is

partly due to the transmission of oropharyngeal microorganisms via passage of

the endotracheal tube into the trachea during intubation, as well as to

depressed host defenses secondary to the patient's severe underlying illness. In

addition, bacteria can collect on the surface of the endotracheal tube over time

and form a biofilm that protects the bacteria from antimicrobial agents or host

defenses.51


Intubation Considerations

In the intubated patient, leakage around the cuff of the endotracheal tube

allows bacteria laden secretions (which pool below the glottis and above the

endotracheal-tube cuff) direct access to the lower respiratory tract.27 The effect

of using an endotracheal tube that has a separate dorsal lumen, which allows

drainage (i.e., removal by suctioning) of the subglottic secretions, has been

compared to that of a conventional endotracheal tube.52

Non-Invasive Positive Pressure Ventilation (NPPV) has been shown to reduce the

need for, and duration of, intubation, and has resulted in improved survival. In

several studies, the use of NPPV resulted in a decreased risk for pneumonia.35

Repeat Endotracheal Intubation

Repeat insertion of the endotracheal tube soon after it is removed from a

patient who is taken off ventilator support has been shown to be a risk factor for

pneumonia. Using Non-Invasive Ventilation instead may help reduce the risk.27

Oral Care

Proper oral care is crucial in intensive care patients, especially those on a

ventilator. Studies have shown that the risk of developing hospital acquired

pneumonia and ventilator associated pneumonia is reduced when a patient

receives appropriate oral care during his or her stay in the intensive care unit.53

To ensure that oral hygiene standards are consistent throughout all facilities,

the following guidelines, from the American Association of Critical Care Nurses,

were developed:54


Recommended Oral Care Interventions For All Hospitalized Patients

Written Protocol and Training

Intervention: Written oral care protocol and training should be in place.

Rationale: Policy is designed to provide a standard of care, which should be

reinforced in training and should allow for consistent care of all patients.

Initial Assessment

Intervention: Conduct an initial admission assessment of the patient’s oral health

and self-care deficits.

Rationale: Assessment allows for initial identification of oral hygiene problems.

Dental Plaque Removal

Intervention: Use a small, soft toothbrush to brush teeth, tongue and gums at

least twice daily to remove dental plaque. Foam swabs or gauze should not be

used, as they are not effective tools for this task.

Rationale: Dental plaque, identified as a source of pathogenic bacteria associated

with respiratory infection, requires mechanical debridement from tooth, tongue

and gingival surfaces.

Toothpaste

Intervention: Use toothpaste, which contains additives that assist in the

breakdown of mucus and biofilm in the mouth.

Rationale: Additives such as sodium bicarbonate have been shown to assist in

removing debris accumulations on oral tissues and teeth.

Antiseptic Mouth Rinse

Intervention: Use an alcohol-free, antiseptic rinse to prevent bacterial colonization

of the oropharyngeal tract.

Rationale: Mouthwashes with alcohol cause excessive drying of oral tissues.

Hydrogen peroxide and CHG-based rinses have been shown to assist in removing

oral debris as well as provide antibacterial properties.

Moisturizer

Intervention: Use a water-soluble moisturizer to assist in the maintenance of

healthy lips and gums at least once every two hours.

Rationale: Dryness and cracking of oral tissues and lips provide regions for

bacterial proliferation. A water-soluble moisturizer allows tissue absorption and

added hydration.

Avoid Lemon Glycerin Swabs

Intervention: Avoid using lemon-glycerin swabs for oral care to moisten oral

mucosa.


Rationale: Lemon-glycerin compounds are acidic and cause drying of oral tissues.

Assessment of Oral Cavity

Intervention: Conduct an initial admission as well as daily assessment of the lips,

oral tissue, tongue, teeth, and saliva of each patient on a mechanical ventilator.

Rationale: Assessment allows for initial identification of oral hygiene problems and

for continued observation of oral health.

Elevate Head

Intervention: Keep head of bed elevated at least 30 degrees, and position patient

so that oral secretions pool into the buccal pocket; especially important during

feeding, brushing teeth, etc.

Rationale: Elevation prevents reflux and aspiration of gastric contents; oral

secretions may drain into the subglottic area where they can become rapidly

colonized with pathogenic bacteria.

