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| <div class="noeditbox">Welcome to [[Glasgow Caledonian University Cardiorespiratory Therapeutics Project]] This project is created by and for the students in the School of Physiotherapy at Glasgow Caledonian University. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox"> | | <div class="editorbox"> |
| '''Original Editors '''- [[Glasgow Caledonian University Cardiorespiratory Therapeutics Project|Students from Glasgow Caledonian University's Cardiorespiratory Therapeutics Project.]] | | '''Original Editors '''- [[Glasgow Caledonian University Cardiorespiratory Therapeutics Project|Students from Glasgow Caledonian University's Cardiorespiratory Therapeutics Project.]] |
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| '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | | '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} |
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| == Definition/Description == | | == Introduction == |
| | [[File:Multidrug-resistant Klebsiella pneumoniaeand neutrophil.jpeg|thumb|Multidrug-resistant bacteria and WBC]] |
| | Hospital-acquired [[pneumonia]] (HAP) is defined as pneumonia that occurs 48 hours or more after hospital admission and is not incubating at hospital admission. |
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| '''Distinguishing between pneumonia and Hospital-acquired pneumonia '''
| | # Early-onset (occurring within 4 days of admission) HAP is usually caused by the same [[Bacterial Infections|bacteria]] and [[Viral Infections|viruses]] as community-acquired pneumonia and has a good prognosis. |
| | | # Late-onset (starting 5 days or more after admission) HAP has a worse prognosis and is usually caused by micro-organisms that are acquired from the hospital environment. MRSA, Pseudomonas aeruginosa and other non-pseudomonal Gram-negative bacteria are the most common causes."<ref>NICE [https://www.nice.org.uk/advice/esnm44 Hospital-acquired pneumonia caused by methicillin-resistant Staphylococcus aureus: telavancin] Available:http://www.nice.org.uk/advice/esnm44/chapter/full-evidence-summary (accessed 25.12.2022)</ref> |
| <br> '''Pneumonia'''
| | HAP is the second most common hospital acquired infection (see [[Healthcare-Associated Infections]]), catheter-associated [[Urinary Tract Infection|urinary tract infections]] being the most common.<ref name=":1">American [https://www.myamericannurse.com/preventing-hospital-acquired-pneumonia/ Nurse Preventing hospital-acquired pneumonia]Available:https://www.myamericannurse.com/preventing-hospital-acquired-pneumonia/ (accessed 25.12.20220</ref> |
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| “Pneumonia is an infection of the lung tissue. When a person has pneumonia the air sacs in their lungs become filled with microorganisms, fluid and inflammatory cells and their lungs are not able to work properly. Diagnosis of pneumonia is based on symptoms and signs of an acute lower respiratory tract infection, and can be confirmed by a chest X-ray showing new shadowing that is not due to any other cause (such as pulmonary oedema or infarction)." <ref name="NICE 2">http://www.nice.org.uk/guidance/cg191/resources/cg191-pneumonia-costing-statement2</ref><br>(NICE clinical guidelines 2014)
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| '''Hospital-acquired pneumonia'''
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| "Hospital-acquired pneumonia is defined as pneumonia that occurs 48 hours or more after hospital admission and is not incubating at hospital admission. Early-onset (occurring within 4 days of admission) hospital-acquired pneumonia is usually caused by the same bacteria and viruses as community-acquired pneumonia and has a good prognosis. Late-onset (starting 5 days or more after admission) hospital-acquired pneumonia has a worse prognosis and is usually caused by micro-organisms that are acquired from the hospital environment. MRSA, Pseudomonas aeruginosa and other non-pseudomonal Gram-negative bacteria are the most common causes."<ref>http://www.nice.org.uk/advice/esnm44/chapter/full-evidence-summary</ref>
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| (NICE Guidelines. Published: 15 July 2014) | |
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| == Epidemiology == | | == Epidemiology == |
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| “At any time 1.5% of hospital inpatients in England have a hospital-acquired respiratory infection, more than half of which are hospital-acquired pneumonia and are not associated with intubation. Hospital-acquired pneumonia is estimated to increase hospital stay by about 8 days and has a reported mortality rate that ranges from 30–70%. Variations in clinical management and outcome occur across the UK.”<ref name="NICE 2" />
