Routine Oral Care Positioning to

¶ … Routine Oral Care Positioning to Prevent Ventilator Acquired Pneumonia Ventilator acquired Pneumonia: Ventilator associated pneumonia or VAP is one of the main infections that are acquired by patients in an ICU. The disease affects about half of the patients who get an infection in an ICU.

When the disease starts, the result is that the patients will have a longer duration of stay in the hospital, which will result in a higher cost of the stay in the hospital as also a higher rate of mortality when compared to other patients who have not suffered this disease. (Afessa, 2004) One of the biggest impacts of ventilators is to increase the chances of pneumonia and there are very important results.

"Patients with VAP had other statistically significant outcomes that indicate they fare poorly compared to patients without VAP: on average, 9.6 additional days on mechanical ventilation, 6.1 additional days in the ICU, and 11.5 additional days in the hospital. The in patient billed charges were also significantly higher among patients with VAP, averaging > $40,000 more compared to patients without VAP." (The Impact of VAP and the role of Improved Oral Care) This is the finding from an important study and there are opinions of other experts to the same effect.

The disease is bacterial pneumonia and the disease takes place when the general pulmonary defense systems do not function as they should or are not able to function due to a high presence of bacteria. In the case of an adequately healthy person, the physical shape of the respiratory tract prevents most of the inhaled or aspirated microorganisms from reaching the alveoli which is required for pneumonia.

There is existing bacterial flora in the upper respiratory tract and they also act as a defense to the reach of pathogens from the oropharynx and colonizing the same. When the patients become sick, the composition of the oropharyngeal flora changes and becomes of a much more virulent type from the regular type. This then leads to their invasion of the lower respiratory tract and the procedure is through bolusaspiration of oropharyngeal organisms.

There may also be inhalation of air borne bacteria from other sources, or a hematogenous spread of the bacteria when the source is a long distance away. (Schleder, 2003) According to experts, aspiration is the main risk for patients with HAP and the type of patients may be those with low levels of consciousness, nasogastric or endotracheal tubes, mechanical ventilation, enteral feeding, gastric disease, surgery or trauma. It is also possible that the concerned bacteria have come from extraneous devices to the lower respiratory tract.

The process is inhalation of aerosols through contaminated respiratory equipment like nebulization devices and humidifiers. The contamination of equipments cause great difficulty to patients who have existing tubes for endotracheal and tracheal areas as these tubes are then directly in touch with the lower respiratory tract which is the area from where the difficulties start. The problems may also start due to defects with the persons in touch with the patients or defects in their procedure of dealing with patients.

When oral bacteria manage to get into lungs, and this may come even from other individuals, then also it may lead to aspiration pneumonia. Getting into the exact figures for these cases, it has been seen that the pathogens start appearing in the oral fluids of two thirds of the patients who have been using tubes for 24 hours.

After that period of 24 hours, most parts of the suction equipment has most of the same bacteria living inside the equipment in colonies, though they have come from the secretions of the patient. Thus when there is a nasogastric tube, there are greater chances of increase of nosocomial sinusitis. The increase in sinusitis in turn increases the chances of HAPA. When the patient is absolutely supine, this requires an increase of aspiration and thus the duration of supine position is a consideration for increase of the risk.

(Schleder, 2003) Oral care to reduce ventilator acquired Pneumonia The result is that hospitals are now trying out measures to stop this infection that comes from the mouth and this requires more oral care. The patients were being given suction to remove fluids along with the brushing of teeth with a toothbrush and using a swab inside the mouth. This method helps the nurses as they do not have to use a separate catheter for suction while still using methods to clean the insides of the mouth of the patients.

Most patients who are in an intensive care unit are already on ventilators and in a totally sedated condition. They are not able to swallow. That is the reason why it becomes the duty of the nurse to remove the fluid inside the mouth of the patient, clean the teeth of the patients, the insides of their mouths and generally moisturize to enable the patient be comfortable.

(Oral Care Products Used to Prevent VAP) Other methods are to elevate the patients head, using proper hand hygiene when touching the patient and taking patients off the ventilator as much as possible. The reason that ventilator acquired pneumonia comes is that bacteria inside the patient's mouth are in a position to colonize the insides of their mouths with the help of dental plaque and other fluids. Pneumonia comes from the infections that exist in the hospitals.

When oral swabbing, brushing of teeth and rinsing are done, those actions are expected to reduce the bacteria present so that they cannot get inside the lungs and cause infection. The level of this infection in intensive care units can vary from 6% to 54%. The effect of infections is to increase the death rates from 20% to nearly 50%. Now there is an extra attention of the regulatory agencies and consumers on the functioning of hospitals and this means that hospitals must take extra care for stopping this infection.

