Ramirez, C

Research Proposal Literature ReviewChristina RamirezWest Coast UniversityResearch Proposal Literature ReviewVentilator-associated pneumonia (VAP) is defined as pneumonia occurring 48-72 hours after endotracheal tube (ETT) intubation. It is predicted to occur early in hospitalization, and to affect 9-27% of all mechanically ventilated patients (MVPs) (Kalanuria, Zai, & Mirski, 2014). Of all health associated infection-related deaths, VAP is responsible for 36-60% of the deaths (Swearer et al., 2015). In addition to death, VAP increases hospital length of stay and overall health costs, up to an additional $40,000 per incidence (Swearer et al., 2015).VAP is characterized by signs of systemic infection, changes in a patients sputum characteristics, progressive infiltrates, and detection of a causative agent (Kalanuria et al., 2014). VAP is the most common nosocomial infection in Intensive Care Units (ICUs), with its risk increasing at a rate of 1-3% per day of intubation (Boltey, Yakusheva, & Costa, 2017). The multifaceted relationship between the endotracheal tube, risk factors, patient immunity, and various risk factors plays a large part of the development of VAP (Kalanuria et al., 2014). To this date, there is no benchmark defining the diagnosis of VAP. Daily bedside evaluation in conjunction with chest radiography can suggest the presence or absence of VAP, but cannot define it (Kalanuria et al., 2014). Munro and Ruggiero described clinical criteria for diagnosis of VAP is a Clinical Pulmonary Infection Score >6 (Munro & Ruggiero, 2014). The Clinical Pulmonary Infection Score considers clinical, physiological, microbiological and radiographic evidence to formulate a numerical value to predict the presence or absence of VAP. When two or more sequential chest radiographs contain new or progressive and persistent pulmonary infiltrates, consolidation, or cavitation, as well as one of the following: temperature greater than 38°C with no other recognized cause; leukopenia; leukocytosis; purulent respiratory secretions; or altered mental status for adults 70 years or older, VAP can be suspected (Munro & Ruggiero, 2014). Furthermore, at least two of the following must be included: (1) new onset purulent change in character of sputum; (2) increased respiratory secretions; (3) new onset or worsening cough; (4) increase in suctioning; (5) tachypnea; (6) bronchial breath sounds; (7) increased oxygen requirement; (8) increased ventilator demand; (9) worsening gas exchange; or (10) positive bronchoalveolar lavage cultures (Munro & Ruggiero, 2014). Several techniques in place to decrease the risk of VAP include but are not limited to elevating the head of the bed (HOB) >30°, daily sedation interruption, and frequent oral care with chlorhexidine gluconate (Munro & Ruggiero, 2014). The purpose of this literature review is to explore the effectiveness of various preventative measures for VAP to highlight the gap in understanding why mechanically ventilated patients continue to develop VAP despite the implementation of these preventative measures.The Ventilator Bundle and PreventionICUs may observe a drop in VAP rates by utilizing a ‘VAP-bundle’ tactic (Kalanuria et al., 2014). The 5-element Institute of Healthcare Improvement (IHI) ‘VAP-bundle’ consists of oral care with chlorhexidine gluconate (CHG), HOB elevation, daily sedation assessment and spontaneous breathing trails, and stress ulcer and deep vein thrombosis prophylaxis (Kalanuria et al., 2014). Munro and Ruggiero concur with the conclusion that combining a set of clear measures together in a bundle enhances care and facilitates implementation by linking it with a clear, tangible set of expectations to follow (2014). Kalanuria and colleagues conducted a before-after study that implemented the IHI VAP-bundle and concluded that it showed a substantial decrease in VAP rates, antibiotic use, and MRSA acquisition (2014). Each of these bundle items has shown to reduce the incidence of VAP. However, some researchers argue against the effectiveness of VAP bundles in preventing VAP among patients. Halpern et al argue that there are inconsistencies in the IHI