| | # HAP is a common cause of pneumonia in those admitted to [[Physiotherapists Role in ICU|intensive care units]] (ICU) or on mechanical [[Ventilation and Weaning|ventilation]]. 9/10 cases of HAP develope in ICUs occur in patients who are intubated and mechanically ventilated. |
| | | # The elderly are more are risk of developing HAP.<ref>Radiopedia [https://radiopaedia.org/articles/hospital-acquired-pneumonia-1?lang=us Hospital-acquired pneumonia] Available:https://radiopaedia.org/articles/hospital-acquired-pneumonia-1?lang=us (accessed 24.12.2022)</ref> |
| (NICE guidelines 2014)
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| Ventilator-acquired pneumonia (VAP) has been studied more comprehensively than HAP. A clear reason for this is VAP is responsible for 86% of the HAP reported (Masterston). <br>
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| The incidence rate of HAP is between 3 and 10 per 1000 hospital admissions (Kieninger, 2009, Stolbrink 2014)
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| Mortality rates from VAP are between 24 and 50% (Masterston) but it is reported to jump to 76% if it is caused my multi drug resistant pathogens (mastersotn) that are often linked to later stage pneumonia (> 5days in hospital). Although it is difficult to determine the exact cause of death in critically ill patients, which will cause discrepancies in any date, Liapikou reports that accurate antibiotics taken at the right time has shows to lower mortality rate for HAP.
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| <br>The chance of infection is estimated to be 3%/day during the first 5 days of ventilation, followed by 2%/day up to day 10 of ventilation and there- after 1%/day.
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| (American Thoracic Society 2005)<br><br> | |
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| == Aetiology ==
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| The most common cause is an accumulation of bacteria, most ordinarily gram-negative bacilli and staphlycoccus aureus, which inhabit the oropharynx and upper airways in seriously ill and ventilated patients. A less common cause is seeding of the lung due to bacteremia; a bacterium that originates in the patients’ blood supply and is transferred to the lungs during gas exchange. Finally inhalation of bacterially contaminated aerosols which transport airborne particles containing Legionella sp, Aspergillus sp, or influenza virus, although this is a relative unfamiliar form of contracting hospitalized pneumonia.
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| <br>Endotracheal intubation and other forms of mechanical ventilation poses the greatest overall risk. Ventilation Associated Pneumonia is a subcategory of hospitalized and contributes more than 85% of all cases, with pneumonia occurring in up to 27% of ventilated patients. Endotracheal intubation related bacteria embed themselves deep into the endotracheal tube cuff enabling them to avoid the body nature immune response while also providing a biofilm of protection from antibiotics.
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| <br>In nonintubated patients, risk factors include previous antibiotic treatment, high gastric pH, resulting from cardiac, pulmonary, hepatic, or renal deficiencies. Major risk factors for postoperative pneumonia are patients older than 70, abdominal or thoracic surgery, and cardiorespiratory functional depletion.
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| == Investigations ==
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| General investigations are not necessary for the majority of patients who are managed in the community. Pulse oximeters allow for simple assessment of oxygenation. When a patient is admitted to hospital:
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| '''FBC with differential white cell count: '''<br>Total white blood cells: All the white cell types are given as a percentage, and as an absolute number per liter. A high WBC is often an indicator of infection (Osei‐Bimpong et al).<br>CRP (to aid diagnosis and as a baseline measure). The C-reactive protein (CRP) test is a diagnostic tool that identifies regions of inflammation (Tracy et al). CRP is a protein manufactured in the liver before dispersal into the blood which occurs a few hours after any form of tissue injury, an acute manifestation of infection, or inflammation caused by another source (Tracy et al). The CRP test can be used in adjunction with signs, symptoms and other tests in order to fully evaluate patients with HAP (Tracy et al).
