1. PNEUMONIA
Mohammad reza rajabi
Bachelor of science in anesthesia
Master of science in critical care
Tehran university of medical sciences
1

2. ‫پنومونی آتیپیک(غیر نمادین اکتسابی از جامعه)‬
‫بیماری تنفسی حاد تب دار با تغییرات التهابی ریه‬ ‫‪‬‬
‫محدود به تیغه های آلوئولی و بافت بینابینی ریه‬ ‫‪‬‬
‫واژه آتیپیک:‬
‫بیانگر تولید خلط متوسط ، فقدان یافته های فیزیکی دال بر تراکم نسج ریه،‬
‫افزایش ‪ ، WBC‬فقدان اگزودای آلوئولی‬
‫علت: مایکوپالسما پنومونیه ( در بچه ها و بالغین جوان شایع تر)‬
‫مکانیسم بیماری زایی:‬
‫اتصال ارگانیسم به اپیتلیوم تنفسی و سپس نکروز سلولی ، واکنش التهابی،‬
‫ریزش اپیتلیوم تنفسی، مهار عمل جاروبی مژه های مخاطی، زمینه ساز‬
‫عفونت ثانویه باکتریال‬
‫2‬

3. ‫درمان پنومونی ویروسی‬
‫بی تاثیر‬ ‫‪ ‬آنتی بیوتیک ها در عفونت های ویروسی‬
‫درمان حمایتی :‬
‫تب و تاکی پنه باعث دفع نامحسوس مایع می شود‬ ‫‪ ‬مایع درمانی‬
‫بهبود تب و سردرد‬ ‫‪‬داروی ضد تب‬
‫بهبود سرفه‬ ‫‪‬ضد سرفه‬
‫کاهش التهاب مجاری تنفسی‬ ‫‪‬بخور گرم‬
‫کاهش عطسه و آبریزش بینی‬ ‫‪‬آنتی هیستامین‬
‫3‬

4. ‫درمان پنومونی‬
‫♠ تجویز آنتی بیوتیک مناسب بر حسب تعیین گرم میکروب‬
‫♠ تجویز سریع آنتی بیوتیک در طی 8-4 ساعت در بیماران مشکوک به‬
‫کلید درمان‬ ‫‪CAP‬‬
‫♠ در پنومونی پنوموکوکی: ادامه درمان 27 ساعت بعد از قطع شدن تب‬
‫♠ در پنومونی با علل باکتریال : ادامه درمان 2-1 هفته بعد از قطع شدن تب‬
‫♠ در پنومونی آتیپیک : درمان 12-01 روز طول می کشد.‬
‫4‬

5. ‫پنومونی آسپیراسیون‬
‫‪ Ω‬ناشی از آسپیراسیون مواد آندروژن و اگزوژن به راه های هوایی تحتانی‬
‫‪ Ω‬شایع ترین نوع : عفونت ناشی از آسپیراسیون باکتری های مستقر در راه های‬
‫هوایی فوقانی‬
‫‪ Ω‬هم در بیمارستان و هم در جامعه اتفاق می افتد.‬
‫عوامل دیگر:‬ ‫عوامل بیماری زا:‬
‫محتویات معده‬ ‫استرپتوکوک پنومونیه‬
‫مواد شیمیایی اگزوژن‬ ‫هموفیلوس آنفلونزا‬
‫استافیلوکوک آرئوس‬
‫5‬

6. ‫تظاهرات بالینی پنومونی‬
‫تدریجی، غیر اختصاصی‬ ‫شروع عالیم پنومونی‬
‫‪ ‬تب و لرز ، سردرد ، درد پلورتیک ،درد عضالنی ، فارنژیت ، خستگی ، تعریق شبانه ،‬
‫خلط موکوسی یا موکوسی – چرکی ، سیانوز مرکزی( لب ها و بستر ناخن ها:عالمت تاخیری‬
‫هیپوکسی) ، ارتوپنه ، تاکی پنه ، سرفه‬
‫بررسی و یافته های تشخیصی:‬
‫تاریخچه‬
‫معاینات جسمی‬
‫رادیوگرافی‬
‫کشت خون‬
‫بررسی خلط‬
‫6‬

7. ‫انواع روش های جمع آوری خلط‬
‫1. شستن دهان با آب (کاهش فلور طبیعی دهان) ، چند بار نفس عمیق ، انجام‬
‫سرفه ، ریختی خلط در ظرف استریل‬
‫ساکشن بینی – تراشه ای‬ ‫2.‬
‫ساکشن دهانی – تراشه ای‬ ‫3.‬
‫بوسیله برونکوسکوپی فیبراپتیک‬ ‫4.‬
‫7‬

8. ‫پنومونی در بیماران با نقص سیستم ایمنی‬
‫‪‬مصرف کورتیکواستروئید ها‬
‫‪‬شیمی درمانی‬
‫‪‬نقصان تغذیه‬
‫‪‬آنتی بیوتیک های وسیع الطیف‬
‫‪‬ایدز‬
‫انواع :‬
‫‪‬پنومونی حاصل از پنوموسیتیس کارینی(‪) PCP‬‬
‫‪‬پنومونی قارچی‬
‫‪‬پنومونی حاصل از مایکوباکتریوم نوبرکلوزیس‬
‫عالئم بالینی:‬
‫تب ، سرفه بدون خلط ، تنگی نفس‬
‫8‬

