Reducing the Incidence of Ventilator-Acquired Pneumonia - Research Paper Example

Pneumonia unlike many respiratory infections is precluded by more than just the biological or primarily speaking the air borne path. Similarly, it requires more attention and also requisite medical supplementation depending on the levels of extremities reaches by various patients at different exposure levels.One of the recent afflictions cindered onto the pneumonia epidemic is the, mechanical cause that has been also rifled on the scheme of causative agents. In this case, it is not a great deal of the bacterial or larval causing pathogen but is the side effects of the mechanical use of medical devices that in the long run alter the normal physiological setup of the body internally causing a recess in either the chemical or fluid constituents of the body. Apparently, there has been various advances suggesting just how the ventilator machine comes into play in afflicting the severely ill patients or the intensive care unit patients and the cutting edge is that its majorly the nasal and bronchial constituents being altered hence reverting to pneumonic episodes. Notably, a bronchoscopy technique has been severally used to analyze the deep default caused by the ventilator system and has been seen that the bronchial alveolar lavage fluid (BAL).The high incidences of mortality and morbidity serve as primarily the main buffers of the ventilator associated pneumonia (VAP). Introduction Polit and Beck in their journal essentials of nursing 8th edition have tried to advance the ideology and theory that head elevation can serve as an aiding element in preventing if not curing the ventilator associated pneumonia. Furthermore they argue that the bronchoscopy technique is not a sufficient choice in analyzing the pneumonic constituents. Nonetheless, they have advanced the head elevation ideology as a way of rescue or retribution of some sort. On the contrary, ventilator-associated pneumonia (VAP) can be defined as a general infection that is common in critical care settings in hospital and is associated with severe clinical outcomes. According to the U.S Centers for Disease Control and Prevention, VAP is defined as a pneumonia that occurs 2 days after the commencement of mechanical aeration (Tablan, 2004). Aspiration of gastric substances is known to be a chief entry path of bacteria into the lungs, which is a significant aspect in the development of VAP. Ventilator-associated pneumonia is a prevalent nosocomial contagion in severely sick patients and is a primary contributor to prolonged stay in the hospital (Muscedere et al. 2010). Notably, VAP is linked to heightened rates of multidrug-resilient infections, lengthy mechanical ventilation period, increased antibiotic use, and increased ICU and hospital stay. Summed together, these elements increase the overall health care costs for the patients with VAP, which may not be taken care of by the insurers. In reference to Alexiou et al. (2009), VAP results to longer periods of ventilation and stay at the ICU, with a maximum of 39 extra days. Heyland and Cook (2012) acknowledge that this additional stay at the hospital causes increased health costs that may even exceed $40, 000 per patient. Additionally, VAP is associated with increased mortality (Joseph et al., 2010). Apparently,the critically ill patients who develop the VAP contagion have a high probability of dying than those without VAP. According to Keeley (2007), patients with VAP are twice more likely to die than those without VAP. Though it is not well known whether patients die with VAP or because of VAP, it is evident that there is a significant benefit of preventing VAP. VAP is a severe contagion that affects almost 14% of critically ill patients. In United States, the occurrence (nVAP/1000 ventilation days) is 13%. It is also estimated that 20% of the patients die out of VAP. Additionally, patients with VAP have a mortality rate of 46% as compared to 31% of critically ill patients without VAP (Heyland & Cook, 2012). Therefore, a failure to control and prevent VAP results to increased patient stay at the ICU and hospital, increased healthy costs and increased chances of death. However, what is not known is that VAP represents an infection that results from a “medical error”. Therefore, it is imperative to engage the hospital in prevention of VAP. Though there are numerous interventions on preventing VAP, this study will focus on the elevation of head of bed. Evidently, this study will explore whether elevating head of bed can reduce the incidence of VAP. This study proposes this intervention because a semi-upright position of ventilated patients promotes the prevention of VAP. According to Drakulovic (1999), this intervention improves the patient’s ventilation. This is because patients in an elevated position have lesser impulsive tidal volumes on pressure provision ventilation as opposed to those seated. Purpose This study will explore on the significance of the elevation of head