Cardiac Output, Venous Return, and Their Regulation
Pneumonia presentation
1. PNEUMONIA
Mohammad reza rajabi
Bachelor of science in anesthesia
Master of science in critical care
Tehran university of medical sciences
1
2. پنومونی آتیپیک(غیر نمادین اکتسابی از جامعه)
بیماری تنفسی حاد تب دار با تغییرات التهابی ریه
محدود به تیغه های آلوئولی و بافت بینابینی ریه
واژه آتیپیک:
بیانگر تولید خلط متوسط ، فقدان یافته های فیزیکی دال بر تراکم نسج ریه،
افزایش ، WBCفقدان اگزودای آلوئولی
علت: مایکوپالسما پنومونیه ( در بچه ها و بالغین جوان شایع تر)
مکانیسم بیماری زایی:
اتصال ارگانیسم به اپیتلیوم تنفسی و سپس نکروز سلولی ، واکنش التهابی،
ریزش اپیتلیوم تنفسی، مهار عمل جاروبی مژه های مخاطی، زمینه ساز
عفونت ثانویه باکتریال
2
3. درمان پنومونی ویروسی
بی تاثیر آنتی بیوتیک ها در عفونت های ویروسی
درمان حمایتی :
تب و تاکی پنه باعث دفع نامحسوس مایع می شود مایع درمانی
بهبود تب و سردرد داروی ضد تب
بهبود سرفه ضد سرفه
کاهش التهاب مجاری تنفسی بخور گرم
کاهش عطسه و آبریزش بینی آنتی هیستامین
3
4. درمان پنومونی
♠ تجویز آنتی بیوتیک مناسب بر حسب تعیین گرم میکروب
♠ تجویز سریع آنتی بیوتیک در طی 8-4 ساعت در بیماران مشکوک به
کلید درمان CAP
♠ در پنومونی پنوموکوکی: ادامه درمان 27 ساعت بعد از قطع شدن تب
♠ در پنومونی با علل باکتریال : ادامه درمان 2-1 هفته بعد از قطع شدن تب
♠ در پنومونی آتیپیک : درمان 12-01 روز طول می کشد.
4
5. پنومونی آسپیراسیون
Ωناشی از آسپیراسیون مواد آندروژن و اگزوژن به راه های هوایی تحتانی
Ωشایع ترین نوع : عفونت ناشی از آسپیراسیون باکتری های مستقر در راه های
هوایی فوقانی
Ωهم در بیمارستان و هم در جامعه اتفاق می افتد.
عوامل دیگر: عوامل بیماری زا:
محتویات معده استرپتوکوک پنومونیه
مواد شیمیایی اگزوژن هموفیلوس آنفلونزا
استافیلوکوک آرئوس
5
7. انواع روش های جمع آوری خلط
1. شستن دهان با آب (کاهش فلور طبیعی دهان) ، چند بار نفس عمیق ، انجام
سرفه ، ریختی خلط در ظرف استریل
ساکشن بینی – تراشه ای 2.
ساکشن دهانی – تراشه ای 3.
بوسیله برونکوسکوپی فیبراپتیک 4.
7
8. پنومونی در بیماران با نقص سیستم ایمنی
مصرف کورتیکواستروئید ها
شیمی درمانی
نقصان تغذیه
آنتی بیوتیک های وسیع الطیف
ایدز
انواع :
پنومونی حاصل از پنوموسیتیس کارینی() PCP
پنومونی قارچی
پنومونی حاصل از مایکوباکتریوم نوبرکلوزیس
عالئم بالینی:
تب ، سرفه بدون خلط ، تنگی نفس
8
9. پنومونی
بیماری التهابی پارانشیم ریه که توسط عوامل مختلف میکروبی ایجاد می شود.
شایع ترین علت مرگ ناشی از بیماری های عفونی در ایاالت متحده
ساالنه 00066 نفر در اثر این بیماری می میرند و هفتمین علت مرگ در امریکا
است.