9. ‫پنومونی‬
‫بیماری التهابی پارانشیم ریه که توسط عوامل مختلف میکروبی ایجاد می شود.‬
‫شایع ترین علت مرگ ناشی از بیماری های عفونی در ایاالت متحده‬
‫ساالنه 00066 نفر در اثر این بیماری می میرند و هفتمین علت مرگ در امریکا‬
‫است.‬
‫9‬

10. ‫طبقه بندی پنومونی‬
‫طبقه بندی چهارگانه:‬
‫باکتریال یا تیپیک‬
‫آتیپیک‬
‫غیرهوازی – حفره ای‬
‫فرصت طلب‬
‫نوع دیگر طبقه بندی:‬
‫پنومونی اکتسابی از جامعه(‪) CAP‬‬
‫پنومونی اکتسابی از بیمارستان (‪) HAP‬‬
‫پنومونی در افراد مبتال به نقص سیستم ایمنی‬
‫پنومونی ناشی از آسپیراسیون‬
‫01‬

11. ‫پنومونی اکتسابی از جامعه‬
‫منشا : باکتریال‬
‫به دنبال عفونت ویروسی دستگاه تنفسی فوقانی(شروع آن ناگهانی)‬
‫شایع ترین علت‬ ‫علت : استرپتوکوک پنومونیه( پنوموکوک)‬
‫عالئم :‬
‫تب باال‬
‫لرز‬
‫درد پلورتیک‬
‫سرفه خلط دار با خلط موکوسی - چرکی‬
‫11‬

12. ‫سایر ارگانیسم های دخیل در پنومونی حاد اکتسابی از جامعه‬
‫1( هموفیلوس آنفلوانزا( شایع ترین علت باکتریال تشدید ‪ ) COPD‬شایع ترین‬
‫ویروس ایجاد کننده پنومونی در نوزادان و بچه ها‬
‫موراکسال کاتارالیس ( تشدید حاد ‪) COPD‬‬ ‫2(‬
‫استافیلوکوک طالئی ( با شیوع باالی عوارض مثل آمپیم و آبسه های ریوی )‬ ‫3(‬
‫کلبسیال پنومونیه ( شایع ترین عامل پنومونی باکتریال گرم منفی)‬ ‫4(‬
‫پسودومونا آئروژینوزا‬ ‫5(‬
‫6( لژیونال پنوموفیلیا‬
‫21‬

13. Health Care–associated Pneumonia
numerous outpatients benefit from health care
services such as dialysis, chemotherapy, or
ambulatory surgery. Similarly, in most nursing
homes and rehabilitation hospitals, patients can
receive intensive and/or invasive medical
therapies
13

14. Four Classes Of Pneumonia
1. Community-acquired pneumonia
2. Ventilator-associated pneumonia
3. Hospital-acquired pneumonia
4. Health care–associated pneumonia
14

15. Community-acquired Pneumonia
(CAP)
 common infectious disease affecting about 1 per 1,000
of the adult population per year.
 An intensive care unit (ICU) admission for severe
CAP is required for 2% of patients
 most frequent pathogen is Streptococcus pneumoniae
 Despite progress in antibiotic therapy
mortality remains elevated
15

16. Diagnosis Of Community-acquired Pneumonia
clinical symptoms:
1.cough 2.dyspnea
3.sputum production 4.pleuritic chest pain
5.elevated body temperature.
These symptoms can be absent or moderated in older
patients.
not specific signs of pneumonia;
a chest radiograph or computed tomography (CT) scan
revealing a new infiltrate
16

17. Chest Radiograph Allows
1.staging of severity
localization
number of involved lobes.
2.detect complications
pleural effusion
Cavitation
acute respiratory distress syndrome [ARDS]
17

18. Definition Of Severe CAP
one of two major criteria :
need for mechanical ventilation
septic shock
two of three minor criteria :
systolic blood pressure < 90 mm Hg
multilobar involvement on chest radiograph
 PaO2/FiO2 < 250 mm Hg)
18

19. Assessing The Severity Of CAP
Four “core” factors )CURB score(:
Confusion
blood Urea nitrogen > 19 mg/dL [7 mmol/L]
Respiratory rate > 30 breaths/minute
Blood pressure—systolic < 90 mm Hg or diastolic <60 mm Hg)
two “additional” factors :
hypoxemia (SpO2 < 92% or PaO2 < 60 mm Hg [8kPa]
bilateral or multilobar involvement on chest radiograph
two “pre-existing” factors :
age 50 years or older
the presence of coexisting disease
19

20. CAP Was Considered Severe
When Any One Of The Following Criteria Was
Present:
1. Respiratory frequency greater than 30 breaths per minute on admission
2. Severe respiratory failure (PaO2/FiO2 <250 mm Hg)
3. Requirement for mechanical ventilation
4. Bilateral or multilobar or extensive (greater than or equal to 50%
within 48 hours of admission) involvement of the chest radiograph
5. Shock (systolic blood pressure less than 90 mm Hg or diastolic blood
pressure less than 60 mm Hg)
6. Requirement for vasopressors for more than 4 hours
7. Low urine output (less than 20 mL/hour or less than 80 mL/4 hours) or
acute renal failure requiring dialysis
20

21. Diagnostic Studies
1.Sputum stains and cultures
2.endotracheal aspiration
3.protected brush
4.bronchoalveolar lavage
5.transtracheal aspiration
6.Blood cultures
drawn before antibiotic therapy, are rarely positive (6%–20% of
cases) and, when positive, are most often for S. pneumoniae,
Staphylococcus aureus, and Gram-negative bacilli.
21