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| <br>'''Blood cultures: '''<br>Blood culture is a microbiological culture of blood. It is employed to detect infections that are spreading through the bloodstream (such as bacteremia, septicemia amongst others). <br>Pneumococcal and legionella urinary antigen tests: <br>Urine tests are administered and designed to locate the presence of both Streptococcus pneumoniae and Legionella species (Marcos et al). Two major pathogens in HAP, which also play a key role in community acquired Pneumonia. The tests are usually in conjunction with both sputum examination and blood testing due to their high specificity (Marcos et al).
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| <br>'''CXR: '''<br> HAP may deliver signs of abnormal opacity in specific areas of the lungs, or even clear consolidation due to inflammation causing abnormal positioning of structures, such as the trachea and mediastinum (Pugin et al).
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| '''Sputum examination and culture. ''' <br>Sputum Examination is a diagnostic tool used to identify bacteria and fungi located in the pulmonary facet (Musher et al). Samples are often obtained through expectorating or in some cases an induced saline can produce the required volumes from lab testing. HAP normally produces sputum in a thick and purulent form, which is common in more cases of infection (Musher et al).
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| <br>'''Blood gases: '''<br>Blood gases will demonstrate how well both the respiratory and the renal systems are functioning (Marc et al). In terms of HAP ABG’s can be used to gain insight into the patient’s oxygen saturation levels as well as demonstrate incidences of both acidosis and alkalosis, both of which can occur due to poor ventilation (Marc et al).
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| <br>'''Aspiration of pleural fluid (for biochemistry and culture). '''<br>Chest aspiration is a diagnostic tool used to investigate the cause of pleural fluid or to improve respiration rates that have dropped due to accumulated fluid (Blackmore et al). Samples of the pleural fluid are sent for analysis which includes cytology for malignant cells and bacteriology for identification of foreign bacteria (Blackmore et al). <br>
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| == Clinical Manifestations<br> ==
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| A patient that develops new or extra pulmonary infiltrates and a fever are signs of HAP. In order to differentiate HAP and other pathologies diagnosis should be based on a radiographic x-ray. To diagnose HAP radiological opacity with alveolar condensation must be present.<ref name="Rello, J.">Rello, J., Vidaur, L., Díaz, E., &amp;amp;amp; Rodríguez, A. (2007). Management of Hospital-Associated Pneumonia in the Intensive Care Unit. In Infectious Diseases in Critical Care (pp. 449-455). Springer Berlin Heidelberg.</ref>
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| The time of onset of HAP is a large determinate of the type of bacteria causing the infection:
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| '''Early-onset HAP''' ''occurring in the first 4 days of hospitalization) is often caused by community-acquired pathogens such as'': <br>Haemophilus influenzae, <br>Streptococcus pneumoniae, or <br>methicillin-susceptible S aureus (MSSA). <br>In this context, pathogens with strong intrinsic or acquired antimicrobial resistances are rarely causative.