9
10. طبقه بندی پنومونی
طبقه بندی چهارگانه:
باکتریال یا تیپیک
آتیپیک
غیرهوازی – حفره ای
فرصت طلب
نوع دیگر طبقه بندی:
پنومونی اکتسابی از جامعه() CAP
پنومونی اکتسابی از بیمارستان () HAP
پنومونی در افراد مبتال به نقص سیستم ایمنی
پنومونی ناشی از آسپیراسیون
01
11. پنومونی اکتسابی از جامعه
منشا : باکتریال
به دنبال عفونت ویروسی دستگاه تنفسی فوقانی(شروع آن ناگهانی)
شایع ترین علت علت : استرپتوکوک پنومونیه( پنوموکوک)
عالئم :
تب باال
لرز
درد پلورتیک
سرفه خلط دار با خلط موکوسی - چرکی
11
12. سایر ارگانیسم های دخیل در پنومونی حاد اکتسابی از جامعه
1( هموفیلوس آنفلوانزا( شایع ترین علت باکتریال تشدید ) COPDشایع ترین
ویروس ایجاد کننده پنومونی در نوزادان و بچه ها
موراکسال کاتارالیس ( تشدید حاد ) COPD 2(
استافیلوکوک طالئی ( با شیوع باالی عوارض مثل آمپیم و آبسه های ریوی ) 3(
کلبسیال پنومونیه ( شایع ترین عامل پنومونی باکتریال گرم منفی) 4(
پسودومونا آئروژینوزا 5(
6( لژیونال پنوموفیلیا
21
13. Health Care–associated Pneumonia
numerous outpatients benefit from health care
services such as dialysis, chemotherapy, or
ambulatory surgery. Similarly, in most nursing
homes and rehabilitation hospitals, patients can
receive intensive and/or invasive medical
therapies
13
14. Four Classes Of Pneumonia
1. Community-acquired pneumonia
2. Ventilator-associated pneumonia
3. Hospital-acquired pneumonia
4. Health care–associated pneumonia
14
15. Community-acquired Pneumonia
(CAP)
common infectious disease affecting about 1 per 1,000
of the adult population per year.
An intensive care unit (ICU) admission for severe
CAP is required for 2% of patients
most frequent pathogen is Streptococcus pneumoniae
Despite progress in antibiotic therapy
mortality remains elevated
15
16. Diagnosis Of Community-acquired Pneumonia
clinical symptoms:
1.cough 2.dyspnea
3.sputum production 4.pleuritic chest pain
5.elevated body temperature.
These symptoms can be absent or moderated in older
patients.
not specific signs of pneumonia;
a chest radiograph or computed tomography (CT) scan
revealing a new infiltrate
16
18. Definition Of Severe CAP
one of two major criteria :
need for mechanical ventilation
septic shock
two of three minor criteria :
systolic blood pressure < 90 mm Hg
multilobar involvement on chest radiograph
PaO2/FiO2 < 250 mm Hg)
18
19. Assessing The Severity Of CAP
Four “core” factors )CURB score(:
Confusion
blood Urea nitrogen > 19 mg/dL [7 mmol/L]
Respiratory rate > 30 breaths/minute
Blood pressure—systolic < 90 mm Hg or diastolic <60 mm Hg)
two “additional” factors :
hypoxemia (SpO2 < 92% or PaO2 < 60 mm Hg [8kPa]
bilateral or multilobar involvement on chest radiograph
two “pre-existing” factors :
age 50 years or older
the presence of coexisting disease
19
20. CAP Was Considered Severe
When Any One Of The Following Criteria Was
Present:
1. Respiratory frequency greater than 30 breaths per minute on admission
2. Severe respiratory failure (PaO2/FiO2 <250 mm Hg)
3. Requirement for mechanical ventilation
4. Bilateral or multilobar or extensive (greater than or equal to 50%
within 48 hours of admission) involvement of the chest radiograph
5. Shock (systolic blood pressure less than 90 mm Hg or diastolic blood
pressure less than 60 mm Hg)
6. Requirement for vasopressors for more than 4 hours
7. Low urine output (less than 20 mL/hour or less than 80 mL/4 hours) or
acute renal failure requiring dialysis
20
21. Diagnostic Studies
1.Sputum stains and cultures
2.endotracheal aspiration
3.protected brush
4.bronchoalveolar lavage
5.transtracheal aspiration
6.Blood cultures
drawn before antibiotic therapy, are rarely positive (6%–20% of
cases) and, when positive, are most often for S. pneumoniae,
Staphylococcus aureus, and Gram-negative bacilli.
21
22. Specific Etiologies In Immunosuppressed
Patients
♠ Immunosuppressed patients
have an increased risk of severe CAP
♠ Human immunodeficiency virus (HIV)
infected patients used to have a 25-fold higher risk of developing bacterial
pneumonia
♠ Patients with chemotherapy-induced neutropenia
( < 500 neutrophils/µL( & prolonged ) >10 days)
♠ Patients with solid organ transplant
♠ monoclonal antibody therapies
♠ Patients treated by anti–tumor necrosis factor (TNF) -
α monoclonal antibodies
22
23. Treatment Of Severe CAP
Antimicrobial spectrum
The ideal antibiotic should have a “kill spectrum” to cover
all pathogens responsible for severe CAP
Timing of initial therapy
administration within 4 hours of admission
23
24. Treatment Of Severe CAP…
Antimicrobial choices
β-Lactam antibiotics
cefotaxime
ceftriaxone
ampicillin
sulbactam)
Macrolides
erythromycin
Clarithromycin
azithromycin
Fluoroquinolones
Levofloxacin
ciprofloxacin
Retrospective studies have suggested that some combination regimens 24
25. Treatment Of Severe CAP…
pneumonia caused by S. pneumoniae Continue until the
patient has been afebrile for 72 hours
Bacteria causing necrosis of the pulmonary parenchyma (e.g.,
S. aureus, P. aeruginosa, Klebsiella, and anaerobes) should
probably be treated for no less than 2 weeks.
