Introduction

Ventilator-associated pneumonia (VAP) is among the most commonly bump into hospital-acquired infections in acute care units and is linked to high costs of care and morbidity. For decades, the pathophysiology, epidemiology, prevention, and treatment of VAP have been extensive; however, a clear prevention strategy is quite essential (Boltey et al., 2017). Effective clinical practice guidelines should serve as a framework for physicians, and other medical staffs to make decisions as well as support best practice for patient care optimization. However, if the guidelines are limited and fail to address all critical components of how to prevent VAP sufficiently, the validity and quality of those guidelinescan be reduced. In this article, the author will systematically review the current guidelines for ventilator‐associated pneumonia (VAP), evaluate their methodological quality as well as their recommendations for empirical de‐escalation strategies and establish if these proposed prevention strategies have led to clinically relevant outcomes.

Ventilator-associated pneumonia

Nosocomial pneumonia is a common infection categorized into two classes: Hospital-acquired pneumonia (HAP), which often develop in hospitalized patients following 48 hours of admission and does not need (though may include) artificial ventilation after diagnosis; and Ventilator-associated pneumonia, which happens among patients in  intensive care unit (ICU) who have received mechanical ventilation through  tracheostomy,or an endotracheal tube for over 48-hours(Sulis et al., 2014).VAPis caused by the invasion of lung parenchyma and the lower respiratory tract by microorganisms. Intubation compromises the integrity of the trachea and oropharynx as well as gastric and oral secretions to enter the lower airways. VAP is the most common cause of nosocomial infection in ICU while HAP is the second most prevalent hospital infection with the highest crude mortality. Early diagnosis, as well as the adoption of VAP prevention strategies, can decrease the development of multi-drug resistant organisms. VAP is associated with prolonged duration of stay in acute care, this increasing the patient management cost. Hence, it makes the VAP prevention a priority, especially in managing critically ill patients.

Ventilator associated pneumonia is an important topic, and its prevention is a notable concern in every hospital.  Most of the prevention and intervention strategies are part of daily nursing care. Nurses have a wide range of vital roles including evaluator, coordinator, educator, manager, and care provider in preventing VAP (Sulis et al., 2014).  Lack of knowledge regarding proper nursing care and infection prevention among registered nurses may become a hurdle in conforming to evidence-based guidelines and strategies for preventing VAP.

The occurrence of Ventilator-associated pneumoniais directly linked to the lack of experienced nurses, inadequate understanding and knowledge about the pathophysiology as well as risk factors concerning the development and prevention approaches of VAP. It is because, nurses working in ICU are in continuous contact with the patients, offering nursing care, performing nearly all mechanical ventilation procedures and guiding other people in contact with patients such as health workers, visitors, and students. Therefore, this topic will help advanced nurse practitioners to have a detailed knowledge about ventilator-associated pneumonia and its prevention strategies to allow them to apply the gained knowledge in their nursing roles.  Understanding VAP pathophysiology, its risk factors, as well as care bundle is critical for proper prevention and treatment of ventilator-associated pneumonia. There must be specific strategies, protocols, and active surveillance in each intensive care units in relation to care bundles and the provided guidelines by Klompas et al. (2014) aim to achieve that.

Addressing VAP topic would allow the author to be committed to reducing Ventilator-associated pneumonia, reducing stay of patients in acute care and improving the care quality for mechanically ventilated patients by coordinating as well as implementing these evidence-based practices.  According to Mogyoródiet al. (2016), VAP cases are preventable, and ventilator bundles have been proven effective in reducing the rates of VAP. Initiating and implementing a bundle for education and prevention of VAP are associated with a reduction in the risk and incidence of VAP. Nurse education is important, as it is associated with improved prevention strategies (Mogyoródiet al., 2016)

PICO/Clinical Questions

P:  The guidelines provided by Klompas et al. (2014), is basically to help nurses and other healthcare workers to improve outcomes for mechanically ventilated children, neonates, and adults.