(Oral Care Products Used to Prevent VAP) There are chances of microscopic tears in gloves which result in spread of germs to a large extent. The best method of removing these germs is to take off the gloves and wash hands thoroughly with soap and water. To prevent infections there has been a recommendation of vaccination for high risk VAP patients in CDC's Guidelines for Preventing Healthcare-Associated Pneumonia, 2003. Another suggested change is using of orotracheal tubes instead of nasotracheal tubes.

This is a recommendation for the prevention of bacterial pneumonia and the main recommendation is for building a barrier against ventilator associated pneumonia. The pneumonia is related to assist ventilation mechanically. The recommendation is a part of CDC guidelines. Some doctors dealing with these cases prefer not to use tubes whenever possible and according to them if the patient can breathe without any tubes in the throat, the chances of infections would become much lower.

(Breathing easy) One of the places where changes have been implemented through oral care and there have been improvements is the surgical intensive care unit at Vanderbilt Medical Center in Nashville, Tennessee. The incidence of ventilator assisted pneumonia was increasing at this hospital from 1999 to 2001. This led the center to start using comprehensive oral care from January 2002 as a part of a total program to remove the incidence of ventilator assisted pneumonia from the center.

The change began to give perceptible results to the therapists and the nurses within a period of months. The changes were noted and within a two-year period, there was a reduction of ventilator assisted pneumonia by as much as 46%. When the figures for 2002 are compared to figures for 2001, there is a clear decrease by 35% and there is another decrease that is seen in 2003 when compared to the figures of 2002.

There is now the use of a kit supplied which provides a Yankauer, suction toothbrushes, suction oral swabs, oropharyngeal catheters, cleaning solutions and mouth moisturizer. Each one of these kits are used on the patients for a period of 24 hours, and this is felt to be the main reason for the reduction of the disease. In earlier years, the hospital used only little sponges or swabs to clean the general area near the mouth and no brushes were used to remove plaque.

It seems that there is a general feeling among doctors that the reason for ventilator assisted pneumonia is plaque. (Miller, 2004) It is not enough to just provide oral care - it is also important to decontaminate all items that are in contact with the patients. It has been seen that many of the items that are used for therapy, or administration of anesthesia used for the respiratory tract can also get contaminated and then they will form the source for future infection.

This can be avoided through establishment of proper rules applicable to the hospital for cleaning of such items, sterilization and change of device. There are CDC guidelines for this purpose and they recommend washing with sterile water, allowing the equipment to dry completely and ensure that routine changing of disposable equipment is carried out.

(Schleder, 2003) Elevating heads of beds for patients on mechanical ventilation Along with the recommendations for removal of plaque, there is also a guideline made by CDC that for proper treatment to "elevate at an angle of 30 to 45 degrees the head of the bed of a patient at high risk for aspiration." The benefits elevation of the head of the bed is on the theory that then gravity will reduce the possibilities of regurgitation that exists in an overly distended stomach.

The recommendation by CDC also clearly states that the patients should not be lying flat unless there is some clinical need for that. At the same time, some medical authorities feel that this is likely to make the patients uncomfortable, though the recommendation is from CDC. This makes them reduce the angle of laying the patients bed at a lower angle than the angle specified by CDC.

(Breathing easy) For patients likely to be infected with VAR there are two main factors - colonization of the oropharynx and the aspiration of bacteria. When the patients are on mechanical ventilation then if the head of the bed is elevated by 30 degrees to 45 degrees, then there is a significant decrease in gastroesophageal reflux and aspiration. According to the experience of some hospitals, this practice should be taken up in all hospitals and all such patients unless there are signs of clear contraindications.

These may be cases like cervical fracture or large bore femoral catheters. This is clearly an easy method to adopt. The practice also should not add to the costs of caring for patients, and the method to be adopted can be taken up directly by the nursing personnel and does not require an approval from the physician before implementation. The simple method of raising the head of the bed can reduce the chance of the patient getting VAR.

(Preventing Ventilator associated Pneumonia) Other precautions We know that the occurrence of pneumonia is quite high and there are also some very simple methods that can be used to reduce the chances of patients getting the disease. Another simple care that can be taken is to stop all visitors who show some symptoms of any respiratory infection to visit the wards of cardiac patients or immuno-suppressed patients. Another method is to ensure that all hospital personnel in these areas are also given inactivated influenza vaccine during October of every year.

This includes the night and weekend staff. The benefit is likely to be less chances of infection coming from that area. During the entire season when influenza occurs,.