Ventilator-Associated Pneumonia: Prevention and Diagnosis

Transcription

1 Ventilator-Associated Pneumonia: Prevention and Diagnosis Kathleen Stoessel, RN, BSN, MS Senior Manager, Clinical Education Kimberly-Clark Health Care September

2 VAP: Prevention and Diagnosis Objectives Review impact of healthcare-associated infections (HAIs) on healthcare in the United States Describe why ventilated patients are susceptible to pneumonia Discuss strategies for preventing ventilator-associated pneumonia (VAP) Identify differences in diagnostic procedures 2 2

3 HAIs in the U.S. HAIs are: the most common complication of hospital care one of the top ten leading causes of death accountable for 1.7 million infections and approximately 99,000 deaths annually 5% of patients who acquire an HAI erode 63% of hospital s net inpatient operating profits 73% of healthcare CEOs cited HAIs as their #1 concern Accessed 8/23/11 3 3

4 Impact of VAP in the U.S. Incidence: 5.2 cases/1000 ventilator days in surgical ICUs (SICUs) 10.2 cases/1000 ventilator days in trauma ICUs Additional days: on ventilator, in ICU, in hospital Estimated cost of treatment per patient: $11,000 - $57,000 Added pressure to eliminate VAP: Centers for Medicare and Medicaid Services (CMS) may cease to reimburse hospitals for costs incurred as a result of VAP Bird D, Zambuto A, O'Donnell C, et al. Arch. Surg. May 2010;145(5):

5 HAIs in U.S. Hospitals OTHER 17% UTI BSI 14% PNEU 15% SSI 22% 32% Healthcare-Associated Infections UTI: Urinary Tract Infection SSI: Surgical Site Infection PNEU: Pneumonia BSI: Bloodstream Infection Klevens, R.M. et. al. Mar-Apr Estimating Health Care-Associated Infections & Deaths in U.S. Hospitals, Public Health Reports, 122,

6 Healthcare Pressured from Accrediting bodies 6 6

7 Healthcare Pressured from Accrediting bodies Consumer Groups 7 7

8 Healthcare Pressured from Accrediting bodies Consumer Groups Government (national, state) 8 8

9 Healthcare Pressured from Accrediting bodies Consumer Groups Government (national, state) 9 9

10 Healthcare Pressured from Accrediting bodies Consumer Groups Government (national, state) Insurance/reimbursement 10 10

11 Accrediting bodies Consumer Groups Government (national, state) Healthcare Pressured from Insurance/reimbursement Litigation 11 11

12 Healthcare Pressured from Accrediting bodies Consumer Groups Government (national, state) Insurance/reimbursement Litigation Media 12 12

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14 Healthcare Pressured from Accrediting bodies Consumer Groups Government (national, state) Insurance/reimbursement Litigation Media Patients and their families 14 14

15 Focus on VAP 15 15

16 What Is VAP? VAP is a pneumonia that develops in a mechanically ventilated patient > 48 hrs after tracheal intubation (traditional definition) Chastre J. Conference Summary: Ventilator-Associated Pneumonia. Respir Care, 2005; 50(7):

17 Why Are Ventilated Patients Susceptible to VAP? 17 17

18 The ETT Cuff Dislodgement, Creases, Folds, Channels Under-inflated cuffs allow leak through Manipulation of tube by HCW or visitors (fluffing pillow) allow leakage Conventional High-volume, Low-Pressure (HVLP) PVC cuffs create folds when inflated: channels to form; fluid leaks past the cuff Young, PJ. et.al A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med, 34(3) 18 18

19 The Mouth Isn t What It Used To Be! Harboring the Enemy One of the most critical risk factors for ventilator-associated pneumonia is microbial colonization of the oropharynx. CDC 2003 Guidelines for the Prevention of Nosocomial Pneumonia states that in 76% of VAP cases, bacteria colonizing the mouth before pneumonia is diagnosed are the same as those causing the pneumonia Munro CL Oral Health and Care in the Intensive Care Unit: State of the Science. Am J CritCare 13(1): CDC. Guideline for prevention of nosocomial pneumonia. MMWR 1997;46(No. RR-1)

20 Saliva Flow of ICU Patients Diminish Rapidly 2.5 Saliva ml/5minutes 0.0 ICU stay = saliva Days After Admission Flow decreases even more rapidly: fever diarrhea reduced intake side effects medications including: sedatives antihypertensives sympothomimetics anticholinergics chemotherapeutic drugs And When.. Xerostomia: severely reduced salivary flow and dry mouth, is common in ICU patients due to fever, diarrhea, reduced intake and medication side effects Dennesen. Inadequate salivary flow and poor oral mucosal status in intubated intensive care unit patients. Crit Care Med 2003; (31)3:

21 Impact of Reduced Saliva on Mucositis/Oral Lesions saliva = mucositis Mucositis index Risk factors for mucositis include: reduced saliva (xerostomia) chemotherapy physical trauma of devices poor oral hygiene intubated on mechanical Ventilation Days After Admission Dennesen et al. Inadequate salivary flow and poor oral mucosal status in intubated intensive care unit patients. Crit 21 Care Med 2003; (31)3:

22 Mucositis Mucositis, inflammation of oral mucus membranes, follows resulting in increased oropharyngeal colonization with respiratory pathogens Dennesenet al. Inadequate salivary flow and poor oral mucosal status in intubatedintensive care unit patients. CritCare Med 2003;31(3):

23 Dental Plaque Development If the intubated and/or critically ill patient does not receive effective oral hygiene, then bacterial plaque structures form heavily within 72 hours Beyond comfort: Oral hygiene as a critical nursing activity in the intensive care unit Berry, AM, & Davidson, PM. Intensive and Critical Care Nursing; June 23,

24 Of Course There is Always the Direct Route Can seed the lungs directly during Intubation Ventilator tube disconnection during open suctioning change-outs diagnostic instrumentation tube drainage patient transport 24 24

25 Contamination: Reported Outbreaks of VAP Traced to Environmental Sources Ice & water Bronchoscopes Nebulized medication Infected patients or healthcare workers Fingernails & hands of healthcare workers Reusable electronic ventilator probes & sensors Ventilator circuits/equipment, humidifiers, respirometers Safdar N, Crnich C, Maki D. the Pathogenesis of Ventilator-Associated Pneumonia: Its Relevance to Developing Effective Strategies for Prevention. June Respiratory Care 50(6):

26 And then the route through injured tissue Tracheal injury can happen during: initial trauma incident ETT insertion; improper placement of ETT ETT rubs trachea; manipulation of ETT tracheal suctioning diagnostic instrumentation continuous subglottic suction that over-dries poor cuff design; over-inflation of cuff Intubation injury Over-inflation or poor balloon design Lesions increase risk of infection seed lung: on lips; inside mouth; tracheal lining Stroud RH, Rassekh CH. Laryngeal Injury as a Result of Endotracheal Intubation. Grand Rounds Presentation, UTMB, Dept. of Otolaryngology 19 May 1999; accessed 4/15/

27 Strategies for Preventing VAP Action Plan to Prevent Healthcare-Associated Infections 27 27

28 Prevention of VAP increasing adherence to currently recommended practices can result in a dramatic reduction in infection rates. Example: Standard precautions (e.g. appropriate hand hygiene and selection and wearing of personal protective equipment) 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

29 Standard Precautions Hand Hygiene Transmission Precautions Back To Basics! Environmental Cleaning 29 29

30 Examples of Studies that Examined Precautions Compliance by HCWs Subjects/Design Appropriate Practice/PPE Use Compliance ICU (medical), Observational Community hospitals, Qualitative survey Handwashing Gloves Gown Handwashing Gloves 36% 62% 63% 61% 44% Trauma unit, Questionnaire survey Recovery nurses, Cross-sectional survey Gloves Gown Eyewear Eyewear with side protectors Mask When caring for: high risk patients low risk patients 85% 18% 47% 16% 4% 81% 31% Gammon J, et al. J. Clin. Nurs. Jan 2008;17(2):

31 And The Somewhat Neglected Role of Surface Contamination 31 31

32 ICU Primed for HAI Extremely vulnerable patients Under-resourced Environmental Services (ES): low wages minimal infection prevention education lack of their own recognition as an essential arm of infection prevention Intensive Care Cleaning and disinfection more difficult delicate circuitry = Careful, don t fry the circuits chemical-sensitive screens = Careful, don t damage intricate wires and hoses = Careful, don t dislodge 3 rd party ES may lose: My patients; My responsibility All make effective disinfection difficult and threatening for patients, equipment, nursing staff, and ES 32 32

33 Survival on Dry Inanimate Surfaces Pathogen: Bacteria Acinetobacter Clostridium difficile (spores) Enterococcus spp. Including VRE and VSE Pseudomonas aeruginosa Staphylococcus aureus (including MRSA) Pathogen: Fungi/Yeast Aspergillus conidia (spores) Candida albicans Pathogen: Viruses Adenovirus Survival on Dry Inanimate Surfaces 3 days to 5 months 5 months 5 days to 4 months 6 hours to 16 months; 5 weeks on dry floors 7 days to 7 months Survival on Dry Inanimate Surfaces Months or longer days Survival on Dry Inanimate Surfaces 7 days to 3 months Coronavirus (e.g. SARS, GI infections, cold) 3-28 days (2) 33 Kramer A. (A Review) BMC Infect Dis 2006;6:130//(2) Bonilla H F, Zervos M J, Kauffman C A. Infect Control Hosp Epidemiol. 1996;17:

34 We Have To Do A Better Job Of Surface Disinfection!! Prior room of infected patients increase risk for new patient MRSA & VRE: Admission room previously occupied by MRSA or VRE-positive patient significantly increased odds of infection Huang S 2006 VRE: Contamination determined by environmental cultures or prior occupancy by VRE-colonized patients increases risk of VRE acquisition Drees M 2008 C. difficile: CDAD prior room occupant: significant risk for CDAD HAI ICACC (K-4194) 2008 Shaughnessy Mostenvironmental checks for C. difficile show it is still present after daily and terminal cleaning!! C. difficile spores with vestiges of vegetative skin 34 34

35 Prevention of VAP Priority Module Recommendation Focus 1 Routine Care of Patients Requiring Mechanical Ventilation HHS Action Plan to Prevent Healthcare-Associated Infections Accessed

36 Routine Patient Care Use non-invasive ventilation whenever possible Use orotracheal rather than nasotracheal intubation when possible 2008 SHEA/ISDA Compendium of Strategies; 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

37 Anatomically Correct ETT Pediatric Adult 37 37

38 Evaluate ETT Cuff Use a cuffed endotracheal tube; questions to ask Does it allow for unavoidable manipulation of ETT without: disrupting the seal resulting in aspiration? rubbing up and down tracheal mucosa? allowing tip to angle toward tracheal walls? Is strong enough to prevent rupture if poked? Does it hold air-pressure over extended period of time? 2008 SHEA/ISDA Compendium of Strategies; 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

39 Cuff Shape and Composition PVC, Silicone, Polyurethane Pliant cuff with excellent cuff-mucosal seal without excessive pressure Pressure evenly distributed while fitting undulations of mucosa over tracheal rings Cuff expands to fit without creating folds and crevasses Cuff does not readily deflate Concentrated pressure Less pressure dependent due to broader contact area Twice the narrow pressure exertion points More surface seal dependant rather than pressure 39 39

40 Monitor Cuff Pressure Cuff pressure should be maintained at greater than 20 cm H 2 O Use dependable inflation technique minimal occlusion minimal leak Record & monitor as per facility policy American Thoracic Society [ATS]/Infectious Diseases Society of America [IDSA] Guidelines for Management of Adults with VAP Am J Respir Crit Care Med. 171: Diaz E, Rodriguez A, Jordi R. Ventilator-Associated Pneumonia: Issues Related to the Artificial Airway. July Respiratory Care 50(7)

41 Minimize Tube Movement Tube movement creates cuff creases & folds Secure tube to prevent cuff movement Consider patient sedation sufficient to tube manipulation or inadvertent extubation Is this tube appropriately secured? Young PJ, Pakeerathan J, Blunt MC, Subramanya S. A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med 2006; 34(3):

42 Routine Patient Care Prevent aspiration by maintaining patients in a semirecumbent position 30 to 45 degree elevation of head of bed (unless otherwise contraindicated) 2008 SHEA/ISDA Compendium of Strategies; 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

43 Recommendation: ET suctioning only when secretions present Suggestions: Pre-oxygenation if O 2 saturation with suctioning Suction without disconnecting from ventilator Use shallow suction NO routine use normal saline instillation prior to ET suction AARC Clinical Practice Guidelines. Respir. Care. June 2010;55(6):

44 Closed system suctioning ET suctioning without for neonates Avoid disconnection and use of lung-recruitment maneuvers Use a suction catheter that occludes less than 50% of the ETT lumen - In infants, use a suction catheter that occludes less than 70% of the ETT lumen Limit suctioning to less than 15 seconds AARC Clinical Practice Guidelines. Respir. Care. June 2010;55(6):

45 Routine Patient Care Perform regular oral care written policy and training decontamination with an antiseptic agent Chlorhexidine rinse recommended by many 2008 SHEA/ISDA Compendium of Strategies; 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

