The purpose of this video is to provide general information and education about the care of
a critically ill child.
It is in no way a substitute for the independent decision-making and judgment by a qualified
health care professional.
The information contained in this video should not be used to make a diagnosis or to overrule
the advice of a qualified health care provider, nor should it be used to provide advice for
emergency medical treatment.
Prevention of Ventilator-Associated pneumonia by Deb Morrow.
Hi, I'm Deb Morrow, a Staff Nurse III and the Infection Prevention Coordinator for the
Cardiovascular Intensive Care Unit at Children's Hospital Boston.
Today I'd like to talk to you about strategies that we use at Children's Hospital Boston
to prevent the development of ventilator-associated pneumonia.
Epidemiology.
Ventilator-associated pneumonia is a leading cause of healthcare-associated infections.
These infections are a significant source of cost, morbidity, and mortality.
Adults with ventilator-associated pneumonia have a 40% mortality rate.
And patients of all ages spend an average of six extra days in the intensive care unit
for the management of pneumonia.
Ventilator-associated pneumonia is preventable.
Pathogenesis.
In a healthy person, the lower airway is a sterile body site.
And the endotracheal tube provides access to the lower airway.
Colonized secretions from the subglottic area, which leak into the lower airway around the
endotracheal tube is the primary mechanism of infection.
Other sources of contamination include aspiration of fluids from the stomach, particularly when
a nasal gastric tube is in place; contaminated respiratory equipment, such as ventilator
parts, water, or bronchoscopes; inhalation of contaminated medications; the contaminated
hands of health care workers, who don't clean their hands before manipulating the endotracheal
tube during intubation or suctioning; seeding from a remote site of infection; or biofilm
buildup on the endotracheal tube.
Let's talk about biofilm for a moment.
Biofilm is a thin mucous film that develops on the inside and outside of every catheter
inserted into the body.
Bacteria colonize the surfaces of these catheters and secreted mucous film, which can protect
the bacteria from antibiotics.
Bacterial multiplication takes place under the biofilm.
The best prevention is to remove endotracheal tubes as soon as possible.
Categories of Ventilator-Associated Pneumonia.
There are two categories of ventilator-associated pneumonia and in general, bacteria are the
most frequently isolated pathogens.
Early onset pneumonia is usually caused by antibiotic susceptible organisms, and it occurs
within the first four days of intubation.
Late onset occurs after four days of intubation, and it is usually caused by antibiotic resistant
bacteria.
And it has the highest rate of mortality.
Patients who are immunocompromised are more likely to have viral or fungal pneumonia than
patients with intact immune systems.
Other risk factors for the development of ventilator-associated pneumonia are prolonged
ventilation and repeated intubations, supine position, immobilization, surgical procedures
of the head, neck, thorax or upper abdomen, and underlying chronic lung disease.
Prevention Bundle.
At Children's Hospital Boston, we have developed a bundle to prevent ventilator-associated
pneumonia, which includes hand hygiene-- which is the cornerstone of every infection prevention
initiative, elevating the head of the bed 30 to 40 degrees, oral hygiene, a daily sedation
break, and a daily assessment of need for the endotracheal tube.
Elevating the head of the bed 30 to 40 degrees will prevent secretions from collecting in
the subglottic area and will prevent aspiration of fluids from the stomach.
Infants in isolettes should be in a reverse Trendelenburg position.
Use of a cuffed endotracheal tube will also prevent colonized secretions from entering
the lungs.
The posterior pharynx should be suctioned on a regular basis and before changing a patient's
position to remove secretions.
Oral hygiene is very important.
During severe illness, the predominantly gram-positive bacteria in the mouth switch to predominantly
gram-negative bacteria.
Gram-negative bacteria thrive in plaque, which can build up on teeth in as little as three
days.
The process of chewing facilitates the production of saliva, which is a natural antibacterial.
However, many patients in the intensive care units are unable to eat.
Saliva production can also be decreased by the use of oxygen therapy, antihypertensives,
anticholinergics, such as atropine sulfate, sympathiomimetics, such as dopamine, antihistamines,
and diuretics.
Oral hygiene keeps mucosa and lips clean, soft, moist and intact, and removes debris
and plaque without damaging the mucosa.
At Boston Children's Hospital, we brush teeth and gums with toothbrush, toothpaste and sterile
water every six hours.
If a patient does not have teeth, we will use a gauze with sterile water and rub all
surfaces of the gums, tongue, and mouth every six hours.
The subglottic area should be suctioned before position change and every four hours to prevent
the buildup of secretions in the posterior pharynx.
It is also important to drain the ventilator tubing away from the patient so that contaminated
fluid from the circuit does not enter the endotracheal tube.
We identify a respiratory plan at patient rounds using a daily goal sheet.
When patients are stable, sedation medications are decreased and paralytic medications are
halted to assess the patient's stability and respiratory status.
If a patient is able to maintain adequate ventilation and vital signs, sedation will
be decreased or stopped.
It is important that the bedside nurse be part of these discussions.
Conclusion.
Evidence-based practices can reduce ventilator-associated pneumonia rates.
You should implement bundles for the management of the intubated patient.
Assess the need for the endotracheal tube every day.
Observe practice for compliance with policy.
Feedback infection rates to staff.
Establish policies for the insertion and maintenance of endotracheal tubes.
Educate doctors and nurses on ventilator-associated pneumonia prevention.
And communication training will help staff to speak up when practice to prevent ventilator-associated
pneumonia is not followed.
That concludes our video on prevention of ventilator-associated pneumonia.
Thank you.
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