bundle elements, including variability’s in VAP diagnostic strategies, the application and compliance of bundle elements, and the personnel diagnosing VAP before and after bundle implementation (Halpern, Sepkowitz, & Pastores, 2012). They add that IHI has been overly expansive in applying the bundle beyond evidence, that oral decontamination with CHG has only shown benefits to two select ICU populations, surgical and trauma, and that certain bundle elements have actually led to harm (Halpern et al., 2012). Certain harmful repercussions of VAP bundles include stress ulcer prophylaxis, which may lead to nosocomial and recurrent Clostridium difficle infection, and HOB, which may increase the risk of thromboembolism and hemodynamic instability (Halpern et al., 2012). Chlorhexidine and Oral CareIntubation leads to an increased risk of oral mucosa injury and dry mouth (Gupta, Gupta, Singh, & Saxena, 2016). These factors, as well as a compromised immune system, cause an increase in bacteria colonization in the oral mucosa, with the ETT serving as a direct route to the lungs (Gupta et al., 2016). Many research studies support the use of CHG 0.12% oral rinse as a cost effective measure to prevent VAP. Swearer et al examined the effect of using CHG on MVPs within 2 hours of admission to the ICU or within 2 hours of intubation in the ICU and then daily during admission (2015). They assessed patients three months prior to implementing the changes and audited 30 adult trauma intensive care unit patients post-practice change. The overall incidence of VAP decreased by 62% (Swearer et al., 2015). Subsequent benefits included a decrease in patient complications, decreased hospital length of stays, and overall decreased health costs (Swearer et al., 2015). Munro and Ruggiero found similar results. They discussed a systemic review and meta-analysis that was conducted by Chan et al of 7 trials with 2144 patients. It was concluded that the oral application of antiseptics significantly reduced the incidence of VAP (2014). They also found that oral decontamination of MVPs using antiseptics is associated with a lower risk of VAP. In addition, The Cochrane Oral Health Group reviewed 35 RCTs oral hygiene care, including oral care solutions, such as CHG and povidone iodine antiseptic mouth rinse and saline, of which only 14% were well conducted and described. The results of the study showed a 40% reduction in the odds of VAP developing in patients who are critically ill (Munro & Ruggiero, 2014). Positioning Aspiration of oropharyngeal or gastric contents is implicated in the pathogenesis of VAP. It is important to keep MVPs in proper position, keeping the HOB between 30-45°, in order to reduce reflux and subsequent risk for VAP (Boltey et al., 2017). Reducing the risk of VAP through primarily HOB positioning (recumbent, supine, semi-recumbent) was evaluated in three randomized control trials enrolling 337 patients altogether. One report found a 76% decrease in VAP rates, whereas the other two found no difference in VAP rates (Klompas, 2014). However, they found that enteral feeding in the supine position substantially increases the risk of developing VAP. Munro and Ruggiero (2014) agreed with the uncertainty of the implementation of head-of-bed (HOB) elevation. They built their conclusion on results from a “Bed Head Elevation Study Group” formed by a group of intensive care experts whom reviewed data in three meta-analyses to determine the quality of evidence for clinically suspected VAP, microbiologically confirmed VAP, and ICU mortality. The data analysis indicated that the effectiveness of 45° HOB evaluation is uncertain, and that maintaining the HOB at a certain elevation for 24 hours a day is not practicable because of various nursing tasks (Munro & Ruggiero, 2014).Endotracheal Tube CareThe use of an ETT cuff while a patient is on mechanical ventilation interrupts the normal mucus clearance, leading to a collection of secretions above the cuff, and contamination of the subglottic pool (Gupta et al., 2016). These secretions then drain into the trachea, leading to increased risk of aspiration into the lungs, increasing the