Pneumonia caused by intracellular organisms should probably
be treated for at least 2 weeks.
25
26. Treatment Of Severe CAP…
Nonantimicrobial Therapy
1.Activated Protein C
2.Corticosteroids
200 mg IV bolus followed by infusion at a rate of 10 mg/hour for 7
days
significant improvement in PaO2/FiO2 and chest radiograph score
& decreased length of hospital stay and mortality
26
27. Expected Clinical Course
Evaluation On Day 3
a decrease in fever and oxygenation requirements is not
observed in responding patients prior to day 3 or 4.
In the absence of rapid clinical deterioration, initial
therapy should not be changed prior to completion of 48
to 72 hours of the initial therapy.
27
28. Ventilator-associated Pneumonia
(VAP)
is defined as a pneumonia occurring in intubated or tracheotomized
patients undergoing mechanical ventilation. Although usual
guidelines suggest a delay of 48 to 72 hours between the beginning
of mechanical ventilation and the occurrence of pneumonia to
qualify for this diagnosis
28
29. Ventilator-associated Pneumonia (VAP)
Defined: hospital-acquired pneumonia occurring
within 48 h after initiation of mechanical
ventilation with trachael intubation
Diagnosis: Presence of a new, persistent, or
progressive infiltrate on a chest X-ray
29
30. Early And Late VAP
Time Pathogens
Early Onset Pneumonia that develops Usually include:
VAP between 48-96 hours after Staphylococcus aureus (Methicillin
being placed on the ventilator sensitive-MSSA)
Haemophilus influenza
Streptococcus pneumoniae
Late Onset Pneumonia that develops Usually include:
VAP after 96 hours )≥5 days) on Staphylococcus aureus (Methicillin
ventilator resistant – MRSA)
Pseudomonas aeruginosa
Acinetobacter or Enterobacter
30
31. Clinical Presentation Of Pneumonia
•Purulent secretions
•Densities on Chest x-ray
•Fever
•Leukocytosis (high wbc)
32. Why Are Ventilated Patients
More Susceptible To Pneumonia?
Normal Clearance Mechanisms and Reflexes are:
1. Air failtration
in nasal cavity
Bypassed
Blocked 2. Mucociliary
escalator
Inhibited 3. Cough
mechanism
32
33. “Aspiration of oropharyngeal
pathogens or leakage of
bacteria around the
endotracheal tube cuff is the
primary route of bacterial
entry into the trachea.”
33
34. Ventilator-associated Pneumonia
(VAP)
major dilemmas regarding VAP :
1. Prevention remains a challenge.
2. There is no gold standard for diagnosis.
3. The rate of multidrug-resistant causative pathogens
has dramatically increased during recent years.
4. Prompt initiation of an adequate antibiotic therapy is
essential.
34
35. Pathogenesis…
rarely associated with VAP :
1. Inhalation of gastric material
2. direct inoculation of bacteria into the lower respiratory tract
through contaminated “devices”
Aerosol
Bronchoscopes
ventilator circuit
Nebulizer
tracheal suctioning
36
36. Pathogenesis…
main route
Aspiration of bacteria colonizing the oropharynx is the main route of
entry into the lower respiratory tract.
Colonization of the oropharyngeal airways by pathogenic micro-
organisms occurs during the first hospital week in most critically ill
patients
The stomach, sinuses, and dental plaque may be potential reservoirs
for pathogens colonizing the oropharynx
37
37. Ventilator-associated Pneumonia
(VAP)
Risk Factors
♠ male gender
♠ pre-existing pulmonary disease
♠ coma
♠ AIDS
♠ head trauma
♠ age older than 60 years
♠neurosurgical procedures
♠ multiorgan system failure
♠ mechanical ventilation
impairs ciliary clearance and cough
limits the draining of secretions that leak around the cuff
♠ other devices
nebulizers or humidifiers
38
38. Increases The Risk Of VAP
1. Accidental extubation, rather than reintubation
2. administered by a nasogastric (rather than a postpyloric )
The nasogastric tube might increase the risk of reflux and subsequent
colonization of the airways
3. H2 blockers or antacids
favors gastric colonization and may contribute to VAP.