46 Feeding Precautions Gastric tubes compromise the stomach sphincter possible reflux & subsequent microbial migration up esophagus Nasogastric tubes can sinusitis, a potential risk factor for pneumonia Prevent regurgitation: do not over fill stomach HOB Heyland DK, Drover JW, Dhaliwal R, et.al. Optimizing the Benefits and Minizing the Risks of Enteral Nutrition in the Critically Ill: role of Small Bowe lfeeding. Journal of Parenteral and Enteral Nutrition Nov/Dec; 26(6) Sup: S51-S57. Hixson S, Sole ML, King T. Nursing Strategies to prevent Ventilator-Associated Pneumonia. AACN Clinical Issues Feb; 9(1): Sucalfate: Girard, R World Health Organization. Prevention of hospital-acquired infections: A Practical Guie, 2 nd edition WHO/CDS/CSR/EPH/

47 Remove Tube As Early As Possible Perform daily assessments of readiness to wean from ventilation Early removal has been shown to VAP CAUTION: If removed too early, re-intubation significantly VAP risk Non-invasive (positive pressure) ventilation may be more appropriate than re-intubation CDC. Guidelines for Preventing Health-Care-Acquired Pneumonia Morbidity and Mortality Weekly Report, 2004; SHEA/ISDA Compendium of Strategies; 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

48 Prevention of VAP Priority Module Recommendation Focus 1 Routine Care of Patients Requiring Mechanical Ventilation 2 Cleaning,Disinfection, and Sterilization of Ventilator Equipment HHS Action Plan to Prevent Healthcare-Associated Infections Accessed

49 Cleaning, Disinfection, and Sterilization of Ventilator Equipment Thoroughly clean all equipment and devices to be sterilized or disinfected Use sterile water for rinsing reusable semi-critical respiratory equipment and devices when rinsing after they have been chemical disinfected 2003 CDC Guideline for Preventing Healthcare Associated Pneumonia; 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

50 Cleaning, Disinfection, and Sterilization of Ventilator Equipment Between treatments on the same patient: clean, disinfect, rinse with sterile water, or dry small-volume in-line or hand-held medication nebulizers CDC Guideline for Preventing Healthcare Associated Pneumonia; 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

51 Cleaning, Disinfection, and Sterilization of Ventilator Equipment Between their use on different patients: clean, disinfect/sterilize reusable components of the breathing system or patient circuit sterilize or subject to high-level disinfection portable respirometers and ventilator thermometers 2003 CDC Guideline for Preventing Healthcare Associated Pneumonia; 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

52 Prevention of Ventilator-Associated Pneumonia Priority Module Recommendation Focus 1 Routine Care of Patients Requiring Mechanical Ventilation 2 Cleaning,Disinfection, and Sterilization of Ventilator Equipment 3 Maintenance of Ventilator Circuit and Associated Devices HHS Action Plan to Prevent Healthcare-Associated Infections Accessed

53 Maintenance of Ventilator Circuit and Associated Devices Condensate collecting in the ventilator circuit can become contaminated from patient secretions Avoid inadvertently flushing condensate into the lower airway or to in-line medication nebulizers when patient turns or bedrail is raised American Thoracic Society [ATS]/Infectious Diseases Society of America [IDSA] Guidelines for Management of Adults with VAP Am J Respir Crit Care Med. 171:

54 Maintenance of Ventilator Circuit and Associated Devices Use only sterile fluid for nebulization and dispense the fluid into the nebulizer aseptically Use only sterile (not distilled, nonsterile) water to fill reservoirs of devices used for nebulization 2003 CDC Guideline for Preventing Healthcare Associated Pneumonia; 2009 HHS Action Plan to Prevent Healthcare-Associated Infections

55 Bundle Prevention Strategies 55 55

56 SMART Approaches for the Prevention of VAP Using Bundles Specific interventions Measurable outcomes Achievable program Relevant Time-bound 56 56

57 VAP Diagnostic Procedures 57 57

58 Major Goal for VAP Management Strategy AEA Antibiotics Appropriate Early Adequate dose While Avoiding: 1. Excessive antibiotics 2. Emergence of multiple-drug-resistant strains Chastre J. Conference Summary: Ventilator-Associated Pneumonia. Respir Care, 2005; 50(7):

59 Pneumonia? Drug reaction? Over-inflation trauma? Respiratory Distress Syndrome? Insufficient surfactant? Cardiac congestion? Pulmonary emboli? There is no gold standard for diagnosing VAP 59 59

60 Issues and Controversies in the Diagnosis of VAP On which clinical criteria should a diagnosis rely? How to differentiate colonization from infection? Which is the most practical, cost effective, AND accurate means to diagnose lower respiratory tract infection? 60 60

61 Diagnostic Strategies & Approaches Clinical Strategy American Thoracic Society [ATS]/Infectious Diseases Society of America [IDSA] Guidelines for Management of Adults with VAP Am J Respir Crit Care Med. 171:

62 Clinical Strategy The clinical assessment of VAP is usually based on: Fever [core temp. > 38.3 C (101 F) WBC (>10,000 per mm 3 ) or WBC (<4,000 per mm 3 ) Purulent tracheal secretions New and/or persistent radiographic infiltrate Fartoukh M. et.al. Diagnosing Pneumonia during Mechanical Ventilation, Am J Respir Crit Care Med, 2003, 168:

63 Limitations of Clinical Strategy Is It Really Pneumonia? Non-Infective Masqueraders of VAP ARDS Aspiration Pneumonitis Atelectasis Congestive Heart Failure Pulmonary Drug Reactions Pulmonary Embolus Pulmonary Hemorrhage BEWARE OF INAPPROPRIATE USE OF ANTIBIOTICS 63 63

64 Diagnostic Strategies & Approaches Clinical Strategy Bacteriologic Strategy American Thoracic Society [ATS]/Infectious Diseases Society of America [IDSA] Guidelines for Management of Adults with VAP Am J Respir Crit Care Med. 171:

65 Microbiologic Sampling Secretions expectorated or collected from the lung are contaminated by bacteria in: Oropharynx Trachea Distal sample / protected techniques allow for collection of lung secretions without contamination 65 65

66 Sputum Culture - Tracheal Aspirate Specificity of 50% 20-30% isolate wrong organism Over treatment Frequently wrong antibiotic Sensitivity % Specificity % American Thoracic Society [ATS]/Infectious Diseases Society of America [IDSA] Guidelines for Management of Adults with VAP Am J Respir Crit Care Med. 171:

67 Bronchoscopic Bronchoalveolar Lavage (BAL) Pros Taken directly from infected area of the lung Enable ID of noninfectious lesions Specific, quantitative, accurate ID of pathogen Sensitivity 42-93% Specificity % Cons Bronchoscope diameter > than some ETT Possible delay [availability of MD/pulmonologist] PEEP [positive end expiratory pressure] Insufficient sterilization may occur Expensive [labor + device: $1,000 + ] American Thoracic Society [ATS]/Infectious Diseases Society of America [IDSA] Guidelines for Management of Adults with VAP Am J Respir Crit Care Med. 171:

68 Bronchoscopic Protected Specimen Brush (PSB) Pros Taken directly from infected area of the lung Enable ID of noninfectious lesions Specific, quantitative, accurate ID of pathogen Sensitivity % Specificity % Cons Bronchoscope diameter > than some ETT Possible delay [availability of pulmonologist] Possible pneumothorax PEEP[positive end expiratory pressure] Insufficient sterilization may occur Expensive [labor + device: $1,000 + ] American Thoracic Society [ATS]/Infectious Diseases Society of America [IDSA] Guidelines for Management of Adults with VAP Am J Respir Crit Care Med. 171:

69 Mini-BAL [Blind BAL, Non-bronchoscopic BAL] Pros Can be performed by nurse or respiratory therapist Disposable no reprocessing issues Cons No visualization Training required Sensitivity and specificity comparable to BAL & PSB Sensitivity % Specificity 66-96% American Thoracic Society [ATS]/Infectious Diseases Society of America [IDSA] Guidelines for Management of Adults with VAP Am J Respir Crit Care Med. 171:

70 ATS/IDSA Guidelines The use of a bronchoscopic bacteriologic strategy has been shown to mortality [compared with a clinical strategy]. Antibiotic therapy should not be postponed for the purpose of performing diagnostic studies [in clinically unstable patients]. Sampling method [bronchoscopic or non-bronchoscopic] depends on local expertise, experience, availability, & cost. American Thoracic Society [ATS]/Infectious Diseases Society of America [IDSA] Guidelines for Management of Adults with VAP Am J Respir Crit Care Med. 171:

71 There is no gold standard for diagnosing VAP VAP Diagnosis: Key Take-Aways AEA antibiotics Clinical signs alone may result in misdiagnosis and inappropriate antibiotic use Sputum cultures are of questionable value Bronchoscopic & Mini-BAL techniques obtain protected lower respiratory tract samples for quantitative cultures When choosing sampling techniques, consider: accuracy, local expertise, availability, cost 71 71

72 VAP: Prevention and Diagnosis Impact of HAIs on Healthcare in the U.S. Susceptibility of ventilated patients to pneumonia Strategies for reducing ventilator-associated pneumonia Differences in diagnostic procedures Thank you! 2011 Kimberly-Clark Worldwide, Inc. All rights reserved. The material in this presentation is proprietary to Kimberly-Clark and may not be reproduced or used without written permission