| | == Clinical Manifestations == |
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| '''Late-onset HAP''' ''developing ≥ 5 days after hospitalization is often caused by aerobic Gram-negative bacilli such as:''<br>P aeruginosa, <br>Enterobacteriaceae, or <br>Acinetobacter) or <br>Methicillin-resistant Staphylococcus aureus (MRSA) Late-onset pneumonia is due to P aeruginosa, Acinetobacter, or MRSA in 30 to 71% of cases.<br>
| | # Symptoms of HAP: includes cough, expectoration, [[Fever|a rise in body temperature]], chest pain or [[Dyspnoea|dyspnea]]. |
| | # Signs include of HAP include: fever, tachypnea, consolidations or crackles.<ref name=":2">Shebl E, Gulick PG. Nosocomial Pneumonia. InStatPearls [Internet] 2021 Jul 21. StatPearls Publishing.Available;https://www.ncbi.nlm.nih.gov/books/NBK535441/#!po=22.7273 (accessed 25.12.2022)</ref> |
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| | For more see [[Pneumonia]] |
| == Physiotherapy and Other Management == | | == Physiotherapy and Other Management == |
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| Physiotherapy and other management. Other health professionals will be treating your patient. What is their input?When addressing HAP, respiratory physiotherapy interventions should be individually tailored around the patient’s symptoms, observing aspects such as degree of pain, mobility capabilities and an array of complex factors (Denehy & Berney). Therefore techniques may include positional manipulations (addressing V/A matching and attempting to uses gravity to potentially enable drainage), manual hyperinflation, percussion, shaking, vibrations, suctioning (if huffing or cough promoting techniques are proving ineffective in regards to sputum extraction), breathing exercises including thoracic expansion and relaxing tidal volumes, while also engaging sputum reduction through active cycle and autogenic drainage techniques) as well as mobilization (Denehy & Berney). The later of course demonstrating great importance not only in terms of improving the patients’ respiratory distress, but also in reducing overall hospitalization.
| | Other health professionals will be treating your patient. What is their input? When addressing HAP, respiratory physiotherapy interventions should be individually tailored around the patient’s symptoms, observing aspects such as degree of pain, mobility capabilities and an array of complex factors<ref name="denehy">Denehy L, Berney S. [https://www.researchgate.net/publication/233585155_Denehy_L_Berney_S_Physiotherapy_in_the_intensive_care_unit_Phys_Ther_Rev_20061149-56 Physiotherapy in the intensive care unit.] Physical Therapy Reviews. 2006;11(1):49. Available: https://www.researchgate.net/publication/233585155_Denehy_L_Berney_S_Physiotherapy_in_the_intensive_care_unit_Phys_Ther_Rev_20061149-56 (accessed 25.12.2022)</ref>. |
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| <br> Published substantial evidence very much supports the role of physiotherapy in the respiratory managing HAF, demonstrating both short-term and longer term benefits (Denehy & Berney). However, its essential to promote physiotherapy treatment as part of a multi-disciplinary approach as aspects including pharmaceutical interventions play an integral part in controlling bacterial diseases, promoting lung function and reducing problematic symptoms (Berney & Denehy 2). | |
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| == Prevention ==
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| Three European societies, (European Respiratory Society (ERS), European, Society of Clinical Microbiology and Infectious Diseases (ESCMID) and European Society of Intensive Care Medicine (ESICM), in 2008 produced a report to further the clinical guidelines of HAP and VAP. Within these guidelines they outline several measures that can have proven to reduce the likelihood of HAP.