4. intracuff pressure less than 20 cm H2O
5.Tracheostomy
6.aerosol treatment
7.supine position
8.patient transportation out of the ICU
9.sedation
10.failed subglottic aspiration
39
39. Diagnostic Strategies And Diagnostic Testing
(VAP)
(a) the diagnosis of pneumonia must be established
fever or hypothermia
leukocytosis or leucopenia
Tachycardia
Purulent sputum
decline in oxygenation
pulmonary infiltrates on chest radiograph
40
40. Diagnostic Strategies And Diagnostic Testing
)VAP(…
b) the etiologic pathogen of this pulmonary parenchymal
infection must be identified
Blood cultures (rarely positive)
bronchoalveolar lavage (BAL)
endotracheal aspiration
protected specimen brush (PSB)
41
41. درجهبندي شدت پنوموني و نیاز به درمان سرپایي یا بستري کردن بیمار و
پیشبیني مرگ ومیر معیار ))PORT
PNEUMONIA PATIENT OUTCOMES RESEARCH TEAM
34
42. Pneumonia Patient Outcomes Research Team
میزان درجه بندی مشخصات بیمار
برابر سن بر حسب سال سن
01 سال منهای سن مرد
01 سال بعالوه سن زن
مدتی که در خانه تحت پرستاری بوده است
بیماری های همراه
03 بیماری های سرطانی
02 بیماری های کبدی
01 بیماری های کلیوی،CVA ، CHF
یافته های بالینی
02 اختالل هوشیاری،03>SBP<90 ، RR
51 T<35OC,T>40OC
01 521<PR
یافته های رادیوگرافیک یا آزمایشگاهی
03 53/7<PH
02 03>Na<130,BUN
01 052> ,PO2<60,Hct<30,BSپلورال افیوژن 44
43. براساس معیار:PORT
نمرهي زیر 07 به طور سرپایي
باالي 09 باید بستري شوند
آنها که 07 تا 09 ميباشند باید مدتي در اورژانس تحتنظر و راجع به بستري و
ترخیص بعداً تصمیمگیري شود.
54
44. Antibiotic Treatment
Principles of Initial Empiric Treatment
1. Prompt initiation of adequate antimicrobial treatment
is a cornerstone of therapy for VAP
2. Iregui et al. studied 107 patients suffering from VAP
33 received delayed appropriate antibiotic treatment—defined as a period
greater than or equal to 24 hours between the time VAP was suspected and
the administration of adequate treatment. These patients exhibited a
significantly higher mortality than those receiving nondelayed treatment
(69.7% vs. 28.4%; p <0.001).
46
45. Guidelines For Initial Empiric Antibiotic Therapy
On the basis of the time of onset of VAP and the presence
or absence of risks for multidrug-resistant pathogens
In patients with no risk factors for multidrug-resistant
pathogens and an early-onset VAP (duration of
hospitalization less than 5 days), limited-spectrum
antibiotic therapy based on monotherapy seems
appropriate
In patients with late-onset VAP (greater than or equal
to 5 days) or exhibiting risk factors for multidrug-
resistant pathogens, a broad-spectrum antibiotic regimen
based on two or three combined antibiotics is usually
required
47
46. Guidelines For Initial Empiric Antibiotic Therapy
1. Early-onset VAP and no risk factors for multidrug-resistant
pathogens
•Ceftriaxone (1–2 g/24 h) or
•Levofloxacin (750 mg/24 h), moxifloxacin (400 mg/24
h), or ciprofloxacin (400 mg/8 h) or
•Ampicillin (1–2 g) plus sulbactam (0.5–1 g)/6 h or
•Ertapenem (1 g/24 h)
48
47. Guidelines For Initial Empiric Antibiotic Therapy…
2. Late-onset VAP or risk factors for multidrug-resistant pathogens
•Antipseudomonal cephalosporin: Cefepime (1–2 g/8–12 h) or ceftazidime (2 g/8
h)
or
•Antipseudomonal carbapenem: Imipenem (500 mg/6 h or 1 g/8 h) or meropenem
(1 g/8 h)
or
•β-Lactam/β-lactamase inhibitor: Piperacillin-tazobactam (4.5 g/6 h)
plus
•Antipseudomonal fluoroquinolone: Levofloxacin (750 mg/24 h) or ciprofloxacin
(400 mg/8 h)
or
•Aminoglycosidea: Gentamicin (7 mg/kg/24 h) or tobramycin (7 mg/kg/24 h) or
amikacin (20 mg/kg/24 h)
plus
•Vancomycin (15 mg/kg/12 h)a
or
•Linezolid (600 mg/12 h)
49
48. Duration Of Therapy
optimal duration was unknown
experts empirically recommended a 14- to 21-day treatment
duration
ATS/IDSA guidelines suggest shortening the duration of therapy
to 7 days
8 - 15 days of antibiotic treatment were equally effective
A prospective, multicenter, randomized, double-blind trial was performed
Recent studies demonstrated that empiric antibiotic therapy could
be safely discontinued after 72 hours when a noninfectious etiology
for the pulmonary infiltrates is discovered or when signs and
symptoms of active infections resolve
50
49. Prognosis Of Ventilator-associated Pneumonia
crude mortality rates : vary from 24% to 76%
*malignancy *immunosuppression
*ASA grade 3 or more *age older than 64 years
