Evidence to Support Nursing Intervention in VAP Prevention in Mechanically Ventilated Premises - Essay Example

Evidence to Support Nursing Intervention(S) in VAP Prevention in Mechanically Ventilated Patients Name Institution Introduction Patients in ICU are likely to succumb to nosocomial infections. The most prevalent nosocomial infection among the ICU patients is pneumonia. Pneumonia affects 27 percent of the critically ill patients. 86% of nosocomial pneumonia cases are related to mechanical ventilation. Pneumonia caused because of mechanical ventilation in ICU patients is called ventilator-associated pneumonia. This kind of pneumonia occurs more than two days after a patient has been subjected to intubation (Munro et al, 2009, p 436). In the United States alone, between about 300,000 cases of ventilator-associated pneumonia occur each year. The mortality rate associated with VAP ranges from 0 and 50%. Apart from mortality, the effects of VAP include increased stays in ICU and medical costs. This paper will look at the evidence present that supports the nursing interventions in preventing the occurrence of VAP. Nursing Interventions There are a number of nursing interventions that are used to prevent the disease. They include elevating the heads of beds with patients receiving mechanical ventilation at angle of between 30 and 45 degrees, using endotracheal tube with a dorsal lumen over the ondotracheal cuff to drain tracheal secretions, which collect in the subglottic area, by continuous suctioning, providing oral hygiene to VAP patients, reducing the duration of ventilation, sedation vacations, endotracheal tube care and leveraging PK/PD characteristics (Evans, 2005, p. 16). Evidence to Support Nursing Interventions The risk of contracting VAP among ICU patients increases with increase in the duration of intubation. The best way to prevent this condition in the critically ill is to avoid carrying out intubation and use noninvasive ventilation if it is possible. Studies carried out by researcher indicate that noninvasive mechanical ventilation produces more favorable outcomes as compared to endotracheal tube placement (Fields, 2008, p.293). This is shown by the low mortality and morbidity rates among patients who have used the noninvasive mechanical ventilation. Research also indicates that the rate of contracting nosocomial pneumonia is low among patients randomized to noninvasive mechanical ventilation. In addition, it has been observed that immunocompromised patients have benefited from noninvasive mechanical ventilation as compared to the ones who have used the invasive mechanical ventilation with regard to morbidity and mortality (Fields, 2008, p.297). Among the intubated patients, the risk of VAP increases with increase in the duration of intubation. This is more evident among patients who have been intubated for more than 5 days (Flanders, Collard & Saint, 2006, p.91). Research suggests that the incidence of ventilator-associated pneumonia increases by one percent per day for the intubated patients. Placing patients in a semirecumbent position reduces the length of aspiration, particularly if the patient is receiving enteral feeds. Research on radionuclide show that infiltration of the trachea by gastric contents goes up if intubated patients are not put in the right position (Munro et al, 2009, p 433). Research indicate that elevating the head of the bed for intubated patients to an angle of 45 degrees leads to dramatic reduction in VAP incidence (Flanders, Collard & Saint, 2006, p.88). However, recent survey carried out by University Hospital Consortium reveals that there is low level of compliance to this simple and cost effective practice among the medical staff in many healthcare facilities. Studies carried out indicate that averagely, the heads of beds of the intubated patients in many hospitals are elevated to angle of 29 degrees instead of the standard 45 degrees (Evans, 2005, p. 17). Kinetic bed therapy is also effective in the reduction of the condition. However, this practice is costly, which makes the practice of raising the patient’s bed head a cheaper alternative. Sometimes, ICU patients contract the disease by breathing in bacterial organisms through the ventilator. The occurrence of bacteria is mainly caused by contamination of the aerosols, condensate and suction catheters. Customarily, ventilator circuits were changed regularly. In most cases, the changes were carried daily. However, examination of practice revealed that it has no benefit to the patient in terms of mortality and morbidity rates (Flanders, Collard & Saint, 2006, p.86). On the