The Pre-brief
Your patient is now intubated. Emergency diverted. But it doesn’t stop there. Now is the time to start preventing VAP by reducing colonization and aspiration. Ventilator Associated pneumonia (VAP), the most common type of nosocomial pneumonia, appears 48-72 hours post intubation. According to the CDC, VAP accounts for up to 27% of all mechanically ventilated patients in the ICU. This can result in increase mortality rates, longer hospital stay, increased morbidity, and accounts for an average of 9 more mechanical ventilator days with 11 additional days in the hospital all which accounts for and estimated $11,000 increased hospital cost per patient.
Early onset VAP can occur 48-96 hours post intubation caused by antibiotic sensitive bacterium, while late onset VAP usually occurs 4 days post intubation and is usually caused by antibiotic resistant bacterium. Endotracheal intubation is a huge cause for VAP. The endotracheal tube creates a direct path between the oral cavity and the lungs.
Diagnosis
Early diagnosis of VAP is critical. Diagnosis can be complicated due to multiple contributing factors. Clinicians heavily rely on clinical signs to diagnose VAP so it is important to have threshold standards of testing.
- Increased White blood cell count
- Respiratory Decline
- Fever
- New infiltrate of chest x ray
- Purulent sputum
- Blood cultures
- Quantitative Bronchoalveloar lavage (BAL)
BAL
The trained respiratory therapist can obtain a quantitative mini-BAL. The mini-BAL can be performed safely in a short amount of time while maintaining ventilation and PEEP. Sensitivity is comparable to a bronchoscopic BAL. It is important to note that this procedure is done without visualization by camera.
RTs role in prevention
As a respiratory therapist, you play a big role in the fight against VAP.
- Oral care prior to intubation if possible.
- Use of Endotracheal tubes with subglottic ports as this allows for secretions above the cuff to be suctioned preventing them from migrating into the lungs.
- Monitor cuff pressure each shift.
- Keep the head of the bed at an angle of 30 degrees or greater.
- Avoid unnecessary ventilator disconnects and ventilator circuit changes while keeping circuit free from condensate.
- Cleaning and disinfecting the ventilator every shift.
- Hand washing.
- Daily spontaneous breathing trials as removing the ETT restores mucociliary function as well as adequate cough of the patient.
- Ask the RN to manage the patient on the ventilator with little to no sedation if possible, as studies have shown that sedation vacation reduced the incident of VAP.
- Oral care every 2 hours with Chlorhexidine rinse. The oral cavity is the source of the bacteria that aspirates into the lungs. It takes only two hours for the mouth the fill with bacteria.
- Early mobility.
The Debrief
- Routine oral care plays a key role in preventing VAP
- A MINI-BAL can be as effective as a Bronchoscopic BAL
- VAP puts a strain on healthcare and can be prevented with proper medical prevention, including respiratory care
References
- JD;, K. (n.d.). Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. https://pubmed.ncbi.nlm.nih.gov/17041138/
- Scott, D. The Direct Medical Costs of Healthcare Associated Infections: Ventilator-associated pneumonia (vap). (2010, November 24). https://www.cdc.gov/hai/vap/vap.html
- Shahabi, M., Yousefi, H., Yazdannik, A., & Alikiaii, B. (2016). The effect of daily sedation interruption protocol on early incidence OF VENTILATOR-ASSOCIATED pneumonia among patients hospitalized in critical care UNITS receiving mechanical ventilation. https://www.ncbi.nlm.nih.gov/pubmed/27904641