*anticipated death within 5 years
severity of disease justifying ICU admission
high APACHE II score
Simplify Acute Physiology Score greater than 37
51
50. Prognosis Of Ventilator-associated Pneumonia…
initial severity of VAP
chest radiographic involvement of more than one lobe
platelet count <150,000 cells/µL
Logistic Organ Dysfunction score > 4
time of onset of VAP > 3 days
Surgery
Hypotension
initial therapeutic approach (delayed initial
appropriate antibiotic treatment)
52
51. Prevention Of Ventilator-associated Pneumonia
£ hand washing
£ glove use
£ sterile equipment
£ Adequate staffing
£ When intubation is necessary, the orotracheal route is preferred
£ Use of Noninvasive positive pressure ventilation
£ reduce the duration of mechanical ventilation
£ Ventilator circuit management
£ optimized sedation and weaning protocols
£ semirecumbent (45-degree) patient position
£ Postpyloric feeding
£ Continuous aspiration of subglottic secretions
53
52. Measures Recommended By The Centers For Disease
Control And Prevention To Reduce The Incidence Of
Ventilator-associated Pneumonia
Changing the breathing circuits of ventilators only when they
malfunction or are visibly contaminated
Preferential use of orotracheal rather than nasotracheal tubes
Use of noninvasive ventilation
Use of an endotracheal tube with a dorsal lumen to allow
drainage of respiratory secretions
54
54. Hospital-acquired Pneumonia
hospital-acquired pneumonia (HAP) :
a pneumonia occurring less than 2 days from hospital
admission, but without any criteria defining ventilator-associated
pneumonia
Mortality rate 18.8% and 53%
56
55. پنومونی بیمارستانی () HAP
عالئم آن 84 ساعت بعد از بستری شدن در بیمارستان تظاهر می یابد.
% 15عفونت های بیمارستانی را به خود اختصاص می دهد.
کشنده ترین عفونت بیمارستانی
تظاهرات بالینی:
تب ، عالئم تنفسی ، خلط چرکی ، لکوسیتوز ، تاکی کاردی ، افیوژن پلور
شرایط مستعد کننده :
افراد دارای بیماری زمینه ای شدید
مصرف داروهای سرکوب کننده ایمنی
درمان آنتی بیوتیکی طوالنی مدت
تهویه مکانیکی
75
56. Health Care–associated Pneumonia And Nursing
Home Pneumonia
HCAN patients who :
was hospitalized in an acute care hospital for 2 or more days
within 90 days of the infection
resides in a nursing home or long-term care facility (LTCF)
received recent intravenous antibiotic therapy, chemotherapy, or
wound care within 30 days of the current infection
attends a hospital or hemodialysis clinic
58
57. Risk Factors In Nursing Home
functional status
diminished ability to clear airways
underlying comorbidities (such as chronic obstructive
pulmonary disease and heart disease)
swallowing disorders
use of sedatives.
59
58. Etiology Of Nursing Home–acquired
Pneumonia
♠ S. pneumoniae
♠ H. influenzae
♠ Gram-negative bacilli
♠ S. aureus
60
59. CDC DEFINITION OF PNEUMONIA
Horan TC, Andrus M, Dudreck MA. CDC/NHSN surveillance definition of health-
care associated infection and criteria for specific types of infection in the acute care 61
60. Etiology- Select Risk Factors For
Pathogens
Streptococcus pneumoniae Smoking, COPD, absence of
antibiotic therapy
Haemophilus influenzae Smoking, COPD, absence of
antibiotic therapy
MSSA Younger age, Traumatic coma,
Neurosurgery
MRSA COPD, steroid therapy, longer
duration of MV, prior antibiotics
Pseudomonas aeruginosa COPD, steroid therapy, longer
duration of MV, prior antibiotics
Acinetobacter species ARDS, head trauma,
neurosurgery, gross aspiration,
prior cephalosporin therapy
Park DR. The microbiology of ventilator-associated pneumonia. 62
61. Objectives
State the definition for ventilator associated
pneumonia (VAP)
Define who is at greatest risk for the development of
VAP
Describe effective strategies for reducing the
incidence of VAP
63
62. How Do We Diagnose? 2-1-2
Radiographic evidence x 2 consecutive days
… New, progressive or persistent infiltrate
… Consolidation, opacity, or cavitation
At least 1 of the following:
… Fever (> 38 degrees C) with no other recognized cause
… Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000
WBC/mm3)
At least 2 of the following:
… New onset of purulent sputum or change in character of secretions
… New onset or worsening cough, dyspnea, or tachypnea
… Rales or bronchial breath sounds
… Worsening gas exchange )↓ sats, P:F ratio < 240, ↑ O2 req.)
