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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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 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 multidrugresistant pathogens. The most common pathogens include:16 P. aeruginosa K. pneumonia (extended spectrum beta-lactamase and Klebsiellaproducing 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 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 homeassociated 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 receive empiric antibiotics as a preventative measure to ensure that the multidrug-resistant pathogens do not colonize and cause the patient to develop 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 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 receive empiric antibiotics as a preventative measure to ensure that the multidrug-resistant pathogens do not colonize and cause the patient to develop 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 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 Not generally recommended but may help identify which procolacitonin patients with respiratory symptoms have pneumonia and need to be hospitalized. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 Polymerase Chain In some difficult cases, PCR may be performed. The test makes Reaction (PCR) 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) nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 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 Lung parenchyma* Values >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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 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 ventilatorassociated 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 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. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 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 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 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. 1. Joseph NM, Sistla S, Dutta TK, Badhe AS, Parija SC. Ventilator-associated pneumonia: a review. Eur. J. Intern. Med. 2010;21:360–8. 2. Albertos R, Caralt B, Rello J. Ventilator-associated pneumonia management in critical illness. Curr. Opin. Gastroenterol. 2011;27:160–6. 3. Timsit J-F, Zahar J-R, Chevret S. Attributable mortality of ventilatorassociated pneumonia. Curr. Opin. Crit. Care. 2011;17:464–71. 4. Sundar KM, Nielsen D, Sperry P. Comparison of ventilator-associated pneumonia (VAP) rates between different ICUs: Implications of a zero VAP rate. J. Crit. Care. 2012;27:26–32. 5. Anand N, Kollef MH. The alphabet soup of pneumonia: CAP, HAP, HCAP, NHAP, and VAP. Semin. Respir. Crit. Care Med. 2009;30:3–9. 6. Langer M, Haeusler EA. Ventilator associated pneumonia (VAP): an impossible diagnosis? Call for a pragmatic approach. Minerva Anestesiol. 2009;75:584–90. 7. Rea-Neto A, Youssef NCM, Tuche F, Brunkhorst F, Ranieri VM, Reinhart K, et al. Diagnosis of ventilator-associated pneumonia: a systematic review of the literature. Crit. Care. 2008;12:R56. 8. Silvestri L, van Saene HKF, Gullo A, de la Cal MA. Guidelines for prevention, diagnosis, and treatment of ventilator-associated pneumonia (VAP) in the trauma patient. J. Trauma. 2007. p. 1062–1064; author reply 1064–1065. 9. Weber DJ, Rutala WA, Sickbert-Bennett EE, Samsa GP, Brown V, Niederman MS. Microbiology of ventilator-associated pneumonia compared nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 with that of hospital-acquired pneumonia. Infect. Control Hosp. Epidemiol. The University of Chicago Press; 2007 Jul 17;28(7):825–31. 10. Alp E, Voss A. Ventilator associated pneumonia and infection control. Ann. Clin. Microbiol. Antimicrob. 2006 Jan;5(1):7. 