APPENDIX – C

Name: Mr. Rama Krishna

Year : M Sc N II year

Topic : Prevention of Ventilator Associated Pneumonia

Group : Staff nurses working at ICUs

No. of people : 50

Place : Conference Hall, Jayabharathi Multispecialty Hospital

Duration : 30 minutes

Method of teaching : Lecture cum discussion

Audio Visual Aids : Charts, Flash cards, Posters, OHP Projector and LCD Projector
Objectives:

General objective: By the end of Structured teaching programme the group will gain in-depth knowledge on Prevention of Ventilator
Associated Pneumonia

Specific objectives: The group will be able to

 Define Ventilator Associated Pneumonia

 Describe the prevalence of Ventilator Associated Pneumonia
 Discuss the Risk factors for Ventilator Associated Pneumonia
 Explain the pathophysiology of Ventilator Associated Pneumonia
 Explain the diagnosis of Ventilator Associated Pneumonia
 Emphasize on Management of Ventilator Associated Pneumonia
 Discuss the prevention of Ventilator Associated Pneumonia
 Discuss the role of nurse in prevention of Ventilator Associated Pneumonia
 Teaching
Time Objective Content and Evaluation
learning
activity
2min To introduce INTRODUCTION:
topic Namasthe !
I am M Sc (N) student of -------------- College of Nursing, now I teach you about
Ventilator Associated Pneumonia.
Mechanical ventilator has prolonged the lives of many clients whose
respiratory function have been compromised by drugs. A mechanical ventilator is
positive or negative pressure breathing device that can maintain ventilator and
oxygen delivery for a prolong period. Caring for a patient on mechanical ventilator Lecture
has become an integral part of nursing care in critical care or general medical cum
surgical units, extended care facilities and home. discussion

Ventilator-associated pneumonia (VAP) is the most frequent infection in

patients admitted to ICUs, and is as associated with an increase in days of ICU stay,
morbidity and mortality. Prevention of VAP is much more cost effective than
treatment, and several guidelines have recommended measures to decrease the
incidence of VAP. The most important measures are continuous medical education,
continuous suctioning of sub-glottic secretions, semi-recumbent position, oral
hygiene with chlorhexidine,26 and selective digestive decontamination.

DEFINITION OF VENTILATOR ASSOCIATED PNEUMONIA:

3min To define Ventilator associated pneumonia, is a nosocomial pneumonia in a patient on Can you
Ventilator mechanical ventilator support by endotracheal tube or tracheostomy for more than Lecture define
Associated 48 hours with signs and symptoms of pneumonia. cum VAP?
Pneumonia Ventilator associated pneumonia (VAP) is defined as a type of pneumonia in a discussion
patient receiving mechanical ventilation that was not present at the time of
 admission to hospital or that occurs 48 hours after intubation and mechanical
ventilation. It is characterized by a new or a progressive pulmonary infiltrate, fever,
leukocytosis and purulent trachea-bronchial secretions

PREVALENCE OF VENTILATOR ASSOCIATED PNEUMONIA:

2min To describe Lecture
the The incidence of VAP is 22.8% in patients receiving mechanical ventilation, cum What is the
prevalence and patients receiving ventilatory support account for 86% of the cases of discussion prevalence
of VAP nosocomial pneumonia. Furthermore, the risk for pneumonia increases 3- to 10-fold of GI
in patients receiving mechanical ventilation. cancer?
VAP is associated with increases in morbidity and mortality, hospital length of
stay, and costs. The mortality rate attributable to VAP is 27% and has been as high
as 43% when the causative agent was antibiotic resistant.

CAUSES AND RISK FACTORS OF VENTILATOR ASSOCIATED

3min To discuss PNEUMONIA:
the causes
and risk The risk factors for VAP can be divided into 3 categories: host related, device Lecture
factors of cum What are
related, and personnel related.
VAP discussion the causes
and risk
 Host-related risk factors include preexisting conditions such as factors for
VAP?
 immunosuppression,
 chronic obstructive lung disease, and
 acute respiratory distress syndrome.
 patients’ body positioning,
 level of consciousness,
 number of intubations, and
  medications, including sedative agents and antibiotics.