64
63. HOB Elevation > 30 Degrees On All Mechanically Ventilated
Patients
Contraindications
Hypotension MAP <70
Tachycardia >150
CI <2.0
Central line procedure
Posterior circulation strokes
Cervical spine instability use
reverse trendelenburg
Some femoral lines ie: IABP no
higher than 30 degrees use reverse
trendelenburg
Increased ICP, No higher than 30
degrees avoid hip flexion
Proning 65
64. Continuous Infusions:
Daily Wake Up
All infusions should be at the lowest rate to achieve
effect
IV bolus therapy should be used to supplement
infusion when necessary
Every patient must be awakened daily unless
contraindicated!
66
65. Daily Wake Up
Wean infusion to off in increments of 10-25% daily
in order to perform a clinical assessment
Rebolus and restart infusion if the patient becomes
symptomatic. Your new continuous IV dose should
be lower than what you began with
Goal is to decrease sedation
67
66. Why?
Sedation Vacation
Has been demonstrated to reduce overall patient sedation
Promotes early weaning
Identified Issues and Concerns
Increases potential for self-extubation
Increases potential for patient pain and anxiety
Increases episodes of desaturation
Anecdotal Experience
Promotes early extubation
No significant increase in patient self-extubation
68
67. Endotracheal Intubation
Contributes to the development of VAP:
… Causes mucosal injury, producing decreased mucociliary
clearance
… Decreases effectiveness of cough
… Increases binding sites for bacteria
… Increases mucus secretion
… Provides a reservoir for bacteria
Reintubation is a significant risk factor for VAP
69
68. Airway Management
Mechanical ventilation
… Avoidance
Mask ventilation trials
… Orotracheal intubation
Nasotracheal intubation may slightly increase the risk for VAP
… Ventilator circuitry changes
Change only when soiled or malfunctioning
… Cuff management
Maintain at 25-30 cm H2O
70
69. Suctioning
Oral suction devices (Yankauer)
… Policies for use and storage not written
… Harbor potentially pathogenic bacteria within 24 hours
… 71% of nurses store the device in its packaging (STAMP)
… Best practice???
Change q day
Rinse with sterile water or NS
Allow to air dry
71
70. Subglottal Suctioning
Should be done using a 14 Fr sterile suction catheter:
… Prior to ETT rotation
… Prior to lying patient supine
… Prior to extubation
Continuous subglottic suctioning
… ETT with dedicated lumen to continuously or
intermittently suction above the cuff may reduce the risk
of VAP
72
71. Continuous Removal Of Subglottic
Secretions
Use an ET tube with
continuous suction
through a dorsal lumen
above the cuff to prevent
drainage accumulation.
73
73. Primary Route Of Bacterial Entry Into
Lower Respiratory Tract
Micro or macro aspiration of
oropharyngeal pathogens
Leakage of secretions
containing bacteria around
the ET cuff
75
74. Risks For MDR
American Thoracic Society, Infectious Diseases Society of America. Guidelines for
the management of adults with hospital-acquired, ventilator-associated, and
healthcare-associated pneumonia.
76
75. Pathophysiology Of Ventilator-associated Pneumonia
(VAP)
Hospital-acquired (nosocomial) pneumonia:
pneumonia that occurs 48 hr or more after admission
to the hospital, and was not incubating at the time of
admission
Healthcare associated pneumonia: pneumonia
associated with 2 or more days of hospitalization
within previous 90 days, residence in a nursing home
or long-term care facility, receipt of intravenous
antibiotic, chemotherapy, or wound care within the
previous 30 days, or attendance at a hospital or
hemodialysis clinic
Ventilator-associated pneumonia:
pneumonia that develops more than 48-72 hr after
endotracheal intubation
77
76. Pathophysiology Of Ventilator-associated Pneumonia