contrary, constant changes of the circuit increase the rate of condensate spillage in the airway. It is therefore normally recommended that the circuit should only be replaced after it has been soiled. Since heated humidifiers enhance the amount of condensate, attention has been shifted to HMEs (Beth et al, 2012, p. 48). The use of HMEs have resulted to reduction in VAP, although to a small extent, are recommended in patients without considerable secretions or who have a high risk of obstruction. Changing the HMEs less regularly leads to further VAP reduction. Daily documentation and assessment of the readiness of the patient to be removed from mechanical ventilation, and regular sedation vacations have been found to result to shorter durations of stay in ICU and mechanical ventilation (Evans, 2005, p.17). These two different interventions are normally combined because they are interdependent in application. Efficient ventilator weaning needs the collaboration of the patient. Sedation must therefore be lightened before attempting weaning. Sedation vacation involves lightening sedative infusions for long enough to attain alertness in the patient. In this practice, the patients are observed to see if they have spontaneous breathing capacity and evaluated if they are ready to wean from mechanical ventilation (Munro et al, 2009, p 435). However, this practice has risks, which include spontaneous extubation, anxiety, pain arterial, and desaturation due to dyssnchrony with mechanical ventilation. Patients must therefore be closely monitored when carrying out these procedures. Endotracheal suction in patients subjected to mechanical ventilation can be done using the closed or open system. Hypothetically, the closed system is deemed efficient in reducing VAP. However, the method has not been tested to determine whether it works or not. Cost analysis of the two systems, that is, the open and closed gives the closed system an advantage over the open system because, the closed system allows the catheter to be reused and can only replaced if it fails to work (Flanders, Collard & Saint, 2006, p.87). However, respiratory have raised concern over residue accumulation in the lumen of endotracheal tubes during ventilation. The normal human mouth has hundreds of bacteria species. These bacteria species are however continually washed out of the oral cavity by swallowing and saliva production (Flanders, Collard & Saint, 2006, p.89). About 150ml of oral secretions accumulate in the mouth of an adult in a 24-hour period. Saliva production in intubated patients is minimal because they receive nothing by mouth. The mouths of such critically ill patients can be colonized with bacteria within 24 hours after admission. Dangerous bacteria can reproduce and build up to a form a dental plaque if unchecked. This dental plaque forms a reservoir of these microorganisms. Secretions that collect in the aerodigestive tract located over the endoctracheal pipe cuff can aspirate into the lungs leading to pneumonia. This assertion is supported by evidence, which show that in majority of the ventilated patients, the bacteria found in the mouth are the same as those found in the lungs (Munro et al, 2009, p 429). This therefore requires constant of suction of the secretion accumulation in the mouth. Both continuous and intermittent suction of subglottic secretions decrease VAP by removing the source of bacterial infection. The intermittent suction of subglotitic secretions can considerably reduce the VAP incidence, the duration of stay in the ICU and the duration a patient is subjected to mechanical ventilation. Continuous suctioning leads to greater protection against VAP. However, it is more expensive than the intermittent suctioning. Oral care has normally been less prioritized in caring for the critically ill, intubated patients. Nurses may see this practice as a comfort measure, or feel that it does not make any difference in VAP. However, this is not the case because frequent and thorough oral hygiene reduces colonization of the tongue, teeth, and gums (Beth et al, 2012, p. 48). Considerable VAP reductions have been realized when oral care is carried out consistently and thoroughly. Findings from one study that compared routine oral care with tooth brushing after every 8 hours for the intubated show that there was a dramatic drop in the incidence of VAP to zero for the group that carried out routine oral care (Munro et al, 2009, p 431). Oral cleansing has been found to reduce the condition in patients who are going through cardiac surgery. This is because it presumably reduces oropharyngeal colonization. Numerous