 Device-related risk factors include:

 the endotracheal tube,

 the ventilator circuit, and
 the presence of a nasogastric or an orogastric tube.

 Personnel-related risk factors includes:

 Failure to wash hands and change gloves between contaminated patients has
been associated with an increased incidence of VAP.
 Failure to wear proper personal protec-resistant organisms have been
identified increases the risk of cross-contamination between patients.

5min To explain PATHOPHYSIOLOGY OF VENTILATOR ASSOCIATED PNEUMONIA:

the Patho-
physiology The onset of VAP can be divided into 2 types: early and late. Early-onset VAP Lecture
of VAP occurs 48 to 96 hours after intubation and is associated with antibiotic-susceptible cum What is the
organisms. Late-onset VAP occurs more than 96 hours after intubation and is discussion patho-
physiology
associated with antibiotic-resistant organisms. of VAP?
The pathophysiology of VAP involves 2 main processes: colonization of the
respiratory and digestive tracts and microaspiration of secretions of the upper and
lower parts of the airway.

 Colonization of bacteria refers to the presence of bacteria without an active

host response. Bacterial colonization of the lungs can be due to spread of
organisms from many different sources, including the oropharynx, sinus
 cavities, nares, dental plaque, gastrointestinal tract, patient-to-patient
contact, and the ventilator circuit. Inhalation of colonized bacteria from any
of these sources can cause an active host response and, ultimately, VAP.
 The presence of an endotracheal tube provides a direct route for colonized
bacteria to enter the lower respiratory tract. Upper airway and oral
secretions can pool above the cuff of an endotracheal tube and line the tube,
forming a biofilm. Starting as early as 12 hours after intubation, the biofilm
contains large amounts of bacteria that can be disseminated into the lungs
by ventilator-induced breaths. In addition, the biofilm may become
dislodged by instillation of saline into the endotracheal tube, suctioning,
coughing, or repositioning of the endotracheal tube.
 Aspiration of gastric contents is another potential cause of VAP, because
the stomach serves as a reservoir for bacteria. Most patients receiving
mechanical ventilation have a nasogastric or an orogastric tube in place for
enteral feedings and administration of medications or for gastric
decompression. The presence of a nasogastric or an orogastric tube
interrupts the gastroesophageal sphincter, leading to increased
gastrointestinal reflux and providing a route for bacteria to translocate to
the oropharynx and colonize the upper airway. Enteral feedings increase
both gastric pH and gastric volume, increasing the risk of both bacterial
colonization and aspiration.

SIGNS AND SYMPTOMS OF VENTILATOR ASSOCIATED

2min To
PNEUMONIA:
emphasize Lecture
on signs and cum
symptoms of People who are on mechanical ventilation are often sedated and are rarely able to discussion What are
VAP communicate. As such, many of the typical symptoms of pneumonia will either be the signs of
absent or unable to be obtained. The most important signs are VAP?
 fever or low body temperature,
  new purulent sputum, and
 hypoxemia (decreasing amounts of oxygen in the blood).

DIAGNOSIS OF VENTILATOR ASSOCIATED PNEUMONIA:

2min Lecture
To describe Diagnosis of ventilator-associated pneumonia is difficult and is not standardized. cum
the diagnosis The criteria used for diagnosis of VAP varies by institution, but tends to be a discussion How to
of VAP diagnose
combination of several of the following radiographic, clinical sign, and laboratory
VAP?
evidence:

