Reducing Ventilator Associated Pneumonia


Good nursing care is mandatory for ALL patients at ALL times, however, some of the
recommendations that follow may not be appropriate for patients on a ventilator < 48 hours.

1.        Institute a care management protocol for all ventilator patients

    Preventive Actions:

    a.        Initiate a plan to prevent pneumonia  

    b.        Document the following nursing care activities:

  •  Keep the head of the bed up at all times 30-45 degrees (unless hemodynamically
    unstable.),  
  • Complete oral care performed every four hours to include: brushing and cleaning teeth,
    tongue, gums, walls of the mouth and thorough suctioning.
  • If on enteral feeding, aspirate for gastric residual every shift.  This should be evaluated on
    an individual patient basis.  For example, if the patient is getting 20cc/hr and the residual
    at 2 hours is 40 cc, the tube feeding is not being absorbed and the patient should be
    evaluated for holding feedings.  Hold feeding if aspirate >100 to 150 cc.  
  • Turn every 2 to 4 hours
  • Out of bed every eight (8) hours if stable.  Ambulate twice per day if clinically possible.
  • Drain condensation from ventilator tubing and dispose of in sanitary sewer (flushable
    device).   
  • Suction the oral cavity and the back of mouth as needed.  Oral suctioning should be
    performed prior to deflating the ET cuff.
  • Evaluate the type and amount of secretions at least every 4 hours and notify the physician
    of changes.
  • Notify physician of any suspected or witnessed aspiration (especially when tube feedings
    are being administered).  Review indications for initiation of ventilator and weaning
    protocols for discontinuing use of ventilator.

    c.        Stress bleed prophylaxis
  • Sulcarafate has been generally recommended for intubated patients, however, H2
    Blockers have been shown to be safe in the treatment of these patients for the first four
    days.

    d.        Prolonged nasal intubation (for more than 48 hours) should be avoided because of
    the association between nosocomial sinusitis and ventilator-associated pneumonia.,  

2.        Prevent contamination of the ventilator circuit

    Preventive Actions:

  • Maintain proper cleaning and sterilization or disinfection of reusable equipment (CDC)
  • Wash hands before and after patient or ventilator contact and wear single patient use
    gloves
  • Change ventilator circuits and in- line suction catheters only when visibly soiled or
    malfunctioning
  • Maintain adequate ventilation and cuff pressure
  • Drain condensation from the ventilator circuit using appropriate technique to avoid
    contamination of the circuit
  • Change Heat and Moisture Exchanger every 72 hours
Resources
References:

Boyce JM, White RL, Spruill EY, Wall M.  cost-effective application of the Centers for Disease Control Guideline for Prevention of Nosocomial
Pneumonia.  Am J Infect Control 1985;13:228-32.
Joiner GA, Salisbury D, Bollin GE.  Utilizing quality assurance as a tool for reducing the risk of nosocomial ventilator-assisted pneumonia.  Am J
Med Qual 1996;11:100-3.
Kelleghan SI, Salemi C, Padilla S, et al.  An effective continuous quality improvement approach to the prevention of ventilator-assisted
pneumonia.  Am J Infect Control 1994;21:322-30.
Gaynes RP, Solomon S.  Improving hospital-acquired infection rates: the CDC experience.  Jt Comm J Qual Improv 1996;22:457-67.
Torres A, Serra-Batlles J, Ros E, et al.  Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation :  the effect of body
position.  Ann Intern Med 1992;116:540-3.
Tablan OC, Anderson LJ, Arden NH, Breiman RF, Butler JC, McNeil MM.  Guideline for prevention of nosocomial pneumonia: the Hospital
Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention.  Infect Control Hosp Epidemiol 1994;15:587-627.  
[Erratum, Infect Control Hosp Epidemiol 1998;19:304-.]
Tasota F, Fisher E, Coulson C, Hoffman L.  Protectig ICU patients from nosocomial infections: practical measures for favorable outcomes.  Critical
Care Nurse 1998;18(1):54-65.
CRAVEN de, Steger KA.  Epidemiology of nosocomial pneumonia : new perspectives on an old disease.  Chest 1995;108:Suppl:1S-16S.
Craven DE, Goularte TA, Make BJ.  Contaminated condensate in mechanical ventilator circuts: a risk factor for nosocomial pneumonia?  Am Rev
Respir Dis 1894;129:625-8.
Cook D, DeJonghe B,  Brochard L, Brun-Buisson C.  Influence of airway management on ventilator-associated pneumonia: evidence from
randomized trials.  JAMA 1998;279(10):781-7.
Rouby JJ, Laurent P. Gosnach M, et al.  Risk factors and clinical relevance of nosocomial maxillary sinusitis in the critically ill.  Am J Respir Crit
Care Med 1994;150:776-83.
Tablan O, Anderson L, Arden N. Breiman R, Butler J, McNeil M,  and The Hospital Infection Control Practices Advisory Committee.  Guideline for
Prevention of Nosocomial Pneumonia: Center for Disease Control.  Infection control and Hospital Epidemiology 1994;15(9):587-627.
Doebbeling BN, Stanley GL, Sheetz CT,  et al.  Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in
intensive care units.  N Engl J Med 1992;327:88-93.
Fink JB, Krause SA, Barret L, Schaaff D, Alex CG.  Extending ventilator circut change interval beyond 2 days reduces the likelihood of
ventilator-asociated pneumonia.  Chest 1998;113(12):267-9.
Rello J, Sonora R, Jubert P, Artigas A, Rue M, Valles J.  Pneumonia in intubated patients : role of respiratory airway care.  Am J Respir Crit Care
Med  1996;154:111-5.
Craven DE, Goularte TA, Make BJ.  Contaminated condensate in mechanical ventilator circuts: a risk factor for nosocomial pneumonia?  Am Rev
Respir Dis 1894;129:625-8.
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