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Tuesday, April 1, 2008

Preventing Ventilator-Associated Pneumonia

How to prevent Ventilator-Associated Pneumonia has been extensively studied. Here are the most common recommendations. Chances are your hospital has already incorporated most of these.
  1. Ventilator Bundles are protocols based on best practice medicine. These should be incorporated in all critical care units to assure all of the following guidelines are met. 
  2. Good handwashing
  3. Sterile technique (as much as possible)
  4. Implementing a ventilator extubation protocol to speed up time from intubation to extubation. 
  5. Making sure the cuff pressure is always 30 CWP or greater. The idea here is that this will prevent secretions from leaking around the cuff. Higher pressures are acceptable so long as intubation is short term, which is the goal of any intubation.
  6. Tracheotomy should be considered for anyone requiring greater than seven days of mechanical ventilation. 
  7. Heated wires should be used to limit opening of the circuit (this seems to be no longer an issue)
  8. Inline suctioning (such as a Ballard) should be used instead of tracheal lavage and suctioning. Lavage and suctioning can still be used, although this should be left to the discretion of the respiratory therapist. 
  9. The head of bed should be raised 45 degrees at all times to prevent aspiration of stomach contents. This should be started as soon as possible, and may even be started in the emergency room prior to the patient being transferred or admitted to critical care.
  10. A feeding tube should be inserted to assure adequate nutrition. 
  11. The mouth should be washed with a Chlorhexidine Oral Rinse and suctioned out every two hours (as appropriate). Studies have shown a good mouth cleansing can greatly reduce the chance of VAP.
  12. Do not use heat and moisture exchangers unless absolutely necessary, such as when you need to transfer the patient. Studies have shown HMEs tend to increase likelihood of VAP.
  13. Sedatives should be limited. There have been a lot of studies and discussions on the use of sedatives on intubated patients. Some suggest limiting sedation in the morning to make sure the patient is awake, cooperative, and understands the plan. Ideally, sedatives should be stopped at least four hours prior to beginning any weaning screen.
  14. Studies show that it is most effective if the circuit is changed weekly, as opposed to daily as the best way of preventing VAP.
  15. Daily chest-x-ray to monitor for signs of pneumonia
  16. Sterile technique and proper technique when inserting lines. We are all instructed to monitor physicians to make sure they use this proper technique.
  17. Stress-ulcer prophylaxis (this would be part of the ventilator bundle, and would be a nursing protocol. Ours includes a daily proton pump inhibitor like Prilosec (omeprazole)
  18. Prophylactic antibiotic therapy (of course there is controversy here too). This is to prevent infections such as pneumonia and sepsis. 
These are some ideas that have been researched over and over the past several years. Newer studies are changing some of the older ideas we had regarding intubation. For instance, back in 1997 when I attended RT school, we were taught never to exceed a cuff pressure of 24 cwp to prevent the occlusion of blood flow. So, as you can see, this has changed considerably, although it's supposedly all for the better. 

Intubation and mechanical ventilation is not a science: it is an art based on a science. So, as you will learn (or have learned) in this profession, we do the best we can with what we know today, and as we learn more we do better. This is the case with advancements in intubation and extubation, as it is in other areas of healthcare. 

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