Oral and Orotracheal Suctioning

Intervention: Suction patient’s mouth and oropharynx routinely and as indicated

by patient’s secretion production, using either continuous subglottic suctioning or

manual method. Do not use same catheter to suction both mouth and trachea.

Rationale: Minimize aspiration of contaminated secretions into lungs.

Prognosis

Ventilator-associated pneumonia is the leading cause of mortality from

nosocomial infections in hospitals. Ventilator-associated pneumonia has an

overall mortality rate of 20 – 40%.55 However, the specific percentage will

depend on the infectious agent, the type of treatment used, and the presence of

any underlying conditions. In instances of early onset VAP, the outcome is more

favorable, as the infection is typically caused by an organism that does not have

multiple drug resistance.16 The outcome for patients with late onset VAP is less

favorable, as the infection is most likely the result of multidrug-resistant

organisms, blood stream infections, and ineffective initial antibiotic therapy.48


The fatality rates for hospital-associated pneumonia in general, and VAP in

particular, are high. In instances of hospital-associated pneumonia, VAP

accounted for 60% of all deaths due to hospital-associated infections.56 In

studies in which invasive techniques were used to diagnose VAP, the mortality

rates ranged from 4% in patients with VAP, but without antimicrobial therapy,

to 73% in patients with VAP caused by Pseudomonas or Acinetobacter spp.31

These wide ranges suggest that a patient’s risk of dying from VAP is affected by

multiple factors, such as the patient's underlying disease(s) and organ failure,

and the infecting organism(s).57

Summary

Mechanical ventilators provide life-saving oxygen to patients through a tube in

the nose, mouth, or trachea. However, sometimes germs will enter through the

tube and take up residence in a patient’s lungs, developing into ventilator-

associated pneumonia. Ventilator-associated pneumonia is a life threatening

illness with a mortality rate of 35 – 50%. Approximately 15 – 25% of all

patients who receive respiratory support through mechanical ventilation develop

VAP. It is most common in patients in trauma, burn and neurosurgical centers,

but it is also present in respiratory support centers and intensive care centers.

While patients may experience pneumonia while they are receiving care in a

healthcare setting, VAP is specific to patients who are receiving mechanical

ventilation. It is diagnosed using specific criteria, which includes the

development of pneumonia within 48 hours of being placed on mechanical

ventilation. In many instances, it can be challenging to diagnose VAP, as the

patient is often experiencing a number of complications and symptoms as a

result of his or her underlying medical condition. In fact, many conditions

produce symptoms that mirror those found in VAP.


Although most cases of VAP are treated successfully with antibiotics, early

diagnosis is critical, especially since many VAP patients are intubated and/or

heavily sedated and unable to alert medical staff to their symptoms. Therefore,

nurses need to be able to recognize risk factors and symptoms to provide these

early diagnoses and allow for the best possible outcome for their patients.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of

Knowledge Questions after reading the article, and providing feedback

in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.


1. The primary risk factor for the development of hospital-associated

bacterial pneumonia is:

a. Presence of community-acquired pneumonia during admission.

b. Mechanical ventilation.

c. Viral infection during the flu season.

d. Non-compliance with respiratory precautions among healthcare

workers.

2. In critically ill, mechanically ventilated patients, signs and

symptoms of VAP include the following except:

a. Fever

b. Purulent Sputum

c. Hypoxemia

d. High blood pressure

3. Early-onset pneumonia (EOP) is VAP pneumonia that develops:

a. Within 24 hours of intubation

b. Within 48 and 96 hours of intubation

c. Between 96 and 110 hours of intubation

d. After two weeks of intubation

4. Placing the patient in a semi-upright position (by elevating the

head of the bed at an angle of _______ may help prevent

aspiration in patients on the ventilator.

a. 10-15 degrees

b. 30 - 45 degrees

c. 45-60 degrees

d. 90 degrees


5. In intubated patients, leakage around the endotracheal cuff allows

secretions to form:

a. Below the glottis and above the endotracheal-tube cuff.

b. Underneath the tongue.

c. Below the carina.

d. In the bronchial tubes.

CORRECT ANSWERS:

1. b

2. d

3. b

4. b

5. a


References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within the

study text.

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