(Panchabhai et al., 2009) states that twice daily oral cleansing with a 0.2% chlorhexadine solution does not decrease the incidence of nosocomial pneumonia in general ICU patients. However, meticulous oral cleansing seems to decrease the risk of the development of pneumonia regardless of the content of solution used for this purpose. More studies using a higher concentration of chlorhexadine (>2%) are required to establish the role of routine antiseptic oral cleansing in ICU patients. More recently, studies have been done on early interventions and the development of VAP. Many ideas and techniques have been revisited, such as standard use of personal
IDENTIFYING A RESEARCHABLE PROBLEM: VENTILATOR ASSOCIATED PNEUMONIA 6 protective equipment, adequate hand washing before and after contact with each patient, staff education and bundles implemented to prevent the development of VAP. These bundles as stated by Institute for Healthcare Improvement (IHI) are a series of interventions that when implemented have proven to reduce the incidence of VAP and include, maintaining the head of bed (HOB) to at least 30-45 degrees, oral cleansing with chlorhexadine at least every two hours, deep vein thrombosis (DVT) prophylaxis, peptic ulcer disease prophylaxis and daily sedation vacations. Other suggestions have been made that implementing continuous suctioning of subglottic secretions may help to reduce the risk of VAP. The CDC has noted a lower incidence (13% versus 29%) and a delayed onset (8.3 days versus 16.2 days) with the use of continuous subglottic suctioning of secretions in the development of VAP. This randomized study showed no effect on mortality, length of stay in the ICU, or duration of mechanical ventilation (CDC, 2003). This type of study needs to be performed on a larger scale and include a cost versus benefit approach, to justify the increased cost when using continuous suctioning in mechanically ventilated patients. Another approach to help prevent micro-aspiration of secretions into the lungs is to maintain the ETT cuff pressure to no less than 20cmH20 (trachea ischemia occurs when pressure are 30 cm H20 or higher) in order to prevent leakage of bacterial pathogens around the cuff (Xue, 2008). Frequent changes of the ventilator circuit tubing (the tubing that connects the patient’s ETT and the ventilator) could have an impact on patient’s acquiring VAP. Suggestions have been made to only change the circuits when visibly soiled and not routinely to minimize the spillage of condensate into the lungs (Koenig & Truwit, 2006). Studies have shown that the
IDENTIFYING A RESEARCHABLE PROBLEM: VENTILATOR ASSOCIATED PNEUMONIA 7 incidence of VAP is not any higher in patients whose ventilator circuits were not changed for the duration of their mechanical ventilation as compared to those that were changed routinely.
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- Fall '15
- Intensive care medicine, Chlorhexidine, ventilator-associated pneumonia, VAP, researchable problem