Академический Документы
Профессиональный Документы
Культура Документы
ventilator-associated
Learn how it develops and strategies you can use to reduce
your patients risk of this common complication.
By William C. Pruitt, RRT, AE-C, CPFT, MBA,
and Michael Jacobs, RN, CCRN, CEN, MSN
4 CriticalCareChoices2005
conditions that
increase the risk of
aspiration, such as
intubation, presence
of a nasogastric
(NG) tube, or
decreased level of
consciousness
conditions that
impair defense
mechanisms, such
as age extremes
(particularly age 70
or older), malnutrition, diabetes, renal
insufficiency, and
chronic obstructive
pulmonary disease
(COPD).
Other risk factors
are related to poor
infection control
technique by health
care providers, including inadequate hand hygiene and failure to wear gloves when handling respiratory secretions or
equipment contaminated with respiratory secretions.
Types of VAP
Determining the type of VAP can help identify the
responsible nosocomial organisms and guide antibiotic therapy.
Early-onset VAP occurs during the first 3 to 4 days
of mechanical ventilation. The causative organisms
often are the same ones responsible for communityacquired pneumonia; likely to be sensitive to traditional antibiotic therapy, theyre usually easier to treat.
Common organisms implicated in early-onset VAP
include Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis.
Late-onset VAP, which occurs 5 or more days after
C
E
2.0
pneumonia?
initiation of mechanical ventilation, is most commonly due to Staphylococcus aureus, Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae,
and the Enterobacter species. Because these pathogens
may be antibiotic-resistant (for example, methicillinresistant S. aureus), they must be treated with more
powerful antibiotics and antibiotic combinations.
Late-onset VAP, which can increase mortality rates by
50%, has become significantly more prevalent in
recent years.
A clinician may choose to start a patient on antibiotics as soon as she suspects VAP or to delay treatment until the pathogen is identified by an invasive
procedure (such as bronchoscopy, protected specimen
brushings, or bronchoalveolar lavage) and lab analysis. Shell base the decision on the severity of disease,
time of onset, and presence of risk factors.
ANCC/AACN
CONTACT
HOURS
CriticalCareChoices2005 5
ventilation), supplemental oxygen, positive end-expiratory pressure, continuous positive airway pressure, and
pressure support. By avoiding intubation and the associated high risk of aspiration around an artificial airway,
this option reduces the risk of VAP.
However, although NPPV has been used for 20 years
by home health care patients needing temporary support, the therapy has the following drawbacks when its
used as a full-support mode instead of traditional
mechanical ventilation.
Because NPPV doesnt secure the airway, leaks with
subsequent loss of tidal volume can be a problem.
The mask may make patients feel claustrophobic.
Suctioning, if needed, can be done nasotracheally or
orotracheally because the patient lacks an artificial airway. Passing the suction catheter though the nasopharynx can be traumatic, and the lower airway may not be
adequately suctioned via this approach. In addition,
nasotracheal suctioning can introduce pathogens into
the lungs, increasing the risk of VAP.
Eating and drinking is difficult if NPPV is being used for
full support. The mask must be removed, interrupting ventilation, for the patient to eat or drink by mouth. Gastric
distension is sometimes a problem, and an NG tube may
be is used to prevent this problem. Patients also may be fed
through the NG tube to avoid discontinuing NPPV.
Because of these drawbacks, NPPV is appropriate only
for short-term ventilator needs. If the patient requires
full ventilatory support for more than 24 hours, hell
need to be intubated and be connected to a traditional
mechanical ventilator.
Ways to prevent VAP
If your patient needs an artificial airway, you can take
steps during the initial insertion to reduce his risk of
developing VAP.
Use meticulous hand hygiene. Wear clean gloves when
appropriate.
Use an oral artificial airway rather than a nasal one if
possible. Nasal intubations increase the risk of nosocomial sinusitis and development of VAP.
Keep the ET tube cuff at minimal occluding volume. This
avoids damage to the tracheal wall. Make sure the cuff is
inflated adequately to reduce the chance that the patient
will aspirate secretions that accumulate above the cuff.