of bed on reducing the incidence of ventilator-acquired pneumonia. Additionally, this study will review the guidelines on head of bed elevation in preventing VAP and offer research-based information to support the guidelines. The study population will be adult ventilated patients who will be assigned to two positions i.e. elevated head of bed at 40o, seated and horizontal positions. Significance to Nursing VAP continues to be a headache to healthcare providers. VAP is a common hospital acquired contagion. This study will benefit both patients and health care providers by offering more insights on how elevating the head of bed can help reduce the incidence of ventilator-associated Pneumonia. Though the raising of the head of bed has been a nursing standard for long, the evidence presented over the years has not been clear (Combes, 2006). The initial studies have purposed to determine an angle that would eliminate aspiration while using a two group cross-over design with a small number of patients (Tablan et al., 2003). This study will have a strong randomized controlled trial design and offer significant results and will not discuss about the best and standard degree of head of bed elevation. Since the right and appropriate elevation degree has been an issue that is not clear, the study will use 40 o position. Maintaining the patients at the three distinct positions will offer a breakthrough in determination of the significance of the elevation of the head of bed in reducing the incidence of VAP. According to Grap and Cantley (2006), this intervention is rarely used. Therefore, this study will give the benefits of elevating the head of the bed for VAP patients. The study will show how elevation of the bed head avoids gastric reflux predisposed by the nasogastric tubes. Additionally, this study will show how simple the intervention is as opposed to other interventions(Grap, 1999). The results of the study will give support to the available literature on the significance of elevation of head of bed in reducing incidence of VAP. It is anticipated that the patients with a raised head of bed at 40 o will have a reduced incidence of VAP and a low mortality rate as compared to those seated or at a horizontal position. Theoretical framework The principle of head elevation is meant to incline the head at an angle relatively between 30* to 45*. The main principle behind it is that it helps in the reverting of mucus effluents that are significantly at a high rate during the ventilator period and help in aerating the body. Although, head elevation through a prescribed angle is described as a semi upright position, it also employed in the subsequent accounts (Polit and Beck, 2014) However, it has been described to have its disadvantages and also more advances are being rifled towards it in terms of its incompetency as a method of preventing or eluding the ventilator associated pneumonia (VAP). Application of the Head elevation Delving into the research field, the application ability of the entire scheme comes into play significantly since it’s by research application and test that a theory can suffice for use in the medical world or any other field as per say.The VAP is a form of pneumonia accosted to patients on a mechanical ventilator support system by an endotracheal tube or tracheostomy for than 48 hours. Evidently, the semi upright position has been used tested on 22 patients at the Michigan state university respiratory center and it was seen that 20 out of the 22 patients showed a great positive response to the induced inclined position and likewise showed signs of early improvement and subsequent healing (Antonni, 1999) To add to the list, the practicality of the theory was further tested on sample sheep since they showed a close to same respiratory make up as humans. It was seen that due to the inclined posture there was a reversal of mucus collection from the anterior regions to the posterior regions hence in a way reducing the collection and congestion of the tracheal path (Antonni, 2011). Following these two research points, it can be clearly seen that the head elevation is a clear cut cloth for the treatment of the VAP ailment. In the International respiratory council (IRC), the inclining of patients has been supplemented automatically in their bed position hence it’s fair to say that it is a theory that has been incepted. This can be heckled to the efforts of pioneers such as Drakulovic and partners who since 1999 have argued and advocated for the use of the head elevation technique (Polit and Beck, 2014). Literature review Evidently, this paper strives to give a decisive insight into pneumonia and also document some of the mode of prevention involved. In particular, we are going to focus on some of the ways in which vector-associated pneumonia can be prevented and reduced in the case of infection(Anderson&Besser, 2004). However, it is worth noting that, in this research paper we are going to lay emphasis on the head elevation in relation to the prevention