Week 12 - Topic 4: Ventilator-Associated Pneumonia Flashcards
What are 2 measures to prevent aspiration?
1) Encourage use of noninvasive ventilation (ex: CPAP or BiPAP)
2) Encourage use of orotracheal tube vs nasotracheal
Why are CPAP and BiPAP non invasive?
They push air into the lungs through the outside rather than through an inside tube
Why would we prefer orotracheal tube rather than nasotracheal?
To diminish risk sinusitis and aspiration pneumonia
How is mechanical ventilation done (2 methods)?
1) Positive pressure (artificial airway): air pushed into the lungs through an endotracheal tube providing oxygen
2) Negative pressure (no artificial airway): mimics ventilation by externally pushing the lungs –> iron lung
What are complications with intubation related to the stomach?
Stress ulcers and GI hemorrhage (rare 1%)
Why do we discourage using prophylactic agents that could reduce stress ulcers?
Increases risk of C dif
How can you prevent VAP?
Extubate when no longer needed
Where does a nasogatric tube end up in?
Esophagus
Where does and endotracheal tube (entry: mouth) end up in?
Trachea
What is at the end of an endotracheal tube once its in the trachea?
A cuff that is inflated to make sure tube stays in place
What is dangerous about the inflated cuff?
Secretions filled with organisms can pool at the top of the cough and go down into the lungs when the cuff is deflated or the tube moves
What are the 4 areas of oropharyngeal colonization?
1) Lips and gums
2) Tongue
3) Teeth
4) Mucous membranes secretions
What is dangerous about oropharyngeal areas with regards VAP? What must you do?
They can create a biofilm onto the tube and go down into the tubes
Clean the mouth with 0.5% chlorhexidine to reduce mouth flora
What is dangerous about suctioning with regards to VAP?
When you suction, you instill normal saline to wash down the trachea. The water and microorganisms can go down into the lungs
A person with green sputum is most likely to be infected with which bacteria?
Pseudomonas colonizing the oropharynx
What are 7 hospital-acquired bacteria causing VAP?
Gram -:
1) Pseudomonas aeruginosa
2) Serratia marcescens
3) Klebsiella spp
4) Acetinobacter spp
Gram +:
5) Staph areus
6) Strep pneumoniae
7) MRSA
According to a study, 50% of patients develop pneumonia from what type of colonization?
Oropharyngeal colonization
Name 6-7 risk factors for VAP
- Intubation (nasal or oral)
- Immobility
- Lying flat in bed
- Gastric distension
- Nasogastric tubes
- Inadequate P in the cuff = easy self-extubation
- Frequent manipulation of ventilator circuits
- Suctioning/instillation of normal saline
- Prolonged ventilator support
- Health conditions (asthma, COPD, emphysema)
Name 6-7 ways to prevent VAP
- Inspect skin and oral mucosa for skin breakdown and flora buildup
- Change tube ties when wet or every 24h
- Rotate oral tube from one end of the mouth to the other
- Lubricate lips to prevent drying
- Mouth care**: oral chlorhexidine 0.5% as mouth rinse every 2-4h and as needed
- Ensure cuff P is measured and recorded on a regular basis
- Take measures to prevent accidental extubation (ensure adequate sedation)
- HOB at 30-45° or reverse Trendelenburg
- Hand hygiene prior to touching NG or suction
- Use dominant hand + sterile glove for hand exposed to secretions
When do you use reverse trendelenburg position as opposed to HOB at 45°?
- Low BP, unstable VS
- Agitated and at risk of falling out of bed
- Compromised circulation from femoral lines
- Spinal cord injury
When do you use high level disinfection vs low level?
High level: for internal surfaces that touch mucous membranes
Low level: for external surfaces
How and when do you clean the external ventilator machine?
Low level disinfection
Clean frequently touched surfaces every shift
How and when do you clean and change circuit/tubing?
High level disinfection
Do not change routinely to avoid manipulation and dislodging fluid, policies vary from 3-7 days.
Change the circuit when it is visibly soiled or malfunctioning.
How and when do you clean humidifiers and nebulizers?
Cleaned and then High level disinfection
Fill humidifiers with sterile water
How often do you change heat moisture exchangers?
Every 48h+
What bacteria may live in the condensate of ventilator circuit tubing?
Serratia sp
Pseudomonas sp
Burkodelia sp
Change bacterial filters every 48h if they are used!
Why do you used Closed Condensation Traps during active humidification?
- Permits drainage without opening the circuit
- Reduces manipulation
- Prevents external contamination
How are you supposed to drain the condensate and why?
Away from the patient to reduce dumping into the pt’s airways
How do you prevent gastric reflux in pts with NG tube?
- Monitor gastric residual volumes before initiating gastric feedings
- Remove NG tubes as soon as possible
- Advocate for post-pyloric feeds (PEG)
Why should a nurse advocate for PEG and what is it?
A tube going through the abdominal wall into the stomach to feed pt
–> Shorter feed time, prevents over-distension and preserves peptic acidity that kills bacteria
When using a bottle of sterile water to clear catheter during suctioning, when should you discard it?
Ideally, after every use
At the end of shift if you have a good technique to keep it sterile (ex: not keeping it open for a long time, not contaminating the bottle or cap)
How should you open a bottle of sterile water?
Using the no touch technique to decant
How often do you change the tubes for open vs closed suctioning?
Open: dispose after every use (since they are single use)
Closed: change when blocked or soiled
How can you prevent conjunctivitis when suctioning patients?
Do not remove suction catheter over the eyes of patient who might receive fallen droplets
For premature babies, cover the eyes
Provide eye care to prevent corneal ulcers and dryness
Where do you store Yankauer oral suction catheters?
In a protective cover, not on ventilator or under patient’s pillow
What type of suctioning do we use for patients who have been intubated for a very long time (>3 days)?
Subglottic secretion suctioning done every 2h
What is sedation vacation?
Lighten up or interrupt sedation a few times
Can reduce overall intubation time
What should you monitor when doing sedation vacation?
- Monitor for increased tone and poor synchrony with the ventilator
- Monitor for self-extubation and desaturation
- Monitor for pain and anxiety
What is excellent practice with regards to immobility in intubated patients?
Deep vein thrombosis prevention = passive exercises, turning, stockings