Newer ET tubes now have a dorsal lumen above the cuff
so you can clear tracheal secretions that accumulate in
the subglottic area with either continuous or frequent
intermittent suctioning.
Consider a tracheostomy tube for patients who need longterm ventilation. This option still needs to be studied to
determine if it provides a clear benefit in reducing VAP.
Observe meticulous infection control. If oral intubation is
used, the reusable laryngoscope blade (and stylet) should
have high-level disinfection before use (for example, with
glutaraldehyde). Sterilization also can be used for these
6 CriticalCareChoices2005
humidifier when its visibly soiled or if its malfunctioning. Fill heated humidifiers with sterile water only.
Patient nutrition and VAP
All critically ill patients have high calorie needs to fight
complications and to heal. Because a mechanically ventilated patient cant take foods or fluids orally, he may
need an enteral tube for feedings. Unfortunately, an
enteral tube increases his risk of aspiration and VAP, so
take these preventive steps:
Advocate for an orogastric tube instead of an NG tube, if
appropriate. An NG tube increases the patients risk of
nosocomial sinusitis and pathogen contamination of the
oropharyngeal area from the nasopharyngeal area.
Routinely verify correct feeding tube placement by more than
one method, including measuring the pH of gastric aspirate.
Monitor the patients tolerance of gastric feedings.
Auscultate bowel sounds and measure abdominal girth
frequently. Measure residual gastric volume at least every
4 hours during continuous feedings and before each
intermittent feeding, to decrease the likelihood of gastric
distension and aspiration. Less than 200 ml is generally
considered an acceptable amount of gastric residual volume, although this can vary from institution to institution. If residual volume is more than 200 ml, stop the
enteral feeding for 2 hours, then reassess residual volume.
Elevate the patients head to at least 30 degrees at all times
for continuous feedings or during and for 1 hour after intermittent feedings. This helps minimize the risk of reflux
and pulmonary aspiration.
Provider Accreditation:
This Continuing Nursing Education (CNE) activity for 2.0 contact hours is provided by Lippincott Williams & Wilkins, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Centers
Commission on Accreditation and by the American Association of Critical-Care
Nurses (AACN 00012278, CERP Category A). This activity is also provider
approved by the California Board of Registered Nursing, Provider Number CEP
11749 for 2.0 contact hours. LWW is also an approved provider of CNE in
Alabama, Florida, and Iowa and holds the following provider numbers: AL
#ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified
for Texas nursing continuing education requirements as Type I.
Your certificate is valid in all states. This means that your certificate of earned
contact hours is valid no matter where you live.
Payment and Discounts:
The registration fee for this test is $13.95.
If you take two or more tests in any nursing journal published by LWW and
send in your CE enrollment forms together, you may deduct $0.75 from the
price of each test.
We offer special discounts for as few as six tests and institutional bulk discounts for multiple tests. Call 1-800-933-6525, ext. 6617 or ext. 6621, for more
information.
CriticalCareChoices2005 7
C E
2.0
ENROLLMENT FORM
A. Registration Information:
Address _______________________________________________________________________________
City _______________________________________ State _________________ ZIP ______________
Telephone ____________________ Fax ____________________ E-mail ____________________
Registration Deadline: May 30, 2007
Contact hours: 2.0
Pharmacology hours: 0.0
Fee: $13.95
B. Test Answers: Darken one circle for your answer to each question.
a
1.
2.
3.
a
4.
5.
6.
a
7.
8.
9.
C. Course Evaluation*
1. Did this CE activity's learning objectives relate to its general purpose? Yes No
2. Was the journal home study format an effective way to present the material? Yes No
3. Was the content relevant to your nursing practice? Yes No
4. How long did it take you to complete this CE activity?___ hours___minutes
5. Suggestion for future topics __________________________________________________________
a
10.
11.
12.
a
13.
14.
15.
*In accordance with the Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of the CE offering may be submitted directly to the Iowa Board of Nursing.