and reduction of VAP. On the contrary, it is worth noting that a number of prevention strategies exist and we are going to highlight them in the subsequent sections of this paper(Muscedere, 2010). For instance there is the non-invasive positive pressure ventilation for patients with the necessary funds, in particular those with immune-compromised with acute exacerbation of chronic pulmonary disease or pulmonary edema(Keeley, 2007). Secondly, we are going to look at the sedation and weaning protocols. Evidently, this is for those patients that are in dire need of mechanical ventilation(Muscedere, 2010). Furthermore, there are the mechanical ventilation mechanisms for prevention. Apparently, this includes the head elevation above 30 degrees and oral care. Notably, in this particular paper we are focusing on mechanical ventilation mechanisms especially the head elevation as mentioned in the previous segment. On the same note, some of the advantages of head elevation are detailed as: For starters, the head elevation is a relatively cheap and easier method as compared to the other forms of pneumonia treatment techniques. Topping the list in terms of expensiveness is the bronchoscopy, a technique that requires a very high level of scientific know how and is very technical (Polit &Beck, 2014).Elevation of head of the bed reduce the length of staying in ICU and it speed up patient’s discharge from hospital after transferred from ICU to the regular floor.Furthermore, the head elevation has been described to not only settle the pneumonic effects but also checks for bodily balance in terms of ensuring good and preferred physiological build. On the other hand, just as like many of the medical applied techniques, there arises several side effects; the main a primarily that of grave concern is the venous stasis in lower extremities. However, the challenge posed by this is being supplemented and take care of by regular neuron-checkup during time treatment(Grap, 1999). In addition to those prevention strategies, we have the removal of subglottic secretions as another prevention mechanism. It is important to note that, the evidence of the efficacy of these mechanisms to inhibit VAP is relatively low and therefore not strong enough to be recommended in clinical practice(Grap, 1999). Apparently, numerous studies have suggested that the employment of the VAP prevention bundles has been attributed to a reduction in the rates of VAP. Research question 1. Can elevating the head for a VAP patient reduce the risk of nosocomial pneumonia? 2. What are some of the ways of preventing VAP? Objective This study is aimed at establishing whether the incidences of ventilator-acquired pneumonia, can be minimized by elevation of the head of a patient by 45 degrees. Research design Quantitative research One of the most noteworthy advantages associated with quantitative research methods include their providing the objective measurements as well as numerical examination of the data gathered during the research process. It also involves the collecting of data through participant observation, surveys, questionnaires and/or interview-schedule(Keeley, 2007). However, quantitative research methods are endorsed for broadening the research activities because of laying stress upon collecting the numerical data by concentrating upon generalizing the research findings on different groups and communities in order to draw out conclusions subsequently(Muscedere, 2010). In addition, another major reason behind conducting the study by selecting quantitative research includes getting access to larger number of respondents. Furthermore, interpretation of results is comparatively easier in the quantitative research process than the qualitative research measures(Anderson&Besser, 2004). Therefore, in this particular research the quantitative design is used. Evidently, this entails the use of randomized controlled trial(Muscedere, 2010). On that note, random adult and ventilated patients are assigned to one or two positions that is, the control group with heads elevated at 25 degrees and the treatment group whose heads are elevated at 45 degrees. Notably, the data collection is based on diagnosis of clinically established pneumonia patients defined by the consensus conference on VAP. Results The research was conducted with thirty people. Apparently, seventeen were in the treatment category, thirteen in the category of the control experiment. Evidently, the study was able to yield that about 29% of these people that is an equivalent to 5 people in the treatment category, 54% in the category of the control were able to be infected with the VAP. Conclusion Evidently, there were some signs of the spread of the VAP reduction as per the above experiment, where the head was elevated at an angle of 45 degrees. It is important to note that, due to the sample size being small, the result did not meet the statistical significance. In a nut shell and recap, the elevation of the head in the treatment of the ventilator