studies carried on the effectiveness of oral decontamination antibiotics alone or administered together with systematic antibiotics indicate a decline in early VAP (Flanders, Collard & Saint, 2006, p.90). However, other studies suggest that the use of oral decontamination alone produces better results than the combination oral decontamination and systematic prophylaxis (Munro et al, 2009, p 432). Despite the positive effects of the two approaches, concern has been raised about the occurrence of organisms that are resistant to antibiotics. This has made it hard to use these approaches in VAP control. In addition, the approaches are labor intensive. Among the organisms that have been found to be very resistant to antibiotics are the ICU housing organisms. An association of nurses for critical care in America developed a guideline that should be used to carry out oral hygiene in ICU patients. The essential basics of this guideline include oral assessment of patients, brushing of teeth, gums and tongue with a soft toothbrush at least two times each day, applying moisturizing agents to lips and oral mucosa, and antiseptic rinsing in selected patients (Fields, 2008, p.295). Foam-tipped dental swabs have been found to be ineffective in removing plaque as compared to toothbrushes. The endotracheal tube can become a dwelling place for bacteria. Biofilms accumulate inside the tubes more often. Research shows about 84 percent of the endotracheal tubes inspected had a biofilm (Fields, 2008, p.294). This biofilm was heavily loaded with bacteria. The formation of this endotracheal tube biofilm, which permits the accumulation of bacteria, plays a contributory role in VAP development. Silver and antiseptic-saturated endotracheal tubes have been shown to reduce this colonization. Experts recommend that orotracheal tubes instead of nasotracheal tubes should be used (Koenig & Truwit, 2006, p.648). This is because nasotracheal tubes have been shown to increase the risk of contracting sinusitis, which is a likely predecessor of VAP. Gastric acidity and volumes affect the VAP incidence. Reducing the acidity of gastric discharge lowers the growth of bacteria. However, PH agents increases chances of bleeding in critically ill patients more than the chances of getting VAP. Sucralafate can be more effective than H2 blockers in preventing. However, it is ineffective in preventing bleeding in the intestines. This makes proton pump inhibitors and H2 blockers to be preferred. Numerous studies have examined gastric feedings versus postpyloric with regard to VAP development and incidence of aspiration. It was discovered that postpyloric feedings are more effective in the VAP reduction (Fields, 2008, p.293). Generally, there are several opportunities available to clinicians to reduce the VAP incidence. Many of these opportunities are costless or minimal-cost interventions, which should be implemented in caring for the critically ill patients. Caring for the critically ill and intubated patients should directed at using interventions to minimize morbidity, reduce mortality, reduce cost, and shorten the length of time used to stay in the ICU (Koenig & Truwit, 2006, p.652). healthcare providers should always emphasize the use of noninvasive intubation rather than the mechanical one if possible, use of orogastric tubes instead of nasogastric tubes, use of oral intubation if it is necessary to use an endotracheal tube, elevating the head of the bed of the VAP patients to an angle of at least 30 degrees, minimal changing of the ventilator circuit which should only be done when it is soiled, and maintaining a high level of hand hygiene on the part of medical staff. Studies carried out by various researchers provide evidence to show the effectiveness of these interventions. References Evans, B. (2005). Best-practice protocols: VAP prevention. Nursing Management, 36(12), 10-19 Fields, L.B. (2008). Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. The Journal of Neuroscience Nursing, 40(5), 291-298 Flanders, S.A., Collard, H.R. & Saint, S. (2006). Nosocomial pneumonia: State of the science. Am J Infect Control, 34, 84-93 Koenig, S.M. & Truwit, J.D. (2006). Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clinical Microbiology Reviews, 19(4), 637-657 Munro, C.L., Grap, M.J., Jones, D.J., McClish, D.K. & Sessler, C.N. (2009). Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. American Journal of Critical Care, 18(5), 428-438 Beth, M., Lance-Smith, M., Reeder, S.J. & Nardi, J. (2012). Using evidence-based practice to prevent ventilator-associated pneumonia. Critical care nurse, 32(4), 41-50 Read More