I: Strategies to prevent VAP and other ventilator-associated events (VAE) in acute hospitals.

C: Strategies to prevent ventilator-associated pneumonia in acute care hospitals by Coffinet al. (2008).

O: More improved and advanced strategies for preventing ventilator-associated events.

Clinical question: Are the updated strategies for reducing VAP and other ventilator-associated events more effective and advanced than strategies proposed by Coffin et al. (2008)?

Guideline Overview

The guidelines first note that patients on mechanical ventilation are at higher risks for VAP and other serious complications such as lobar atelectasis,pulmonary embolism, pulmonary edema, pneumothorax, and acute respiratory distress syndrome. It also notes that VAP is associated with the increased mortality rate, increased patient’s duration of mechanical ventilation, extended stay in ICU and overall hospital stay duration, increased anti-microbial and higher direct medical cost. The guideline provides interventions that improve objective outcomes with minimal negative effect, outcome neutral interventions but cost effective, innervations that lower rates of VAP but with little evidenced based research, and interventions that improve objective, however, has some risks. It also recommends the innervations to be and not to be considered for adoptions (Klompas et al., 2014)

The guideline providescertain strategies for each group of patient proposed (adult,  infants and children, and preterm neonates. The basic practices to prevent VAP and other VAEs in adult include reduction of sedation, avoiding intubation if possible,  maintaining and improving physical conditioning, reducing pooling of secretions above the endotracheal tube cuff, maintaining ventilator circuits, and elevating the head of the bed to 30-45 degrees. The special approaches include using selective decontamination of the oropharynx to minimize the aero-digestive tract microbial burden, administer prophylactic probiotics, and performing care with chlorhexidine. Approaches generally not recommended for adults include prone positioning, kinetic beds, silver-coated prophylaxis, early tracheotomy, early parental nutrition, and stress ulcer prophylaxis(Klompas et al., 2014). The guideline does not provide a recommendation for closed/in line endotracheal suctioning approach. For the PretermNeonates, the guideline offers the following approaches to preventing VAP and VAP. The basics proposed include using non-invasive positive pressure ventilation in a selected population, reducing mechanical ventilation duration, assess willingness to  extubate daily, avoiding sedation, avoiding unplanned extubation, reduce breaks in the ventilator circuit, providing daily oral care with sterile water, and  replace the ventilator only if a malfunction or soiled. The special approaches include Lateral recumbent positioning, Closed/in-line suctioning systems, and reverse trendelenburg positioning. The generally not recommended method includes the use of antiseptics for oral care, daily spontaneous breathing trials, prophylactic broad-spectrum antibiotics, silver-coated endotracheal tubes, and prophylactic synbiotics and probiotics. In addition, the guidelines for infants and children the basics approaches such as using non-invasive positive pressure, avoiding unplanned extubations, daily oral care, elevate the bed’s head to 30-45 degrees, using cuffed endotracheal tubes, replacing ventilator circuits only if necessary. Special approaches include avoiding daily sedation, prophylactic probiotics. Generally not recommended include selective digestive decontamination or oropharyngeal and systemic antimicrobial therapy. Not recommended is closed/in suctioning(Klompas et al., 2014)