1. Temperature greater than 380C or less than 360C

2. White blood cell count greater than 12,000/mm3 or less than 4,000/mm3
3. Purulent secretions, increased secretions, or change in secretions
4. Positive tracheal cultures or bronchoalvelolar lavage cultures
5. Some sign of respiratory distress, such as shortness of breath, rapid
breathing, abnormal breathing sounds when listening with stethoscope
6. Increased need for oxygen on the ventilator
7. Chest X-Rays: at least two serial x-rays showing sustained or worsening
shadowing (infiltrates or consolidations)
8. Positive cultures that were obtained directly from the lung environment,
such as from the trachea or bronchioles

MANAGEMENT OF VENTILATOR ASSOCIATED PNEUMONIA:

3min Lecture
Treatment of VAP should be matched to known causative bacteria. However, when
To discuss cum
management VAP is first suspected, the bacteria causing infection is typically not known and Discussion What is the
of VAP broad-spectrum antibiotics are given (empiric therapy) until the particular treatment
bacterium and its sensitivities are determined. for VAP?
 Possible empirical therapy combinations include (but are not limited to):

 vancomycin/linezolid and ciprofloxacin,

 cefepime and gentamicin/amikacin/tobramycin
 vancomycin/linezolid and ceftazidime
 Ureidopenicillin plus β-lactamase inhibitor such as piperacillin/tazobactam
or ticarcillin/clavulanate
 a carbapenem (e.g., imipenem or meropenem)

Therapy is typically changed once the causative bacteria are known and continued
until symptoms resolve (often 7 to 14 days). For patients with VAP not caused by
nonfermenting Gram-negative bacilli (like Acinetobacter, Pseudomonas
aeruginosa) the available evidence seems to support the use of short-course
antimicrobial treatments (< or =10 days).

People who do not have risk factors for MDR organisms may be treated differently
depending on local knowledge of prevalent bacteria. Appropriate antibiotics may
include ceftriaxone, ciprofloxacin, levofloxacin, or ampicillin/sulbactam.

PREVENTION OF VENTILATOR ASSOCIATED PNEUMONIA:

2min To explain
prevention Prevention of VAP involves limiting exposure to resistant bacteria, discontinuing Lecture
of VAP cum How to
mechanical ventilation as soon as possible, and a variety of strategies to limit
discussion prevent
infection while intubated. VAP?
The health care protocol for prevention of ventilator associated pneumonia
recommended by Institute for Clinical Systems Improvement as follows:

1. Nursing and Respiratory care

2. Medications
1. Nursing and Respiratory care:
 Head of the Bed: In the absence of medical contraindications, elevate the head
of the bed at an angle of 30-45 degrees for a patient at high risk for aspiration
(e.g., a person receiving mechanically assisted ventilation and/or who has an
enteral tube in place).
 Cuff Pressure: Cuff pressure should be maintained at 20-25 cm H2O. Minimal
leak technique is discouraged
 Circuit Changes: Less frequent changes do not lead to increased incidence of
ventilator-associated pneumonia. Circuit changes should occur when visibly
soiled rather than routinely
 Heated Humidifiers, and Heat and Moisture Exchangers: The Centers for
Disease Control and Prevention recommends that heat and moisture exchangers
not be changed more frequently than every 48 hours or when they become
visibly soiled or mechanically malfunction
 Oral care: Assess the oral cavity and provide oral care every 6-8 hours and as
needed, using a 0.12% or 2% chlorhexidine solution. Apply water-soluble
mouth moisturizer and/or lip balm every 6-8 hours (after oral care) and as
needed to maintain moisture.
 Secretion Removal with Specially Designed Endotracheal Tubes: Use a
dedicated suction line for endotracheal tube suctioning of respiratory
secretions. Rotate position of oral endotracheal tube not less than every 24
hours. If endotracheal dorsal lumen is used, remove deep oral/subglottic
secretions continuously per manufacturer's recommendations.
 Kinetic Bed Therapy: Kinetic bed therapy (continuous lateral rotation) can
reduce the incidence of ventilator-associated pneumonia.
 Sedation Reduction: Regular testing of the patient's ability to sustain adequate
ventilation, oxygenation and breathing comfort (e.g., spontaneous breathing
trial) has been shown to significantly reduce duration of mechanical ventilation
for acute respiratory failure. Daily cessation (after the second day of intubation)
 of continuous infusions of sedative medications decreases the duration of
mechanical ventilation and decreases diagnostic testing to evaluate impaired
mental status that occurs after intensive care admission
 Weaning Readiness: Daily (or more frequently), brief weaning trials allow
early assessment of patients' ability to sustain ventilation, oxygenation,
breathing comfort and hemodynamic stability. Studies have shown that
respiratory therapist or nurse-driven protocols that communicate to physicians
the patient's tolerance and physiological response to 30-60 minutes of
unsupported (e.g., continuous positive airway pressure [CPAP] or t-piece) or
minimally supported breathing (e.g., pressure support of 7 cm H2O) leads to
decreased duration of mechanical ventilation. Combining daily sedation
cessation followed by a spontaneous breathing trial is more effective than
performing daily spontaneous breathing trials alone.
2.Medications:

 Stress Ulcer Prophylaxis: The preventive practices with the strongest

supportive evidence were sucralfate instead of H2-antagonists for stress ulcer
prophylaxis, and selective digestive tract decontamination. Assess the need for
ongoing stress ulcer prophylaxis. Discontinuation of prophylaxis should be
considered if the patient is extubated, if there is no significant gastrointestinal
bleeding upon transfer out of the intensive care unit, traumatic brain or spinal
cord injury does not exist,
 Venous Thromboembolism Prophylaxis: It is recommended that on
admission to a critical care unit, all patients be assessed for their risk of venous
thromboembolism, and that accordingly, most patients should receive
thromboprophylaxis.

ROLE OF NURSE IN PREVENTION OF VENTILATOR ASSOCIATED

 PNEUMONIA:
5min To discuss
the role of Intensive care nurses are in the best position to put evidence based guidelines Lecture
nurse in into practice as they are at the patient’s bedside 24 hours daily providing nursing cum What is the
prevention care and therefore play an important role in the prevention of VAP (Biancofiore, et discussion role of
of VAP al.,2007). Nevertheless nurses need to have an awareness of the problem as well as nurse in
knowledge on current research evidence so as to adhere to such practices. prevention
The guidelines for the prevention of VAP were developed in 2004 by the of VAP?
To Canadian Critical Care Trials Group to address this problem in the intensive care
summarize unit.
the topic
5min There are 21 strategies on the guidelines for prevention of VAP developed by
the panel above and these are divided into 10 physical strategies, three positional
strategies and eight pharmacological strategies. For the purpose of this study, only
strategies under the evidence based guidelines for prevention of VAP that are
relevant to nursing practice will be discussed as these were the strategies included
in the data collection tool. Those are:
1. Physical strategies:
 Route of endotracheal intubation : Orotracheal intubation is also associated
with a decreased incidence of sinusitis and the incidence of VAP is lower in
patients who do not develop sinusitis. Therefore the orotracheal route of
intubation is recommended when intubation is necessary.
 Frequency of ventilator circuit changes: the frequency of ventilator circuit
changes does not influence the incidence of VAP. Cost considerations favour
less frequent changes. Therefore new circuits for each patient, and changes if
the circuit becomes soiled or damaged is recommended, but no scheduled
ventilator circuit changes.
 Airway humidification: type of humidifier: it was concluded that there is no
difference in the incidence of VAP between patients whose airways are
humidified using a heat and moisture exchanger and those whose airways are
humidified using a heated humidifier. Therefore both types of humidifiers can
be recommended.
 Airway humidification: frequency of humidifier changes: Reduction in the
 frequency of humidifier changes might be considered as a cost reduction
measure. Therefore changes of humidifiers every 5 to 7 days or as clinically
indicated are recommended.
 Endotracheal suctioning system: closed vs. open : Safety considerations such
as patient and health care worker exposure to aerosolized secretions favour the
use of closed systems. Therefore, the use of closed endotracheal suctioning
system is recommended.
 Endotracheal suctioning system: frequency of change : scheduled daily
changes and unscheduled changes of closed suctioning systems have no effect
on VAP. Cost considerations favor less frequent changes. Therefore it is
recommended that closed suctioning systems be changed for each patient and
as clinically indicated.
 Subglottic secretion drainage: The use of subglottic secretion drainage is
recommended in patients expected to be mechanically ventilated for more than
72 hours.
2. Positional strategies:
 Kinetic bed therapy: the use of rotating beds is associated with a decreased
incidence of VAP. However, feasibility, safety and cost concerns may be
barriers to implementation. Therefore the use of rotating kinetic beds should be
considered.
 Semirecumbent positioning: semirecumbent positioning may be associated
with a decreased incidence of VAP. Therefore it is recommended that the head
of the bed be elevated to 45 degrees. When this is not possible, attempts to raise
the head of the bed to as near as to 45 degrees as possible should be considered.