22. Specific Etiologies In Immunosuppressed
Patients
♠ Immunosuppressed patients
have an increased risk of severe CAP
♠ Human immunodeficiency virus (HIV)
infected patients used to have a 25-fold higher risk of developing bacterial
pneumonia
♠ Patients with chemotherapy-induced neutropenia
( < 500 neutrophils/µL( & prolonged ) >10 days)
♠ Patients with solid organ transplant
♠ monoclonal antibody therapies
♠ Patients treated by anti–tumor necrosis factor (TNF) -
α monoclonal antibodies
22

23. Treatment Of Severe CAP
 Antimicrobial spectrum
The ideal antibiotic should have a “kill spectrum” to cover
all pathogens responsible for severe CAP
 Timing of initial therapy
administration within 4 hours of admission
23

24. Treatment Of Severe CAP…
Antimicrobial choices
β-Lactam antibiotics
cefotaxime
ceftriaxone
ampicillin
sulbactam)
 Macrolides
erythromycin
Clarithromycin
azithromycin
Fluoroquinolones
Levofloxacin
ciprofloxacin
Retrospective studies have suggested that some combination regimens 24

25. Treatment Of Severe CAP…
 pneumonia caused by S. pneumoniae Continue until the
patient has been afebrile for 72 hours
 Bacteria causing necrosis of the pulmonary parenchyma (e.g.,
S. aureus, P. aeruginosa, Klebsiella, and anaerobes) should
probably be treated for no less than 2 weeks.
 Pneumonia caused by intracellular organisms should probably
be treated for at least 2 weeks.
25

26. Treatment Of Severe CAP…
Nonantimicrobial Therapy
1.Activated Protein C
2.Corticosteroids
200 mg IV bolus followed by infusion at a rate of 10 mg/hour for 7
days
significant improvement in PaO2/FiO2 and chest radiograph score
& decreased length of hospital stay and mortality
26

27. Expected Clinical Course
Evaluation On Day 3
a decrease in fever and oxygenation requirements is not
observed in responding patients prior to day 3 or 4.
In the absence of rapid clinical deterioration, initial
therapy should not be changed prior to completion of 48
to 72 hours of the initial therapy.
27

28. Ventilator-associated Pneumonia
(VAP)
is defined as a pneumonia occurring in intubated or tracheotomized
patients undergoing mechanical ventilation. Although usual
guidelines suggest a delay of 48 to 72 hours between the beginning
of mechanical ventilation and the occurrence of pneumonia to
qualify for this diagnosis
28

29. Ventilator-associated Pneumonia (VAP)
 Defined: hospital-acquired pneumonia occurring
within 48 h after initiation of mechanical
ventilation with trachael intubation
 Diagnosis: Presence of a new, persistent, or
progressive infiltrate on a chest X-ray
29

30. Early And Late VAP
Time Pathogens
Early Onset Pneumonia that develops Usually include:
VAP between 48-96 hours after Staphylococcus aureus (Methicillin
being placed on the ventilator sensitive-MSSA)
Haemophilus influenza
Streptococcus pneumoniae
Late Onset Pneumonia that develops Usually include:
VAP after 96 hours )≥5 days) on Staphylococcus aureus (Methicillin
ventilator resistant – MRSA)
Pseudomonas aeruginosa
Acinetobacter or Enterobacter
30

31. Clinical Presentation Of Pneumonia
•Purulent secretions
•Densities on Chest x-ray
•Fever
•Leukocytosis (high wbc)

32. Why Are Ventilated Patients
More Susceptible To Pneumonia?
Normal Clearance Mechanisms and Reflexes are:
1. Air failtration
in nasal cavity
Bypassed
Blocked 2. Mucociliary
escalator
Inhibited 3. Cough
mechanism
32

33. “Aspiration of oropharyngeal
pathogens or leakage of
bacteria around the
endotracheal tube cuff is the
primary route of bacterial
entry into the trachea.”
33

34. Ventilator-associated Pneumonia
(VAP)
major dilemmas regarding VAP :
1. Prevention remains a challenge.
2. There is no gold standard for diagnosis.
3. The rate of multidrug-resistant causative pathogens
has dramatically increased during recent years.
4. Prompt initiation of an adequate antibiotic therapy is
essential.
34

35. Pathogenesis…
rarely associated with VAP :
1. Inhalation of gastric material
2. direct inoculation of bacteria into the lower respiratory tract
through contaminated “devices”
Aerosol
Bronchoscopes
ventilator circuit
Nebulizer
tracheal suctioning
36

36. Pathogenesis…
main route
Aspiration of bacteria colonizing the oropharynx is the main route of
entry into the lower respiratory tract.
Colonization of the oropharyngeal airways by pathogenic micro-
organisms occurs during the first hospital week in most critically ill
patients
The stomach, sinuses, and dental plaque may be potential reservoirs
for pathogens colonizing the oropharynx
37

37. Ventilator-associated Pneumonia
(VAP)
Risk Factors
♠ male gender
♠ pre-existing pulmonary disease
♠ coma
♠ AIDS
♠ head trauma
♠ age older than 60 years
♠neurosurgical procedures
♠ multiorgan system failure
♠ mechanical ventilation
impairs ciliary clearance and cough
limits the draining of secretions that leak around the cuff
♠ other devices
nebulizers or humidifiers
38