associated pneumonia VAP is of significance and it’s quite a great relief that it has been incepted into modern medicine as was the vision of earlier pioneers. Prevention of VAP First and foremost it is worth noting that the prevention of VAP entails the inhibiting or reducing the exposure to the resistant bacteria. In addition, the removing of the mechanical ventilation and other methods that serve to minimize the infection while still intubated. Notably, the spread of this disease is pretty much like any other communicable disease thus the importance to maintain good hygiene. For instance the proper washing of hands, sterilizing instruments involving invasive procedures and simply the isolation of individuals carrying the resistant pathogen are a couple of techniques that can be incorporated in a bid to curb the spread of this disease(Keeley, 2007). In addition to that, in some cases a few aggressive weaning mechanisms can be employed in a bid to reduce the time exposure of the individual in the intubation stage of the disease(Anderson&Besser, 2004). For instance, sedation has been proved to be one of the techniques that can reduce the intubation stage of the infection. Furthermore, the placement of feeding tubes beyond the pylorus of the stomach has also been used as a method of prevention of VAP. On the same note, antiseptic mouth wash, for example the chlorohexadine has also been proved as a viable method of prevention too. Studies have also postulated that the use of moisture exchangers in the place of humidifiers can also serve to reduce tremendously the incidences of VAP(Grap, 1999). On the contrary, research has shown that the occurrence of VAP is about 25% who are in need of mechanical ventilation. It is worth noting, that VAP may develop at different time in the intubation period, however, it usually shows after a few day of infection(Anderson&Besser, 2004). This can be attributed to the fact that the VAP bacteria require the intubation in order to develop. VAP that sprouts after a few day of intubation is usually attributed to have fewer resistant pathogens and thus can be treated with ease as compared to the one that occurs at the latter days after intubation(Keeley, 2007). However, due to the fact that respiratory failure which requires mechanical ventilation can at time be fatal, VAP’s role in the mortality spectrum has been subject of speculation and therefore at time it is difficult to establish whether the cause of death of a patient is due to VAP(Anderson&Besser, 2004). On the other hand, the mortality is more likely to happen when the VAP pathogen is associated with another pathogen for instance pseudomena. People who have the respiratory distress syndrome are like to contract VAP easily(Anderson&Besser, 2004). In summation, it is clear that the elevation of the head to an angle let say, 45 degrees can serve to minimize the contraction of VAP. In addition to that, we have been able to comprehensively look at mechanisms that can be put in place in a bid to prevent the contraction of VAP. To this end, it is worth noting that every individual has a part to play in the control, prevention and the care of VAP patients. Reference C, P. (2012). Ventilator associated pneumonia. In Respiratory diseases and modern medicine (5th ed., Vol. 2, p. 300). N/A, N/A: Fort times press. Pollitt, D. F., & Beck, C. T. (2014). Essentials of nursing research: appraising evidence for nursing practice (8th Ed.). Philadelphia: university press. Antonni. T. (2011), the physiology of body inclination, ver. 5 vol. 2 N/A Michigan University press. Alexiou VG, Ierodiakonou V, Dimopoulos G, Falagas ME (2009). Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. Journal of Critical Care, 24:515–522. Combes A. (2006). Backrest elevation for the prevention of ventilator-associated pneumonia: back to the real world? Critical Care Med, 34:559–561. Craven, D. E., De Rosa, F. G., & Thornton, D. (2002). Nosocomial pneumonia: Emerging concepts in diagnosis, management and prophylaxis. Curr Opin Crit Care, 8(5), 421. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. (1999). Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: A randomized trial. Lancet,354 (9193):1851-1858. Grap, M. J., Cantley, M., et al. (1999). Use of backrest elevation in critical care: Pilot study. Am J Crit Care, 8(1), 475. Heyland, D. K., Cook, D. J., (2009). The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Clinical Trial Group. Am J Resp Crit Care Med, 159(4, Pt. 1), 1249. Joseph NM, Sistla S, Dutta TK, Badhe AS, Parija SC.(2010). Ventilator-associated pneumonia: a review. Eur J Intern Med, 21:360–368. . Keeley L. (2007). Reducing the risk of ventilator-acquired pneumonia through head of bed elevation. Nurs Crit Care, 12(6):287-294. Muscedere J., Day A., Heyland D.K. (2010).Clinical Infectious Diseases. 51 Suppl 1:S120-5 Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R.(2004). Guidelines for preventing health-care - associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004 Read More