risk of VAP (Gupta et al., 2016). ETT care during mechanical ventilation is essential to decrease the risk of VAP. The benefits of subglottic secretion drainage (SSD) have been analyzed in three meta-analyses with a consistent signal of a reduction in VAP. In a systemtic review done of 13 randomized clinical trials, which met the inclusion criteria with a total of 2442 randomized patients, 12 trials reported a reduction in VAP using a subglottic secretion drainage ETT tube, rather than a standard ETT tube (Hellyer, Ewan, Wilson, & Simpson, 2016). The use of the subglottic secretion drainage device showed a reduce ICU length of stay of -1.52 days, decreased duration of patients being mechanically ventilated -108 days, and an increased time to first episode of VAP 2.66 days (Hellyer et al., 2016). Klompas et al agreed with the concluded benefits of proper ETT care during mechanical ventilation. In the study by Klompas et al, instilling saline prior to tracheal suctioning decreased the risk of microbiologically confirmed VAP (Klompas et al., 2014). Munro and Ruggiero agree regarding ETT care, stating that a mucus shaver, which shaves mucus and secretions from the inner lumen of the ETT plays a role in VAP prevention, and decreases the formation of biofilm, ultimately contributing to the prevention of VAP (2014).ConclusionHospital-acquired infections (HAIs), including VAP are a significant cause of morbidity and mortality in hospitalized patients, and are associated with an increased length of stay and overall health costs. Several studies have evaluated different techniques of VAP prevention. In this literature review, there is strong evidence supporting the effectiveness of using CHG for oral or digestive decontamination in reducing VAP in MVPs, as well as the benefits of subglottic secretion drainage and proper ETT care. However, the lack of quality of evidence regarding elevating the HOB to 30-45° makes that intervention less desired. Following this literature review, several questions arise. These questions include the following:In MVPs, how does using CHG 0.12% oral solution within 2 hours of admission or within 2 hours of intubation and then daily reduce the risk of VAP compared with povidone iodine solution?In MVPs, how does a higher nurse-patient ratio, compared to a lower nurse-patient ratio affect the likelihood of patients developing VAP?Is the implementation of oral care, such as CHG 0.12% oral rinse and povidone iodine solution daily more likely to reduce the incidence of VAP, compared with proper ETT care?ReferencesBoltey, E., Yakusheva, O., & Costa, D. (2017). 5 Nursing Strategies to Prevent Ventilator-associated Pneumonia. American Nurse Today,12(6), 42-43.Gupta, A., Gupta, A., Singh, T., & Saxsena, A. (2016). Role of oral care to prevent VAP in mechanically ventilated Intensive Care Unit patients. Journal of Anesthesia,10(1), 95. doi:10.4103/1658-354x.169484Halpern, N. A., Hale, K. E., Sepkowitz, K. A., & Pastores, S. M. (2012). A world without ventilator-associated pneumonia. Critical Care Medicine,40(1), 267-270. doi:10.1097/ccm.0b013e318232e3ecHellyer, T. P., Ewan, V., Wilson, P., & Simpson, A. J. (2016). The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. Journal of the Intensive Care Society,17(3), 238-243. doi:10.1177/1751143716644461Kalanuria, A., Zai, W., & Mirski, M. (2014). Ventilator-associated pneumonia in the ICU. Critical Care,18(2), 208. doi:10.1186/cc13775Klompas, M., Branson, R., Eichenwald, E. C., Greene, L. R., Howell, M. D., Lee, G., . . . Berenholtz, S. M. (2014). Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update. Infection Control & Hospital Epidemiology,35(S2). doi:10.1017/s0899823x00193894Munro, N., & Ruggiero, M. (2014). Ventilator-Associated Pneumonia Bundle. AACN Advanced Critical Care,25(2), 163-175. doi:10.1097/nci.0000000000000019Swearer, J. N., Hammer, C. L., Matthews, S. M., Meunier, J. L., Medler, K. L., Kamer, G. S., . . . Sawyer, A. J. (2015). Designing Technology to Decrease Pneumonia in Intubated Trauma Patients. Journal of Trauma Nursing,22(5), 282-289. doi:10.1097/jtn.0000000000000155

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