38. Increases The Risk Of VAP
1. Accidental extubation, rather than reintubation
2. administered by a nasogastric (rather than a postpyloric )
The nasogastric tube might increase the risk of reflux and subsequent
colonization of the airways
3. H2 blockers or antacids
favors gastric colonization and may contribute to VAP.
4. intracuff pressure less than 20 cm H2O
5.Tracheostomy
6.aerosol treatment
7.supine position
8.patient transportation out of the ICU
9.sedation
10.failed subglottic aspiration
39

39. Diagnostic Strategies And Diagnostic Testing
(VAP)
(a) the diagnosis of pneumonia must be established
fever or hypothermia
leukocytosis or leucopenia
Tachycardia
Purulent sputum
decline in oxygenation
pulmonary infiltrates on chest radiograph
40

40. Diagnostic Strategies And Diagnostic Testing
)VAP(…
b) the etiologic pathogen of this pulmonary parenchymal
infection must be identified
Blood cultures (rarely positive)
bronchoalveolar lavage (BAL)
endotracheal aspiration
protected specimen brush (PSB)
41

41. ‫درجهبندي شدت پنوموني و نیاز به درمان سرپایي یا بستري کردن بیمار و‬
‫پیشبیني مرگ ومیر معیار )‪)PORT‬‬
‫‪PNEUMONIA PATIENT OUTCOMES RESEARCH TEAM‬‬
‫34‬

42. ‫‪Pneumonia Patient Outcomes Research Team‬‬
‫میزان درجه بندی‬ ‫مشخصات بیمار‬
‫برابر سن بر حسب سال‬ ‫سن‬
‫01 سال منهای سن‬ ‫مرد‬
‫01 سال بعالوه سن‬ ‫زن‬
‫مدتی که در خانه تحت پرستاری بوده است‬
‫بیماری های همراه‬
‫03‬ ‫بیماری های سرطانی‬
‫02‬ ‫بیماری های کبدی‬
‫01‬ ‫بیماری های کلیوی،‪CVA ، CHF‬‬
‫یافته های بالینی‬
‫02‬ ‫اختالل هوشیاری،03>‪SBP<90 ، RR‬‬
‫51‬ ‫‪T<35OC,T>40OC‬‬
‫01‬ ‫521<‪PR‬‬
‫یافته های رادیوگرافیک یا آزمایشگاهی‬
‫03‬ ‫53/7<‪PH‬‬
‫02‬ ‫03>‪Na<130,BUN‬‬
‫01‬ ‫052>‪ ,PO2<60,Hct<30,BS‬پلورال افیوژن‬ ‫44‬

43. ‫براساس معیار:‪PORT‬‬
‫نمرهي زیر 07 به طور سرپایي‬
‫باالي 09 باید بستري شوند‬
‫آنها که 07 تا 09 ميباشند باید مدتي در اورژانس تحتنظر و راجع به بستري و‬
‫ترخیص بعداً تصمیمگیري شود.‬
‫54‬

44. Antibiotic Treatment
Principles of Initial Empiric Treatment
1. Prompt initiation of adequate antimicrobial treatment
is a cornerstone of therapy for VAP
2. Iregui et al. studied 107 patients suffering from VAP
33 received delayed appropriate antibiotic treatment—defined as a period
greater than or equal to 24 hours between the time VAP was suspected and
the administration of adequate treatment. These patients exhibited a
significantly higher mortality than those receiving nondelayed treatment
(69.7% vs. 28.4%; p <0.001).
46

45. Guidelines For Initial Empiric Antibiotic Therapy
On the basis of the time of onset of VAP and the presence
or absence of risks for multidrug-resistant pathogens
 In patients with no risk factors for multidrug-resistant
pathogens and an early-onset VAP (duration of
hospitalization less than 5 days), limited-spectrum
antibiotic therapy based on monotherapy seems
appropriate
 In patients with late-onset VAP (greater than or equal
to 5 days) or exhibiting risk factors for multidrug-
resistant pathogens, a broad-spectrum antibiotic regimen
based on two or three combined antibiotics is usually
required
47

46. Guidelines For Initial Empiric Antibiotic Therapy
1. Early-onset VAP and no risk factors for multidrug-resistant
pathogens
•Ceftriaxone (1–2 g/24 h) or
•Levofloxacin (750 mg/24 h), moxifloxacin (400 mg/24
h), or ciprofloxacin (400 mg/8 h) or
•Ampicillin (1–2 g) plus sulbactam (0.5–1 g)/6 h or
•Ertapenem (1 g/24 h)
48

47. Guidelines For Initial Empiric Antibiotic Therapy…
2. Late-onset VAP or risk factors for multidrug-resistant pathogens
•Antipseudomonal cephalosporin: Cefepime (1–2 g/8–12 h) or ceftazidime (2 g/8
h)
or
•Antipseudomonal carbapenem: Imipenem (500 mg/6 h or 1 g/8 h) or meropenem
(1 g/8 h)
or
•β-Lactam/β-lactamase inhibitor: Piperacillin-tazobactam (4.5 g/6 h)
plus
•Antipseudomonal fluoroquinolone: Levofloxacin (750 mg/24 h) or ciprofloxacin
(400 mg/8 h)
or
•Aminoglycosidea: Gentamicin (7 mg/kg/24 h) or tobramycin (7 mg/kg/24 h) or
amikacin (20 mg/kg/24 h)
plus
•Vancomycin (15 mg/kg/12 h)a
or
•Linezolid (600 mg/12 h)
49