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| '''Generally recommended general measures:'''
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| *Alcohol-based hand disinfection
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| *Use of microbiologic surveillance
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| *Monitoring and early removal of invasive devices
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| *Programs to reduce antimicrobial prescriptions
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| *Generally recommended specific measures
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| *Avoidance of endotracheal intubation
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| *Avoidance of reintubation
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| *Preference of noninvasive ventilation (NIV)
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| *Preference of orotracheal intubation and orogastric tubes
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| *Maintenance of the ET cuff pressure at approximately 20 cmH2O
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| *Avoidance of flushing the condensate into the lower airway or to in-line medication nebulizers Patient positioning (semirecumbent position)<ref>Torres, A., Ewig, S., Ruhrgebiet, T., und Augusta-Kranken, E. K. H., Bochum, A., Lode, H., ... & Saint Joseph, G. H. P. DIAGNOSING, TREATING AND PREVENTING HOSPITAL ACQUIRED PNEUMONIA: A EUROPEAN PERSPECTIVE. Intensive Care Med (2009) 35:9–29</ref>
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| (Torres et al. 2008)
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| '''Additional measures which might be helpful in distinct settings and populations:'''
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| *Continuous aspiration of subglottic secretions
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| *Endotracheal tubes coated with antiseptics or silver
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| *Preference of heat-moisture exchangers (HMEs) over heater humidifiers (HH)
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| *Oral decontamination
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| *Selective decontamination of the digestive tract (SDD)<ref>Torres, A., Ewig, S., Ruhrgebiet, T., und Augusta-Kranken, E. K. H., Bochum, A., Lode, H., ... & Saint Joseph, G. H. P. DIAGNOSING, TREATING AND PREVENTING HOSPITAL ACQUIRED PNEUMONIA: A EUROPEAN PERSPECTIVE. Intensive Care Med (2009) 35:9–29</ref>
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| (Torres et al. 2008)
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| Torres, A., Ewig, S., Ruhrgebiet, T., und Augusta-Kranken, E. K. H., Bochum, A., Lode, H., ... & Saint Joseph, G. H. P. DIAGNOSING, TREATING AND PREVENTING HOSPITAL ACQUIRED PNEUMONIA: A EUROPEAN PERSPECTIVE. Intensive Care Med (2009) 35:9–29
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| As VAP is a cause of 85% of HAP, goals aims to reducing VAP will reduce the incidence rate of HAP.
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| A literature review by Masterton et al. 2008 highlighting the use of the 4 E’s, Engagement, education, execution, and evaluation. It offers a guide for the translation of evidence into practice. Each ‘E’ has it own subtitles as shown below:
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| '''Engagement:'''<br>Develop a multidisciplinary team<br>Involve local champions<br>Encourage peer networking<br>'''Education'''<br>Hold educational sessions<br>Provide educational materials<br>'''Execution'''<br>Standardise care processes<br>Create redundancy<br>'''Evalauation'''<br>Measurement of performance<br>Feedback on outcome to staff
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| Masterton, R. G., Galloway, A., French, G., Street, M., Armstrong, J., Brown, E., ... & Wilcox, M. (2008). Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy, 62(1), 5-34.
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| <br> | | Substantial evidence supports the role of physiotherapy in the respiratory managing HAP, demonstrating both short-term and longer term benefits<ref name="denehy" />. |
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| Encouraging this system of implementation offers a pragmatic approach to implementing change and advancing staff knowledge and techniques. With due diligence incidences of VAP could be heavily reduced.
| | Techniques may be found here [[Respiratory Physiotherapy]] and [[Respiratory Physiotherapy for ICU Patients]] Examples include: |
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| '''The VAP Guidelines Committee and the Canadian Critical Care Trials group in 2008 recommended several approaches to encourage a reduction in incidences:'''
| | * [[Manual Hyperinflation|Manual hyperinflation]] |
| | * Percussion, shaking, vibrations, |
| | * [[Suctioning]] (if huffing or cough promoting techniques are proving ineffective in regards to sputum extraction), |
| | * [[Breathing Exercises|Breathing exercises]] |
| | * Mobilization<ref name="denehy" />. <br> |
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| *The orotracheal route of intubation should be used when intubation is necessary
| | == Prognosis == |
| *There should be no scheduled ventilator circuit changes but new circuits for each patient, and changes if the circuits become soiled or damaged
| | HAP is linked with increased death rates. The death rates associated with VAP ranges from 20% to 50% in different studies.<ref name=":2" /> |
| *Changes of heat and moisture exchangers with each patient, also every 5-7 days and as clinically indicated
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| *Closed endotracheal suctioning system, and that the system is changed for each patient and as clinically indicated.