(VAP)
Sources of pathogens include the
environment (water and equipment) and
bacteria transferred between patients by staff
Severity of underlying disease, prior surgery,
exposure to antibiotics, and use of invasive
respiratory equipment major risk factors
Intubation and mechanical ventilation
increase the risk of hospital-acquired
pneumonia 6- to 21-fold
78
77. Pathophysiology Of Ventilator-associated Pneumonia
(VAP)
Aspiration of oropharyngeal pathogens (aerobic
gram-negative bacilli, Staphylococcus aureus) by
leakage around the endotracheal tube cuff major
route of entry for bacteria into lower respiratory
tract
Infected biofilm in the endotracheal tube with
subsequent embolization to distal airways may be
important
Complications: drug-resistant pneumonia,
polymicrobial pneumonia, superinfection with
Pseudomonas aeruginosa or Acinetobacter with high
mortality, empyema, lung abscess, Clostridium
difficile colitis, occult infection, bacteremic sepsis
with multiple organ involvement
79
78. Pathophysiology Of Tuberculosis
(Chronic Pneumonia)
Source of Mycobacterium tuberculosis an
infected patient with active pulmonary
disease
M. tuberculosis transmitted by coughing,
sneezing, or talking with release of infected
respiratory secretion as aerosols (droplet
nuclei)
Droplet nuclei (1-5 µm) penetrate deep
alveolar spaces and M. tuberculosis infects
non-immune macrophages as facultative
intracellular pathogens
80
79. Clinical Signs And Symptoms Of Atypical Pneumonia
Syndrome
Sore throat and hoarseness initially
Fever, malaise, coryza, headache, and cough with
variable sputum production
Leukocyte >10,000/mm3 in ~20% of cases
Chest X-ray usually indicates more extensive
pulmonary involvement than clinical findings suggest,
with unilateral or bilateral patchy infiltrates in a
bronchial or peribronchial distribution
Extrapulmonary findings with Legionella
pneumophila: mental status changes, loose stools or
diarrhea, bradycardia, elevated liver enzymes,
hypophosphatemia, hyponatremia, elevated serum
lactate dehydrogenase, and elevated serum creatinine
levels
81
80. Clinical Signs And Symptoms Of Chronic
Pneumonia
Initially fever, chills, and malaise
Progressive anorexia and weight loss
Pulmonary symptoms appear later with worsening
cough productive of sputum, dyspnea, hemoptysis,
and/or pleuritic chest pain
Leukocyte count often normal (exceptions:
pancytopenia in miliary tuberculosis, neutrophilic
leukocytosis in pulmonary actinomycosis)
X-ray findings: nodular or rounded lesions, cavities,
with characteristic involvement of upper lobes
(tuberculosis, histoplasmosis)
82
82. Problem Identification
Patients that are receiving continuous
mechanical ventilation have 6 to 21 times
greater risk of developing hospital-associated
pneumonia than patients not on mechanical
ventilation
Tablan OC, “Guidelines for preventing health-care--associated pneumonia, 2003,” Recommendations
of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC), 2003.
According to an AJCC study, VAP occurs in 10 to
65% of ventilated critical care patients
mortality rates between 20 and 70%
Sole ML, Am J Crit Care, 2002
84
83. Problem Identification
A recent, 9,080-patient study found that the average VAP
patient spends 9.6 additional days on mechanical
ventilation, 6.1 extra days in the ICU, and
11.5 more days in the hospital
And VAP costs over $40,000 per case to
treat—all paid for by the facility
Rello, Chest, 2002
85
84. VAP . . .WHAT IS IT?
Ventilator-Associated Pneumonia
Most common nosocomial bacterial
infection among patients requiring
mechanical ventilation
Rello, Chest, 2002
86
85. VAP
Increased mortality in critically ill
patients (20% - 70%)
Increased cost of care:
$40,000 additional cost per patient
CDC guidelines from Preventing Healthcare Pneumonias, 2003
AACN Practice alert
87
86. Risk Factors
For Developing VAP
Patients at extreme of age spectrum; malnutrition; severe
underlying conditions
Artificial airway
Colonization of dental plaque with respiratory pathogens
Bacterial colonization of the oropharyngeal area
Aspiration of subglottic secretions
Head of bed < 30 degrees
88
87. Risk Factors
For Developing VAP
Colonization of Dental Plaque with respiratory pathogens
Bacterial Colonization of the oropharyngeal area
Aspiration of subglottic secretions
89
88. Recommended
Best Practice
Water based moisturizers provide hydration
Non-alcoholic oral rinses
Mouthwash with hydrogen peroxide actives naturally
occurring peroxidase which resists bacterial
colonization in the oral pharynx
Nursing Mgt., Vol. 34, Supplement 3, May 2003
90
89. Recommended
Best Practice
Soft bristle toothbrush removes plaque and
stimulates the mucosa
Sodium bicarbonate toothpaste overcomes odor,
dissolves mucous, eliminates breeding ground for
bacteria, and reduces acidity
Mouthwash with an antiseptic agent has an
antimicrobial effect on the oral cavity
Nursing Mgt., Vol. 34, Supplement 3, May 2003
91
91. In the absence of medical contraindication(s).
CDC Guideline for Prevention of Healthcare Associated Pneumonias, 2003
Drakulovic et al, Lancet, 1999,354:1851
93
92. Oral Cavity
Suction the oral cavity
Swab the oral cavity every 4 hours and PRN to cleanse
and maintain oral mucosal integrity
Moisturize oral cavity every 4 hours
94
95. Nosocomial Pneumonia
Second most common nosocomial infection in US
… 15% of all hospital-associated infections
… incidence range from 4.2 to 7.7/1000 discharges
Associated with substantial morbidity and mortality: VAP mortality can
reach 60% in ICU
Risk Factors for nosocomial pneumonia
… extremes of age
… severe underlying disease
… immunosuppression
… depressed sensorium
… cardiopulmonary disease
… thoracic-abdominal surgery
… mechanically assisted ventilation
97
97. What Is VAP?
A nosocomial pneumonia associated with mechanical
ventilation that develops within 48 hours or more of hospital
admission and which was not developing at the time of
admission
- early onset VAP
- late onset VAP
Langer M. et al. Intensive Care Med 1987;13:342-6
99
98. Why Do We Care?
Hospital acquired pneumonia (HAP) is the second most
common hospital infection
VAP is the most common intensive care unit (ICU) infection
(10-20%)
90% of all nosocomial infections occurring in ventilated
patients are pneumonias
100
99. Diagnosis And Treatment Of
Ventilator-associated Pneumonia
Avoid
overtreatment
Immediate
without VAP
treatment of
patients with
VAP
Objective 1
Objective 2
101
100. How To Diagnosis Of VAP?
1. Clinical approach : CPIS
2. Bacteriological approach : quatitative culture
with or without bronchoscope
102
103. Am J Respir Crit Care Med 2000;162:505-11 105
104. GRAM STAIN
Sputum or tracheal
suction gram stain
NO ORGANISMS
in non-neutropenic pts.
NO HAP/VAP 94%
106
105. Bacterial Culture Of Tracheal
Secretion
Qualitative culture
- non specific
Semi-quantitative culture
- low specificity
Quantitative culture : TS, BAL, PSB
- increase specificity
107
106. Identification Of The Problem
VAP Statistics
… leading cause of death due to nosocomial
infection in ICUs.
… Mechanically-ventilated patients: 9% to 28%
… Mortality rate: 40% - 80%.
… Hospital length of stay: 4-9 days.
… Hospital cost: $29,000 - $40,000 per patient.
108
107. Current Guidelines
Oral care with antiseptic agents can decrease the incidence of
VAP.
No optimal concentration or formulation is specified.
Oral hygiene (removal of plaque from teeth and gums) is
recommended every 12 hours.
Oral care (removal of secretions from oropharynx and
moisturizing the mouth and lips) is recommended every 4
hours.
109
108. Nosocomial pneumonia ranks second in morbidity and first
in mortality among nosocomial infections
mortality rate of VAP : 54% -71%
VAP occurs : 9% to 24% of patients
The treatment of nosocomial pneumonia adds 5 to 7 days to
the hospital stay of surviving patients
mortality is particularly high in pneumonia attributed to
Pseudomonas or Acinetobacter.
110
109. Risk Factors For Ventilator-associated Pneumonia
(VAP)
presence of an endotracheal tube and continuous ventilatory
support
enteral nutrition therapy
lack of elevation of the head of the bed and the patient’s
position
dental plaque
111
110. Presence Of An Endotracheal Tube Allows :
direct entry of bacteria into the pulmonary tract
impairs the cough reflex
slows the action of the mucociliary escalator
slows promotes excessive secretion of mucus
112
111. Significance Of Nosocomial Pneumonias
Increases ventilatory support requirements and ICU stay by
4.3 days
Increases hospital LOS by 4 to 9 days
Increases cost - > $11,000 per episode
Estimates of VAP cost / year for nation > $ 1.2 billion
113
112. One of the most critical risk factors for the development of
nosocomial pneumonia in patients who are receiving
continuous ventilatory support (ie, VAP) is colonization of
the oropharynx
114
113. Factors Increase Bacterial Colonization Of The
Oropharynx
mechanical ventilation
Within 48 hours of hospital admission, the composition of the oropharyngeal
flora of critically ill patients undergoes a change to predominantly gram-
negative organisms, constituting a more virulent flora that includes potential
VAP pathogens.
dental plaque
dental plaque of patients in the ICU is colonized by potential respiratory
pathogens
such as “methicillin-resistant Staphylococcus aureus” and “Pseudomonas
aeruginosa”.
115
114. Prevention Strategies
Head elevation
Ventilator equipment changes
Continuous removal of subglottic secretions
Handwashing
116
115. Continuous Removal Of Subglottic
Secretions
Use an ET tube with
continuous suction
through a dorsal
lumen above the cuff
to prevent drainage
accumulation.
117
118. VAP Prevention
Wash hands or use an alcohol-based waterless antiseptic agent
before and after suctioning, touching ventilator
equipment, and/or coming into contact with respiratory
secretions.
120
119. No Data
To Support These Strategies
Use of small bore versus large bore gastric tubes
Continuous versus bolus feeding
Gastric versus small intestine tubes
Closed versus open suctioning methods
Kinetic beds
121