48. Duration Of Therapy
 optimal duration was unknown
 experts empirically recommended a 14- to 21-day treatment
duration
 ATS/IDSA guidelines suggest shortening the duration of therapy
to 7 days
 8 - 15 days of antibiotic treatment were equally effective
A prospective, multicenter, randomized, double-blind trial was performed
Recent studies demonstrated that empiric antibiotic therapy could
be safely discontinued after 72 hours when a noninfectious etiology
for the pulmonary infiltrates is discovered or when signs and
symptoms of active infections resolve
50

49. Prognosis Of Ventilator-associated Pneumonia
 crude mortality rates : vary from 24% to 76%
 *malignancy *immunosuppression
*ASA grade 3 or more *age older than 64 years
*anticipated death within 5 years
 severity of disease justifying ICU admission
high APACHE II score
Simplify Acute Physiology Score greater than 37
51

50. Prognosis Of Ventilator-associated Pneumonia…
 initial severity of VAP
chest radiographic involvement of more than one lobe
platelet count <150,000 cells/µL
Logistic Organ Dysfunction score > 4
time of onset of VAP > 3 days
Surgery
Hypotension
 initial therapeutic approach (delayed initial
appropriate antibiotic treatment)
52

51. Prevention Of Ventilator-associated Pneumonia
£ hand washing
£ glove use
£ sterile equipment
£ Adequate staffing
£ When intubation is necessary, the orotracheal route is preferred
£ Use of Noninvasive positive pressure ventilation
£ reduce the duration of mechanical ventilation
£ Ventilator circuit management
£ optimized sedation and weaning protocols
£ semirecumbent (45-degree) patient position
£ Postpyloric feeding
£ Continuous aspiration of subglottic secretions
53

52. Measures Recommended By The Centers For Disease
Control And Prevention To Reduce The Incidence Of
Ventilator-associated Pneumonia
 Changing the breathing circuits of ventilators only when they
malfunction or are visibly contaminated
 Preferential use of orotracheal rather than nasotracheal tubes
 Use of noninvasive ventilation
 Use of an endotracheal tube with a dorsal lumen to allow
drainage of respiratory secretions
54

53. 55

54. Hospital-acquired Pneumonia
hospital-acquired pneumonia (HAP) :
 a pneumonia occurring less than 2 days from hospital
admission, but without any criteria defining ventilator-associated
pneumonia
 Mortality rate 18.8% and 53%
56

55. ‫پنومونی بیمارستانی (‪) HAP‬‬
‫‪‬عالئم آن 84 ساعت بعد از بستری شدن در بیمارستان تظاهر می یابد.‬
‫‪ % 15‬عفونت های بیمارستانی را به خود اختصاص می دهد.‬
‫‪‬کشنده ترین عفونت بیمارستانی‬
‫تظاهرات بالینی:‬
‫تب ، عالئم تنفسی ، خلط چرکی ، لکوسیتوز ، تاکی کاردی ، افیوژن پلور‬
‫شرایط مستعد کننده :‬
‫‪‬افراد دارای بیماری زمینه ای شدید‬
‫‪‬مصرف داروهای سرکوب کننده ایمنی‬
‫‪‬درمان آنتی بیوتیکی طوالنی مدت‬
‫‪‬تهویه مکانیکی‬
‫75‬

56. Health Care–associated Pneumonia And Nursing
Home Pneumonia
HCAN patients who :
 was hospitalized in an acute care hospital for 2 or more days
within 90 days of the infection
 resides in a nursing home or long-term care facility (LTCF)
 received recent intravenous antibiotic therapy, chemotherapy, or
wound care within 30 days of the current infection
 attends a hospital or hemodialysis clinic
58

57. Risk Factors In Nursing Home
 functional status
 diminished ability to clear airways
 underlying comorbidities (such as chronic obstructive
pulmonary disease and heart disease)
 swallowing disorders
 use of sedatives.
59

58. Etiology Of Nursing Home–acquired
Pneumonia
♠ S. pneumoniae
♠ H. influenzae
♠ Gram-negative bacilli
♠ S. aureus
60

59. CDC DEFINITION OF PNEUMONIA
Horan TC, Andrus M, Dudreck MA. CDC/NHSN surveillance definition of health-
care associated infection and criteria for specific types of infection in the acute care 61

60. Etiology- Select Risk Factors For
Pathogens
Streptococcus pneumoniae Smoking, COPD, absence of
antibiotic therapy
Haemophilus influenzae Smoking, COPD, absence of
antibiotic therapy
MSSA Younger age, Traumatic coma,
Neurosurgery
MRSA COPD, steroid therapy, longer
duration of MV, prior antibiotics
Pseudomonas aeruginosa COPD, steroid therapy, longer
duration of MV, prior antibiotics
Acinetobacter species ARDS, head trauma,
neurosurgery, gross aspiration,
prior cephalosporin therapy
Park DR. The microbiology of ventilator-associated pneumonia. 62

61. Objectives
 State the definition for ventilator associated
pneumonia (VAP)
 Define who is at greatest risk for the development of
VAP
 Describe effective strategies for reducing the
incidence of VAP
63

62. How Do We Diagnose? 2-1-2
 Radiographic evidence x 2 consecutive days
… New, progressive or persistent infiltrate
… Consolidation, opacity, or cavitation
 At least 1 of the following:
… Fever (> 38 degrees C) with no other recognized cause
… Leukopenia (< 4,000 WBC/mm3) or leukocytosis (> 12,000
WBC/mm3)
 At least 2 of the following:
… New onset of purulent sputum or change in character of secretions
… New onset or worsening cough, dyspnea, or tachypnea
… Rales or bronchial breath sounds
… Worsening gas exchange )↓ sats, P:F ratio < 240, ↑ O2 req.)
64

