Week 12 - Topic 4: Ventilator-Associated Pneumonia

Question 1

What are 2 measures to prevent aspiration?

Answer 1

1) Encourage use of noninvasive ventilation (ex: CPAP or BiPAP)
2) Encourage use of orotracheal tube vs nasotracheal

Question 2

Why are CPAP and BiPAP non invasive?

Answer 2

They push air into the lungs through the outside rather than through an inside tube

Question 3

Why would we prefer orotracheal tube rather than nasotracheal?

Answer 3

To diminish risk sinusitis and aspiration pneumonia

Question 4

How is mechanical ventilation done (2 methods)?

Answer 4

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

Question 5

What are complications with intubation related to the stomach?

Answer 5

Stress ulcers and GI hemorrhage (rare 1%)

Question 6

Why do we discourage using prophylactic agents that could reduce stress ulcers?

Answer 6

Increases risk of C dif

Question 7

How can you prevent VAP?

Answer 7

Extubate when no longer needed

Question 8

Where does a nasogatric tube end up in?

Answer 8

Esophagus

Question 9

Where does and endotracheal tube (entry: mouth) end up in?

Answer 9

Trachea

Question 10

What is at the end of an endotracheal tube once its in the trachea?

Answer 10

A cuff that is inflated to make sure tube stays in place

Question 11

What is dangerous about the inflated cuff?

Answer 11

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

Question 12

What are the 4 areas of oropharyngeal colonization?

Answer 12

1) Lips and gums
2) Tongue
3) Teeth
4) Mucous membranes secretions

Question 13

What is dangerous about oropharyngeal areas with regards VAP? What must you do?

Answer 13

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

Question 14

What is dangerous about suctioning with regards to VAP?

Answer 14

When you suction, you instill normal saline to wash down the trachea. The water and microorganisms can go down into the lungs

Question 15

A person with green sputum is most likely to be infected with which bacteria?

Answer 15

Pseudomonas colonizing the oropharynx

Question 16

What are 7 hospital-acquired bacteria causing VAP?

Answer 16

Gram -:

1) Pseudomonas aeruginosa
2) Serratia marcescens
3) Klebsiella spp
4) Acetinobacter spp

Gram +:

5) Staph areus
6) Strep pneumoniae
7) MRSA

Question 17

According to a study, 50% of patients develop pneumonia from what type of colonization?

Answer 17

Oropharyngeal colonization

Question 18

Name 6-7 risk factors for VAP

Answer 18

• 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)

Question 19

Name 6-7 ways to prevent VAP

Answer 19

• 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

Question 20

When do you use reverse trendelenburg position as opposed to HOB at 45°?

Answer 20

• Low BP, unstable VS
• Agitated and at risk of falling out of bed
• Compromised circulation from femoral lines
• Spinal cord injury

Question 21

When do you use high level disinfection vs low level?

Answer 21

High level: for internal surfaces that touch mucous membranes

Low level: for external surfaces

Question 22

How and when do you clean the external ventilator machine?

Answer 22

Low level disinfection

Clean frequently touched surfaces every shift

Question 23

How and when do you clean and change circuit/tubing?

Answer 23

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.

Question 24

How and when do you clean humidifiers and nebulizers?

Answer 24

Cleaned and then High level disinfection

Fill humidifiers with sterile water

Question 25

How often do you change heat moisture exchangers?

Answer 25

Every 48h+

Question 26

What bacteria may live in the condensate of ventilator circuit tubing?

Answer 26

Serratia sp
Pseudomonas sp
Burkodelia sp

Change bacterial filters every 48h if they are used!

Question 27

Why do you used Closed Condensation Traps during active humidification?

Answer 27

• Permits drainage without opening the circuit
• Reduces manipulation
• Prevents external contamination

Question 28

How are you supposed to drain the condensate and why?

Answer 28

Away from the patient to reduce dumping into the pt’s airways

Question 29

How do you prevent gastric reflux in pts with NG tube?

Answer 29

• Monitor gastric residual volumes before initiating gastric feedings
• Remove NG tubes as soon as possible
• Advocate for post-pyloric feeds (PEG)

Question 30

Why should a nurse advocate for PEG and what is it?

Answer 30

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

Question 31

When using a bottle of sterile water to clear catheter during suctioning, when should you discard it?

Answer 31

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)

Question 32

How should you open a bottle of sterile water?

Answer 32

Using the no touch technique to decant

Question 33

How often do you change the tubes for open vs closed suctioning?

Answer 33

Open: dispose after every use (since they are single use)

Closed: change when blocked or soiled

Question 34

How can you prevent conjunctivitis when suctioning patients?

Answer 34

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

Question 35

Where do you store Yankauer oral suction catheters?

Answer 35

In a protective cover, not on ventilator or under patient’s pillow

Question 36

What type of suctioning do we use for patients who have been intubated for a very long time (>3 days)?

Answer 36

Subglottic secretion suctioning done every 2h

Question 37

What is sedation vacation?

Answer 37

Lighten up or interrupt sedation a few times

Can reduce overall intubation time

Question 38

What should you monitor when doing sedation vacation?

Answer 38

• Monitor for increased tone and poor synchrony with the ventilator
• Monitor for self-extubation and desaturation
• Monitor for pain and anxiety

Question 39

What is excellent practice with regards to immobility in intubated patients?

Answer 39

Deep vein thrombosis prevention = passive exercises, turning, stockings