11. Giantsou E, Liratzopoulos N, Efraimidou E, Panopoulou M, Alepopoulou E, Kartali-Ktenidou S, et al. Both early-onset and late-onset ventilatorassociated pneumonia are caused mainly by potentially multiresistant bacteria. Intensive Care Med. 2005 Nov;31(11):1488–94. 12. Roy G. Interventions by critical care nurses reduce VAP. Dynamics. 2007;18:28–31; quiz 32–33. 13. Wunderink R, Brun-Buisson C, Kuti EL, Patel AA, Coleman CI. Impact of inappropriate antibiotic therapy on mortality in patients with ventilatorassociated pneumonia and blood stream infection: A meta-analysis. J. Crit. Care. 2008;23(1):91–100. 14. Park DR. The Microbiology of Ventilator-Associated Pneumonia. Respir Care. 2005 Jun 1;50(6):742–65. 15. Kollef MH, Morrow LE, Niederman MS, Leeper K V, Anzueto A, Benz-Scott L, et al. Clinical characteristics and treatment patterns among patients with ventilator-associated pneumonia. Chest. American College of Chest Physicians; 2006 May 1;129(5):1210–8. 16. Tejerina E, Frutos-Vivar F, Restrepo MI, Anzueto A, Abroug F, Palizas F, et al. Incidence, risk factors, and outcome of ventilator-associated pneumonia. J. Crit. Care. 2006;21(1):56–65. 17. Lutfiyya MN, Henley E, Chang LF, Reyburn SW. Diagnosis and treatment of community-acquired pneumonia. Am. Fam. Physician. 2006;73:442–50. 18. Waterer GW, Rello J, Wunderink RG. Management of community-acquired pneumonia in adults. Am. J. Respir. Crit. Care Med. 2011;183:157–64. 19. Ewig S, Welte T, Chastre J, Torres A. Rethinking the concepts of community-acquired and health-care-associated pneumonia. Lancet Infect. Dis. 2010;10:279–87. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 20. Wilkinson M, Woodhead MA. Guidelines for community-acquired pneumonia in the ICU. Curr. Opin. Crit. Care. 2004;10:59–64. 21. Community-Acquired Pneumonia [Internet]. Available from: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/i nfectious-disease/community-acquired-pneumonia/#s0020 22. Mechanical Ventilation [Internet]. Available from: http://emedicine.medscape.com/article/304068-overview#aw2aab6b4 23. Haitsma JJ. Physiology of mechanical ventilation. Crit. Care Clin. 2007;23:117–134, vii. 24. James MM, Beilman GJ. Mechanical ventilation. Surg. Clin. North Am. 2012;92:1463–74. 25. Santanilla JI, Daniel B, Yeow M-E. Mechanical ventilation. Emerg. Med. Clin. North Am. 2008;26:849–862, x. 26. Mechanical Ventilation [Internet]. Available from: http://emedicine.medscape.com/article/304068-overview 27. Papadakos PJ, Karcz M, Lachmann B. Mechanical ventilation in trauma. Curr. Opin. Anaesthesiol. 2010;23:228–32. 28. Putensen C, Hering R, Wrigge H. Controlled versus assisted mechanical ventilation. Curr. Opin. Crit. Care. 2002;8:51–7. 29. Lung M, Codina G, Lung M, Codina G. Molecular diagnosis in HAP/VAP. [Review]. Curr. Opin. Crit. Care. 2012;18:487–94. 30. Augustyn B. Ventilator-Associated Pneumonia: Risk Factors and Prevention. Crit. Care Nurse. 2007 Aug 1;27(4):32–9. 31. Singer BD, Corbridge TC. Basic invasive mechanical ventilation. South. Med. J. 2009;102:1238–45. 32. Dobson K, Scott A. Review of ICU nutrition support practices: implementing the nurse-led enteral feeding algorithm. Nurs. Crit. Care. 12(3):114–23. 33. Chen Y-C. Critical analysis of the factors associated with enteral feeding in preventing VAP: a systematic review. J. Chin. Med. Assoc. 2009;72:171–8. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 34. Blackburn GL, Wollner S, Bistrian BR. Nutrition support in the intensive care unit: an evolving science. Arch. Surg. American Medical Association; 2010 Jun 1;145(6):533–8. 35. Safdar N, Crnich CJ, Maki DG. The Pathogenesis of Ventilator-Associated Pneumonia: Its Relevance to Developing Effective Strategies for Prevention. Respir Care. 2005 Jun 1;50(6):725–41. 36. Torres A, Ferrer M, Badia JR. Treatment guidelines and outcomes of hospital-acquired and ventilator-associated pneumonia. Clin. Infect. Dis. 2010;51 Suppl 1:S48–S53. 