63. HOB Elevation > 30 Degrees On All Mechanically Ventilated
Patients
Contraindications
 Hypotension MAP <70
 Tachycardia >150
 CI <2.0
 Central line procedure
 Posterior circulation strokes
 Cervical spine instability use
reverse trendelenburg
 Some femoral lines ie: IABP no
higher than 30 degrees use reverse
trendelenburg
 Increased ICP, No higher than 30
degrees avoid hip flexion
 Proning 65

64. Continuous Infusions:
Daily Wake Up
 All infusions should be at the lowest rate to achieve
effect
 IV bolus therapy should be used to supplement
infusion when necessary
 Every patient must be awakened daily unless
contraindicated!
66

65. Daily Wake Up
 Wean infusion to off in increments of 10-25% daily
in order to perform a clinical assessment
 Rebolus and restart infusion if the patient becomes
symptomatic. Your new continuous IV dose should
be lower than what you began with
 Goal is to decrease sedation
67

66. Why?
Sedation Vacation
 Has been demonstrated to reduce overall patient sedation
 Promotes early weaning
Identified Issues and Concerns
 Increases potential for self-extubation
 Increases potential for patient pain and anxiety
 Increases episodes of desaturation
Anecdotal Experience
 Promotes early extubation
 No significant increase in patient self-extubation
68

67. Endotracheal Intubation
 Contributes to the development of VAP:
… Causes mucosal injury, producing decreased mucociliary
clearance
… Decreases effectiveness of cough
… Increases binding sites for bacteria
… Increases mucus secretion
… Provides a reservoir for bacteria
 Reintubation is a significant risk factor for VAP
69

68. Airway Management
 Mechanical ventilation
… Avoidance
 Mask ventilation trials
… Orotracheal intubation
 Nasotracheal intubation may slightly increase the risk for VAP
… Ventilator circuitry changes
 Change only when soiled or malfunctioning
… Cuff management
 Maintain at 25-30 cm H2O
70

69. Suctioning
 Oral suction devices (Yankauer)
… Policies for use and storage not written
… Harbor potentially pathogenic bacteria within 24 hours
… 71% of nurses store the device in its packaging (STAMP)
… Best practice???
 Change q day
 Rinse with sterile water or NS
 Allow to air dry
71

70. Subglottal Suctioning
 Should be done using a 14 Fr sterile suction catheter:
… Prior to ETT rotation
… Prior to lying patient supine
… Prior to extubation
 Continuous subglottic suctioning
… ETT with dedicated lumen to continuously or
intermittently suction above the cuff may reduce the risk
of VAP
72

71. Continuous Removal Of Subglottic
Secretions
Use an ET tube with
continuous suction
through a dorsal lumen
above the cuff to prevent
drainage accumulation.
73

72. Drainage Of Subglottic Secretions
74

73. Primary Route Of Bacterial Entry Into
Lower Respiratory Tract
 Micro or macro aspiration of
oropharyngeal pathogens
 Leakage of secretions
containing bacteria around
the ET cuff
75

74. Risks For MDR
American Thoracic Society, Infectious Diseases Society of America. Guidelines for
the management of adults with hospital-acquired, ventilator-associated, and
healthcare-associated pneumonia.
76

75. Pathophysiology Of Ventilator-associated Pneumonia
(VAP)
 Hospital-acquired (nosocomial) pneumonia:
pneumonia that occurs 48 hr or more after admission
to the hospital, and was not incubating at the time of
admission
 Healthcare associated pneumonia: pneumonia
associated with 2 or more days of hospitalization
within previous 90 days, residence in a nursing home
or long-term care facility, receipt of intravenous
antibiotic, chemotherapy, or wound care within the
previous 30 days, or attendance at a hospital or
hemodialysis clinic
 Ventilator-associated pneumonia:
pneumonia that develops more than 48-72 hr after
endotracheal intubation
77

76. Pathophysiology Of Ventilator-associated Pneumonia
(VAP)
 Sources of pathogens include the
environment (water and equipment) and
bacteria transferred between patients by staff
 Severity of underlying disease, prior surgery,
exposure to antibiotics, and use of invasive
respiratory equipment major risk factors
 Intubation and mechanical ventilation
increase the risk of hospital-acquired
pneumonia 6- to 21-fold
78

77. Pathophysiology Of Ventilator-associated Pneumonia
(VAP)
 Aspiration of oropharyngeal pathogens (aerobic
gram-negative bacilli, Staphylococcus aureus) by
leakage around the endotracheal tube cuff major
route of entry for bacteria into lower respiratory
tract
 Infected biofilm in the endotracheal tube with
subsequent embolization to distal airways may be
important
 Complications: drug-resistant pneumonia,
polymicrobial pneumonia, superinfection with
Pseudomonas aeruginosa or Acinetobacter with high
mortality, empyema, lung abscess, Clostridium
difficile colitis, occult infection, bacteremic sepsis
with multiple organ involvement
79

78. Pathophysiology Of Tuberculosis
(Chronic Pneumonia)
 Source of Mycobacterium tuberculosis an
infected patient with active pulmonary
disease
 M. tuberculosis transmitted by coughing,
sneezing, or talking with release of infected
respiratory secretion as aerosols (droplet
nuclei)
 Droplet nuclei (1-5 µm) penetrate deep
alveolar spaces and M. tuberculosis infects
non-immune macrophages as facultative
intracellular pathogens
80

