VAP: Methods of prevention in acute care patients

What is the best way to prevent the occurrence of ventilator associated pneumonia?

Presented by: Scott Babcock, RN

What is VAP?

VAP= Ventilator Associated Pneumonia
Most common type of infection in mechanically ventilated patients
Time of onset: >48 hours post intubation
48-72 hours-early onset: Streptococcus, Staphylococcus
>72 hours- late onset: Pseudomonas, Acinetobacter
Primary cause: aspiration of oropharyngeal secretions




Collard, H.R., & Saint, S. (2008).

Article #1: The gold standard: American Association of Critical Care Nurses practice guidelines

Type of study: Report of expert committee
Level of evidence: Level 5
Sample size: n/a
Limitations: n/a
Recommendations:
Elevate patient head of bed 30-45 degrees
Use of continuous suction ET tubes
No timed changes of ventilator circuit


American Association of Critical Care Nurses (2008).

Article #2: Reduction of the risk of VAP through head of bed elevation; a randomized controlled trial

Type of study: Quantitative/ Randomized clinical trial
Level of evidence: Level 2
Sample size: 30 patients
Limitations: Small sample size could result in type II error; power calculation suggests that trial size of n=130 would be required for statistically significant results

Results: Elevating the head of bed showed a clinically significant, but not statistically significant reduction in the incidence of VAP. A study with a larger sample size is suggested

Keeley, L. (2007).

Article #3: Meta-Analysis of patient positioning, subglottic suctioning, digestive tract decontamination, continuous oscillation, and stress ulcer prophylaxis

Type of Article: Meta-analysis of multiple randomized control trials
Level of evidence: Level 1
Sample size: Multiple
Limitations: n/a
Results: Studies showed stastically significant reduction in VAP from head of bed elevation
Meta-analysis of continuous oscillation showed mixed results
Meta-analysis of continual subglottic suctioning showed promising results, more study recommended
Meta-analysis of selective digestive tract decontamination showed stastically significant reductions in VAP in four out of seven trials
Meta-analysis showed inconclusive results of H2 antagonists vs. sucralfate administration

Collard, H.R., & Saint, S. (2008)

Article #4: Systematic literature review of oral hygiene practices in ICU patients on mechanical ventilation

Type of article: Systematic literature review; NOT a meta-analysis
Level of evidence: Level 1
Sample size: 55 studies
Limitations: Several of the studies had high risk for bias, four studies had sample sized too small to eliminate type II error
Results: Use of chlorhexidine gluconate found to be effective in reduction of oral bacterial colonization and subsequent risk of VAP
Use of Sodium Bicarbonate not determined to be more effective than other oral care agents
No significant difference found between Listerine and chlorhexidine in preventing bacterial colonization
Effectiveness of hydrogen peroxide as an oral care agent not established
Saline, sterile water, and tap water not recommended as oral care agents



Berry, A.M., Davidson, P.M., Masters, J., & Rolls, K. (2007)

Article #5:Evidence based nursing practices to prevent ventilator acquired pneumonia; a literature review

Type of article: Literature review, not a systematic review
Level of evidence: Level 5
Sample size: n/a
Limitations: Lack of literature analysis fails to lend strength to the cited sources
Results: Suggestions from this article include the following: regular hand washing to lower the risk of oral contamination, semi-recumbent positioning (head of bed 30-45 degrees), placement of orogastric rather than nasogastric tubes
Regular oral care, including brushing and use of chlorhexidine gluconate as an oral decontaminating agent, is strongly recommended

O’Keefe-McCarthy, S. (2006)

Article #6: Prevention of VAP; a literature review of European studies

Type of article: Systematic literature review, several meta-analyses reviewed
Level of evidence: Level 1
Sample size: Varied
Limitations: n/a
Results: Study suggests that well designed “ventilator bundles” (i.e. a group of evidence based interventions within a single protocol) in conjunction with nurse compliance with these interventions significantly reduce the incidence of VAP in ventilated patients.
Bundles should include:
Head of bed elevation
Daily sedation holidays
Stress ulcer prophylaxis
Deep vein thrombosis prophylaxis
Consistent oral care

Ruffell, A. & Adamcova, L. (2008)

Conclusions

Prevention is better than cure!
“Ventilator bundles” are effective tools in the prevention of VAP
Ventilator care bundles should include elements for oral care, head of bed elevation, DVT and stress ulcer prophylaxis, subglottic suctioning of secretions, and consistent hand washing
Nurse compliance with ventilator bundles is vital
Continuing education of nurses
More research is needed to better define “best practice”

References

American Association of Critical Care nurses (2008). AACN practice alert: Ventilator-associated pneumonia. Critical Care nurse, 28(3), 83-85.
Berry, A.M., Davidson, P.M., Masters, J., & Rolls, K. (2007). Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. American Journal of Critical Care, 16(6), 552-562.
Collard, H.R., & Saint, S. (n.d.). Prevention of ventilator-associated pneumonia. In Making health care safer: A critical analysis of patient safety practices (chap. 17). Retrieved November 10, 2008 from http://www.arhq.gov.
Keeley, L. (2007). Reducing the risk of ventilator-acquired pneumonia through head of bed elevation. Nursing in Critical Care, 12(6), 287-294.
O’Keefe-McCarthy, S. (2006). Evidence-based nursing strategies to prevent ventilator-acquired pneumonia. Dynamics, 17(1), 8-11.
Ruffell, A. & Adamcova, L. (2008). Ventilator-associated pneumonia: prevention is better than cure. Nursing in Critical Care, 13(1), 44-53.