37. Rello J, Diaz E. Pneumonia in the intensive care unit. Crit. Care Med. 2003;31:2544–51. 38. Craven DE, Hjalmarson KI. Ventilator-associated tracheobronchitis and pneumonia: thinking outside the box. Clin. Infect. Dis. 2010 Aug 1;51 Suppl 1(Supplement_1):S59–66. 39. Klompas M. Does this patient have ventilator-associated pneumonia? JAMA. American Medical Association; 2007 Apr 11;297(14):1583–93. 40. Cerny J, Rosmarin AG. Why Does My Patient Have Leukocytosis? Hematol. Oncol. Clin. North Am. 2012. p. 303–19. 41. Porzecanski I, Bowton DL. Diagnosis and treatment of ventilator-associated pneumonia. Chest. American College of Chest Physicians; 2006 Aug 1;130(2):597–604. 42. Pneumonia | University of Maryland Medical Center [Internet]. Available from: http://umm.edu/health/medical/reports/articles/pneumonia#ixzz2pIsoUkO R 43. Magret M, Amaya-Villar R, Garnacho J, Lisboa T, Díaz E, Dewaele J, et al. Ventilator-associated pneumonia in trauma patients is associated with lower mortality: results from EU-VAP study. J. Trauma. 2010;69:849–54. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38 44. Shorr AF, Sherner JH, Jackson WL, Kollef MH. Invasive approaches to the diagnosis of ventilator-associated pneumonia: a meta-analysis. Crit. Care Med. 2005;33:46–53. 45. CDC - Ventilator Associated Pneumonia [Internet]. Available from: http://www.cdc.gov/nhsn/pdfs/pscmanual/6pscvapcurrent.pdf 46. Zilberberg MD, Shorr AF. Ventilator-associated pneumonia: the clinical pulmonary infection score as a surrogate for diagnostics and outcome. Clin. Infect. Dis. 2010 Aug 1;51 Suppl 1(Supplement_1):S131–5. 47. Aarts M-AW, Hancock JN, Heyland D, McLeod RS, Marshall JC. Empiric antibiotic therapy for suspected ventilator-associated pneumonia: a systematic review and meta-analysis of randomized trials. Crit. Care Med. 2008;36:108–17. 48. Kollef MH, Kollef KE. Antibiotic utilization and outcomes for patients with clinically suspected ventilator-associated pneumonia and negative quantitative BAL culture results. Chest. American College of Chest Physicians; 2005 Oct 1;128(4):2706–13. 49. Hospital-Acquired, Health Care-Associated, and Ventilator-Associated Pneumonia Empiric Therapy [Internet]. Available from: http://emedicine.medscape.com/article/2012032-overview 50. Fagon J-Y, Rello J. Targeted antibiotic management of ventilatorassociated pneumonia. Clin. Microbiol. Infect. 2006 Dec;12(s9):17–22. 51. Li Bassi G, Torres A. Ventilator-associated pneumonia: role of positioning. Curr. Opin. Crit. Care. 2011 Feb;17(1):57–63. 52. Branson RD. The ventilator circuit and ventilator-associated pneumonia. Respir. Care. 2005;50:774–785; discussion 785–787. 53. Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med. 2006 Feb;32(2):230–6. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 54. DeKeyser Ganz F, Fink NF, Raanan O, Asher M, Bruttin M, Nun M Ben, et al. ICU nurses’ oral-care practices and the current best evidence. J. Nurs. Scholarsh. 2009 Jan;41(2):132–8. 55. M. HR, A. FU, E. CS, M.T. PJ, B. MR, E. TG. Ventilator-associated pneumonia (VAP) is the main mortality risk factor in patients following cardiac surgery. Eur. J. Anaesthesiol. 2011. p. 176–7. 56. Vallés J, Pobo A, García-Esquirol O, Mariscal D, Real J, Fernández R. Excess ICU mortality attributable to ventilator-associated pneumonia: the role of early vs late onset. Intensive Care Med. 2007 Aug;33(8):1363–8. 57. Nguile-Makao M, Zahar J-R, Français A, Tabah A, Garrouste-Orgeas M, Allaouchiche B, et al. Attributable mortality of ventilator-associated pneumonia: respective impact of main characteristics at ICU admission and VAP onset using conditional logistic regression and multi-state models. Intensive Care Med. 2010;36:781–9. The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature, and is not designed to address any specific situation. 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