79. Clinical Signs And Symptoms Of Atypical Pneumonia
Syndrome
 Sore throat and hoarseness initially
 Fever, malaise, coryza, headache, and cough with
variable sputum production
 Leukocyte >10,000/mm3 in ~20% of cases
 Chest X-ray usually indicates more extensive
pulmonary involvement than clinical findings suggest,
with unilateral or bilateral patchy infiltrates in a
bronchial or peribronchial distribution
 Extrapulmonary findings with Legionella
pneumophila: mental status changes, loose stools or
diarrhea, bradycardia, elevated liver enzymes,
hypophosphatemia, hyponatremia, elevated serum
lactate dehydrogenase, and elevated serum creatinine
levels
81

80. Clinical Signs And Symptoms Of Chronic
Pneumonia
 Initially fever, chills, and malaise
 Progressive anorexia and weight loss
 Pulmonary symptoms appear later with worsening
cough productive of sputum, dyspnea, hemoptysis,
and/or pleuritic chest pain
 Leukocyte count often normal (exceptions:
pancytopenia in miliary tuberculosis, neutrophilic
leukocytosis in pulmonary actinomycosis)
 X-ray findings: nodular or rounded lesions, cavities,
with characteristic involvement of upper lobes
(tuberculosis, histoplasmosis)
82

81. Specimen Collection, Staining, Evaluation, And
Culture
 Pharyngitis: throat swab
 Acute pneumonia: sputum
 Ventilator-associated pneumonia: bronchoalveolar lavage (BAL),
bronchial brushings
 Chronic pneumonia: sputum, BAL
83

82. Problem Identification
 Patients that are receiving continuous
mechanical ventilation have 6 to 21 times
greater risk of developing hospital-associated
pneumonia than patients not on mechanical
ventilation
Tablan OC, “Guidelines for preventing health-care--associated pneumonia, 2003,” Recommendations
of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC), 2003.
 According to an AJCC study, VAP occurs in 10 to
65% of ventilated critical care patients
 mortality rates between 20 and 70%
Sole ML, Am J Crit Care, 2002
84

83. Problem Identification
 A recent, 9,080-patient study found that the average VAP
patient spends 9.6 additional days on mechanical
ventilation, 6.1 extra days in the ICU, and
11.5 more days in the hospital
 And VAP costs over $40,000 per case to
treat—all paid for by the facility
Rello, Chest, 2002
85

84. VAP . . .WHAT IS IT?
Ventilator-Associated Pneumonia
Most common nosocomial bacterial
infection among patients requiring
mechanical ventilation
Rello, Chest, 2002
86

85. VAP
Increased mortality in critically ill
patients (20% - 70%)
Increased cost of care:
$40,000 additional cost per patient
CDC guidelines from Preventing Healthcare Pneumonias, 2003
AACN Practice alert
87

86. Risk Factors
For Developing VAP
Patients at extreme of age spectrum; malnutrition; severe
underlying conditions
Artificial airway
Colonization of dental plaque with respiratory pathogens
Bacterial colonization of the oropharyngeal area
Aspiration of subglottic secretions
Head of bed < 30 degrees
88

87. Risk Factors
For Developing VAP
 Colonization of Dental Plaque with respiratory pathogens
 Bacterial Colonization of the oropharyngeal area
 Aspiration of subglottic secretions
89

88. Recommended
Best Practice
 Water based moisturizers provide hydration
 Non-alcoholic oral rinses
 Mouthwash with hydrogen peroxide actives naturally
occurring peroxidase which resists bacterial
colonization in the oral pharynx
Nursing Mgt., Vol. 34, Supplement 3, May 2003
90

89. Recommended
Best Practice
 Soft bristle toothbrush removes plaque and
stimulates the mucosa
 Sodium bicarbonate toothpaste overcomes odor,
dissolves mucous, eliminates breeding ground for
bacteria, and reduces acidity
 Mouthwash with an antiseptic agent has an
antimicrobial effect on the oral cavity
Nursing Mgt., Vol. 34, Supplement 3, May 2003
91

90. Albert, NEJM 1981; Preston, AJM 1981; Tablan, 1994
92

91. In the absence of medical contraindication(s).
CDC Guideline for Prevention of Healthcare Associated Pneumonias, 2003
Drakulovic et al, Lancet, 1999,354:1851
93

92. Oral Cavity
 Suction the oral cavity
 Swab the oral cavity every 4 hours and PRN to cleanse
and maintain oral mucosal integrity
 Moisturize oral cavity every 4 hours
94

93. Brush Teeth
 Brush teeth 2 times per day to remove dental plaque
95

94. Oropharyngeal Suctioning
 Suction every 12 hours to remove secretions from the
oropharyngeal area above the vocal cords.
96

95. Nosocomial Pneumonia
 Second most common nosocomial infection in US
… 15% of all hospital-associated infections
… incidence range from 4.2 to 7.7/1000 discharges
 Associated with substantial morbidity and mortality: VAP mortality can
reach 60% in ICU
 Risk Factors for nosocomial pneumonia
… extremes of age
… severe underlying disease
… immunosuppression
… depressed sensorium
… cardiopulmonary disease
… thoracic-abdominal surgery
… mechanically assisted ventilation
97

96. Nosocomial Infections
Lower Respiratory Infections
Modifiable Risk Factors
 Strong evidence  Some evidence
… Avoid over sedation
… Semi-recumbent
… Avoid paralytics
… Noninvasive
… Closed suctioning
ventilation
… Orotracheal
… Continuous lateral intubation
rotation … Maintain adequate
cuff pressures
… Subglottic
… Avoid H2
suctioning antagonists 98