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| *The use of subglottic secretion drainage in patients expected to be mechanically ventilated for > 72hrs
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| *Bed head to be elevated to 45°. If this angle is not possible then as much elevation as possible is recommended
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| *The use of oral antiseptic chlorhexidine
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| *The use of oral antiseptic povidone-iodione should be considered with patients with severe head injury
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| *Rotating beds should be considered
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| | == Prevention == |
| | Several basic nursing interventions are associated with reducing HAP risk— |
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| == Resources <br> == | | * Following infection prevention standards |
| | * Elevating the head of the bed 30 to 45 degrees to prevent aspiration |
| | * Seeing to good oral hygiene (cleaning teeth, gums, tongue, dentures) |
| | * Increasing patient mobility with ambulation to eg three times a day (as appropriate) |
| | * Educating patient re coughing and deep breathing, and use of incentive spirometry.<ref name=":1" /> |
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| '''NHS website'''<br>http://www.nhs.uk/conditions/pneumonia/Pages/Introduction.aspx
| | For more see [[Infection Prevention and Control]] |
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| '''Patient website'''<br>http://www.patient.co.uk/health/pneumonia-leaflet<br>
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| == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
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| '''Chest physiotherapy for the prevention of ventilator-associated pneumonia'''<br>'''Objective''': Study on whether chest physiotherapy designed to enhance sputum clearance has the capacity to decreases the occurrence of VAP. <br>'''Methods''': Sixty adult patients intubated and mechanically ventilated for at least 48 h. Chest physiotherapy (intervention group) or sham physiotherapy (control group) was administered. Control and intervention groups were well matched for age, sex, and admission PaO2/FiO2 ratio, APACHE II score, and Glasgow Coma Score. There were no differences in the duration of mechanical ventilation, length of stay in ICU or mortality. VAP was assessed daily by combined clinical assessment and the clinical pulmonary infection score. <br>'''Results''': VAP occurred in 39% (14/36) of the control group and 8% (2/24) of the intervention group.<br>'''Conclusion''': In this small trial, chest physiotherapy in ventilated patients was independently associated with a reduction in VAP. However, more research must be implemented in order to confirm findings and deliver more in-depth findings in regard to exact treatment parameters and techniques. <ref name="Ntoumenopoulos">Ntoumenopoulos, G., J. Presneill, M. McElholum, and J. Cade. "Chest physiotherapy for the prevention of ventilator-associated pneumonia." Intensive care medicine 28, no. 7 (2002): 850-856.</ref> <br><br>
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| <div class="researchbox">
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| '''Effects of manual hyperinflation and suctioning on respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia. '''<br>'''Objective''': This study aims to investigate the effect of tracheal on respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia. <br>'''Methods''': Fifteen adult patients with ventilator-associated pneumonia were recruited and acted as their own controls. Manual hyperinflation followed by suction (manual hyperinflation plus suction) and suction alone were applied consecutively, in random order, on two occasions, four hours apart. Respiratory variables, CL and RAW, were measured five times and the averaged value documented. <br>'''Results''': CL increased by 22% and RAW decreased by 21%, up to 30 minutes after manual hyperinflation plus suction, but not after suction alone.<br>'''Conclusion''': This study suggests that manual hyperinflation in conjunction with suction induces beneficial changes in respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia. <ref name="Choi">Choi, Jessica Siu-Ping, and Alice Yee-Men Jones. "Effects of manual hyperinflation and suctioning on respiratory mechanics in mechanically ventilated patients with ventilator-associated pneumonia." Australian Journal of Physiotherapy 51, no. 1 (2005): 25-30.</ref><br>
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| </div>
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| == References == | | == References == |
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| see [[Adding References|adding references tutorial]].
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| <references /> | | <references /> |
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| [[Category:Glasgow_Caledonian_University_Project]] | | [[Category:Glasgow_Caledonian_University_Project]] |
| | [[Category:Acute Care]] |
| | [[Category:Cardiopulmonary]] |
| | [[Category:Older People/Geriatrics]] |
| | [[Category:Acute Respiratory Disorders - Conditions]] |
| | [[Category:Older People/Geriatrics - Conditions]] |