Critique of the Guideline

The guideline is developed using evidenced based studies and the methods proposed have been studied and proven effective. Proposed methods such as Subglottic suctioning endotracheal tubes, Head of the bed elevation, the use of Subglottic suctioning endotracheal tubes, Antimicrobial-coated endotracheal tubes, Selective digestive tract decontamination, Oral decontamination, and Probiotics are evidence based and have shown to provide a positive outcome (Keyt et al., 2014). In addition, the team that developed the guideline are academic scholars with vast experience in the medical field and research.  The body that developed the guideline, The Society For Healthcare Epidemiology of America (SHEA)  is a well-known professional body that improves public health by creating infection prevention measures as well as antibiotic stewardship among providers of healthcare.  The guideline creation has relied on about 241 most relevant peer reviewed healthcare journals on the prevention of VAP, indicating how elaborative and proven the methods are.  The guideline is an improvement of Coffin et al. (2008).  These peer reviews have exhaustively discussed nearly all the methods proposed, done evidenced based research to prove their effectiveness and come up with precise strategies.  The guideline used several randomized, double-blind placebo-controlled clinical trial, severalsystematic reviews, and meta-analysis, systematic review jour, randomizedstudies to develop the strategies indicating how accurate and precise the proposed strategies are. The recent guidelines from the various organization were also considered to avoid needles redundancy.

The proposed guideline will improve the quality of healthcare offered to patients in acute care especially those in the mechanical ventilator.  It will also help prevent ventilator-associated pneumonia, and other healthcare acquired infections. The guideline will reduce mortality rates, the risk of other infections, and reduce patient harm as well as exposure to needless antibiotics and minimize the development of antibiotic resistance.  It also provides evidence based strategies on the most effective as well as management of non-immuno compromised patients with VAP/HAP.  It will also help nurses to know about VAP prevention strategies in detail to enable them to apply the knowledge in nursing practice for VAP/HAP prevention. The guideline is patient centered as it targets to reduce the rate of infection in the acute care system and ensure nurses offer quality care to patients.

The guideline is worth being implemented since it provides strategies that are  evidence based and have been indicated to reduce Associated Healthcare infections such as VAP and HAP. The guideline is precise and all-inclusive. I would implement the strategy the way it is without making any changes since it covers nearly everything that is required now.  The guideline provided strategies to be used to prevent occurance of HAP/VAP in the acute care setting. The strategies provided are detailed, evidence based and have been proven to  produce a positive outcome.

In conclusion, the article systematically reviewed the current guidelines for ventilator‐associated pneumonia (VAP) by Klompas And associates (2014), evaluate their methodological quality as well as their recommendations for empirical de‐escalation strategies and establish if these proposed prevention strategies have led to clinically relevant outcomes.

References

Boltey, E., Yakusheva, O., & Costa, D. K. (2017). 5 Nursing strategies to prevent ventilator-associated pneumonia. American nurse today, 12(6), 42-43.

Coffin, S., Klompas, M., Classen, D., Arias, K., Podgorny, K., & Anderson, D. et al. (2018). Strategies to Prevent Ventilator-Associated Pneumoniain Acute Care Hospitals. Infection Control And Hospital Epidemiology, 29(1), 31-40. doi: 10.1086/591062

Keyt, H., Faverio, P., &Restrepo, M. I. (2014). Prevention of ventilator-associated pneumonia in the intensive care unit: a review of the clinically relevant recent advancements. The Indian journal of medical research, 139(6), 814-21.

Klompas, M., Branson, R., Eichenwald, E., Greene, L., Howell, M., & Lee, G. et al. (2014). Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update. Infection Control & Hospital Epidemiology, 35(08), 915-936. doi: 10.1086/677144

Mogyoródi, B., Dunai, E., Gál, J., &Iványi, Z. (2016). Ventilator-associated pneumonia and the importance of education of ICU nurses on prevention – Preliminary results. Interventional medicine & applied science, 8(4), 147-151.

Sulis, C., Walkey, A., Abadi, Y., Campbell Reardon, C., & Joyce-Brady, M. (2014). Outcomes of a ventilator-associated pneumonia bundle on rates of ventilator-associated pneumonia and other health care-associated infections in a long-term acute care hospital setting. American Journal Of Infection Control, 42(5), 536-538. doi: 10.1016/j.ajic.2014.01.020

https://www.researchgate.net/publication/305843315_Strategies_to_Prevent_Ventilator-Associated_Pneumonia_in_Acute_Care_Hospitals_2014_Update

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