97. What Is VAP?
 A nosocomial pneumonia associated with mechanical
ventilation that develops within 48 hours or more of hospital
admission and which was not developing at the time of
admission
- early onset VAP
- late onset VAP
Langer M. et al. Intensive Care Med 1987;13:342-6
99

98. Why Do We Care?
 Hospital acquired pneumonia (HAP) is the second most
common hospital infection
 VAP is the most common intensive care unit (ICU) infection
(10-20%)
 90% of all nosocomial infections occurring in ventilated
patients are pneumonias
100

99. Diagnosis And Treatment Of
Ventilator-associated Pneumonia
Avoid
overtreatment
Immediate
without VAP
treatment of
patients with
VAP
Objective 1
Objective 2
101

100. How To Diagnosis Of VAP?
1. Clinical approach : CPIS
2. Bacteriological approach : quatitative culture
with or without bronchoscope
102

101. Mandell Principles and Practice of Infectious Disease 6th ed.2005,3362-70
103

102. Clinical diagnosis
104

103. Am J Respir Crit Care Med 2000;162:505-11 105

104. GRAM STAIN
Sputum or tracheal
suction gram stain
NO ORGANISMS
in non-neutropenic pts.
NO HAP/VAP 94%
106

105. Bacterial Culture Of Tracheal
Secretion
 Qualitative culture
- non specific
 Semi-quantitative culture
- low specificity
 Quantitative culture : TS, BAL, PSB
- increase specificity
107

106. Identification Of The Problem
 VAP Statistics
… leading cause of death due to nosocomial
infection in ICUs.
… Mechanically-ventilated patients: 9% to 28%
… Mortality rate: 40% - 80%.
… Hospital length of stay: 4-9 days.
… Hospital cost: $29,000 - $40,000 per patient.
108

107. Current Guidelines
 Oral care with antiseptic agents can decrease the incidence of
VAP.
 No optimal concentration or formulation is specified.
 Oral hygiene (removal of plaque from teeth and gums) is
recommended every 12 hours.
 Oral care (removal of secretions from oropharynx and
moisturizing the mouth and lips) is recommended every 4
hours.
109

108.  Nosocomial pneumonia ranks second in morbidity and first
in mortality among nosocomial infections
 mortality rate of VAP : 54% -71%
 VAP occurs : 9% to 24% of patients
 The treatment of nosocomial pneumonia adds 5 to 7 days to
the hospital stay of surviving patients
 mortality is particularly high in pneumonia attributed to
Pseudomonas or Acinetobacter.
110

109. Risk Factors For Ventilator-associated Pneumonia
(VAP)
 presence of an endotracheal tube and continuous ventilatory
support
 enteral nutrition therapy
 lack of elevation of the head of the bed and the patient’s
position
 dental plaque
111

110. Presence Of An Endotracheal Tube Allows :
 direct entry of bacteria into the pulmonary tract
 impairs the cough reflex
 slows the action of the mucociliary escalator
 slows promotes excessive secretion of mucus
112

111. Significance Of Nosocomial Pneumonias
 Increases ventilatory support requirements and ICU stay by
4.3 days
 Increases hospital LOS by 4 to 9 days
 Increases cost - > $11,000 per episode
 Estimates of VAP cost / year for nation > $ 1.2 billion
113

112.  One of the most critical risk factors for the development of
nosocomial pneumonia in patients who are receiving
continuous ventilatory support (ie, VAP) is colonization of
the oropharynx
114

113. Factors Increase Bacterial Colonization Of The
Oropharynx
 mechanical ventilation
Within 48 hours of hospital admission, the composition of the oropharyngeal
flora of critically ill patients undergoes a change to predominantly gram-
negative organisms, constituting a more virulent flora that includes potential
VAP pathogens.
 dental plaque
dental plaque of patients in the ICU is colonized by potential respiratory
pathogens
such as “methicillin-resistant Staphylococcus aureus” and “Pseudomonas
aeruginosa”.
115

114. Prevention Strategies
 Head elevation
 Ventilator equipment changes
 Continuous removal of subglottic secretions
 Handwashing
116

115. Continuous Removal Of Subglottic
Secretions
Use an ET tube with
continuous suction
through a dorsal
lumen above the cuff
to prevent drainage
accumulation.
117

116. HOB Elevation
HOB at 30-45º
118

117. Handwashing
What role does handwashing play
in nosocomial pneumonias?
119

118. VAP Prevention
Wash hands or use an alcohol-based waterless antiseptic agent
before and after suctioning, touching ventilator
equipment, and/or coming into contact with respiratory
secretions.
120

119. No Data
To Support These Strategies
 Use of small bore versus large bore gastric tubes
 Continuous versus bolus feeding
 Gastric versus small intestine tubes
 Closed versus open suctioning methods
 Kinetic beds
121

120. Reference
1. U. Lucangelo, P. Pelosi, W.A. Zin, A. Aliverti (eds.) Respiratory
System and Artificial Ventilation. ©Springer 2008
2. Infectious Diseases in Critical Care Medicine.third edition.
Edited by Burke A. Cunha, # 2010 by Informa Healthcare USA,
Inc. Informa Healthcare is an Informa business
3. Gabrielli, Andrea; Layon, A. Joseph; Yu, Mihae ,Civetta, Taylor,
& Kirby's: Critical Care, 4th Edition Copyright ©2009
Lippincott Williams & Wilkins, Chapter 111 ,Respiratory
Infections in the ICU
122