These are the nine strategies that are relevant to nursing practice in the guidelines
for prevention of ventilator associated pneumonia. These strategies, if implemented
by intensive care nurses, have proven to decrease the risk of VAP and therefore are
important steps in increasing positive outcomes to mechanically ventilated patients
in the ICU as well as to promote the implementation of evidence based nursing and
medicine.
2min SUMMARY:

I have discussed with you various aspects of Ventilator Associated Pneumonia and
its prevention in-detail.

CONCLUSION: Reducing hospital-acquired pneumonia continues to pose a

challenge for healthcare providers. Nurses plays very important role in reducing the
complications related to Ventilator associated Pneumonia.

REFERENCES:

1. Hixon S, Lou Sole M, King T. Nursing strategies to prevent ventilator

associated pneumonia. AACN Clinical issues: Advanced Practice in Acute
and Critical Care vol. 9, no.1; 1998.

2. Munro C, Grap M, Elswick R. Oral health status and development of

ventilator associated pneumonia: a descriptive study. American Journal of
Critical Care, vol. 15; 2006.

3. Grap M, Munro C, Hummel R, Elswick R, Mckiney J. Effect of backrest

elevation on the development of ventilator-associated pneumonia. American
Journal of Critical Care, vol. 14; 2005.

3. Grap J, Munro C, Ashianti B, Bryant S. Oral care interventions in critical

care: frequency and documentation. American Journal of Critical Care,
vol. 12, no. 2;2003
4. Abbott, C., Dremsa, T. & Stewart, D.W., et al. 2006. Adoption of a
Ventilator-Associated Pneumonia Clinical Practice Guideline. Worldviews
 on Evidence-Based Nursing, vol. 3, no. 4, pp. 139 – 152.
5. Augustyn, B. 2007. Ventilator associated pneumonia: risk factors and
prevention. Critical Care Nurse, vol. 27, no. 4, pp. 32 – 39.
6. Biancofiore, G., Barsotti, E. & Catalani, V., et al. 2007. Nurses’ knowledge
and application of evidence-based guidelines for preventing ventilator
associated pneumonia. Minerva Anestesiologica, vol. 73, no. 3, pp. 129 –
134.

WEBSITES:
 www.medtronic.com/.../ventilator-associated-pneumonia/guidelines.html
 www0.sun.ac.za/Physiotherapy_ICU_algorithm/Documentation/Changes on... ·
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 criticalcarecanada.com/presentations/2012/new_definitions_for_vap.pdf · PDF
file
 www.ihi.org/resources/Pages/Publications/Evidencebasedclinical...
 https://www.cdc.gov/hai/vap/vap.html
 www.ncbi.nlm.nih.gov › … › Indian J Med Res › v.139(6); 2014 Jun
 https://en.wikipedia.org/wiki/Ventilator-associated_pneumonia
 http://ccn.aacnjournals.org/content/27/4/32.full