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Category Archives: Pulmonary function

Preventing Ventilator-Associated Pneumonia in Adults: Sedation and Weaning

Preventing Ventilator-Associated Pneumonia in Adults: Sedation and WeaningThere have been conflicting reports on the use and benefits of heat/moisture exchangers (HMEs) compared to heated humidifiers for preventing VAP. A recent metaanalysis by Kola and cowork-ers demonstrated a reduction in the relative risk of developing VAP in the HME group (relative risk, 0.7; 95% CI, 0.5 to 0.04) but may have been affected by the large difference in the outcomes in one of the studies. For patients with a mean ventilation duration > 7 days, the relative risk for VAP fell to 0.57 in the HME group (95% CI, 0.38 to 0.83). A more recent, large, randomized study by Lacherade and coworkers found no benefit for the HME group. In another study of HMEs using historical control subjects, patients who received mechanical ventilation > 2 days reported a significant reduction in VAP (p = 0.01). medicine-against-diabetes.net
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Preventing Ventilator-Associated Pneumonia in Adults: Sedation and Weaning

Efforts to reduce acute lung injury by using smaller tidal volumes and lower pressures have been suggested along with sedation vacations to facilitate weaning. Recently, Schweickert and coworkers evaluated seven complications in 128 patients receiving mechanical ventilation and continuous infusions of sedative drug who were randomized to daily interruption of sedative infusions (n = 66) vs sedation directed by the medical ICU team without this strategy (n = 60). Daily interrupted sedative infusions reduced ICU length of stay (6.2 days vs 9.9, p < 0.01), duration of mechanical ventilation (4.8 vs 7.3 days, p < 0.003), and the incidence of complications per patient (13 complications in 12 patients vs 26 complications in 19 patients, p < 0.04).
Weaning protocols are recommended to limit the duration of mechanical ventilation. Dries and co-workers, using a standardized weaning protocol, reduced days of mechanical ventilation (ventilator days/ICU days) from 0.47 to 0.33, numbers of patients failing ventilation (25 vs 43), and reduced rates of VAP (15% to 5%). Although there are a number of confounding variables with the study design, efforts to remove the endotracheal tube without reintubation should be encouraged.
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Preventing Ventilator-Associated Pneumonia in Adults: Noninvasive Positive Pressure Ventilation

Preventing Ventilator-Associated Pneumonia in Adults: Noninvasive Positive Pressure VentilationNoninvasive positive pressure ventilation (NPPV) provides ventilatory support without the need for intubation and for earlier removal of the endotracheal tube to reduce complications related to prolonged intubation. Burns and coworkers, in a recent Cochrane review, reported significant benefits: decreased mortality (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.22 to 0.76), lower rates of VAP (RR 0.28; 95% CI, 0.0.90 to 0.85); decreased length of ICU and shorter hospital stays; and lower duration of mechanical support. The impact of NPPV is greater in patients with COPD exacerbations or congestive heart failure than for patients with VAP. Recent data also indicate that NPPV may not be a good strategy to avoid reintubation after initial extubation, and is recommended for hospitals with staff who are experienced in this technique.
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Preventing Ventilator-Associated Pneumonia in Adults: Lactobacillus GG

This impressive result for an inexpensive, nontoxic, topically applied modality warrants further attention but is difficult to reconcile with the absence of effect on ventilator-days, length of stay, or mortality. It is important to measure how prophylactic use of chlorhexidine and chlorhexidine-colistin complement other effective prevention strategies, and resistance could become an important issue over time. so
Iseganan, a topical antimicrobial peptide, active against aerobic and anaerobic Gram-positive and Gram-negative bacteria and yeasts, was evaluated in a randomized, double-bind trial to prevent VAP. Although there was a significant reduction in colonization in the treatment group, the rate of VAP among survivors (16% vs 20%) and 14-day morality was similar (22% vs 18%). Although protegrins are ubiquitous antimicrobial peptides, and in human trials were able to reduce oral colonization by two logs, these results raise several questions about ise-ganan efficacy and why it failed.
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Preventing Ventilator-Associated Pneumonia in Adults: Transfusion Risk

Preventing Ventilator-Associated Pneumonia in Adults: Transfusion RiskAlthough transfusion was suggested as a risk factor of nosocomial infection and a modifiable risk factor for VAP in the American Thoracic Society/Infectious Diseases Society of America guideline, in a secondary analysis from a recent, large study of transfusions, it was identified as an independent risk factor for VAP. This may become a more important modifiable risk factor, as recent data from Levy and coworkers reported that patients receiving mechanical ventilation received transfusions at a higher pretransfusion hemoglobin level than patients not receiving mechanical ventilation (8.7 vs 8.2, p < 0.0001).
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Preventing Ventilator-Associated Pneumonia in Adults: Enteral Feeding Protocol

There were also questions on the generalizability of ITT to medical ICU patients. In a recent randomized study of 1,200 medical ICU patients, ITT did not significantly reduce hospital mortality overall, and increased mortality in patients with ICU stays < 3 days. However, the ITT group had reduced acquired renal failure, duration of mechanical ventilation, and length of ICU and hospital stay. Difficulty in predicting length of stay is difficult; concerns about the risks of hypoglycemia, resource implications, and assessing the benefit of ITT in different hospitals require further evaluation. canadian pharmacy
Enteral feeding is preferred to parenteral feeding, but aspiration pneumonia is a complication. Bowman and coworkers instituted an evidence-based, enteral feeding protocol in which 78 to 85% of patients reached their enteral feeding goal and aspiration pneumonia rates decreased from 6.8 to 3.2/1,000 patient days. Such protocols should be reviewed by multidisciplinary committees to standardize enteral nutrition protocols and risk reduction for VAP.
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Preventing Ventilator-Associated Pneumonia in Adults: Patient Position

Preventing Ventilator-Associated Pneumonia in Adults: Patient PositionIn contrast to rotational beds, semirecumbent patient position is a low-cost, easily accessible intervention, and may be a more practical and more tolerable approach than rotational beds or prone body position. Maintaining patients who are receiving mechanical ventilation or who are enterally fed in a 30° to 45° semirecumbent position, particularly during enteral feeding, continues to be strongly recommended based on the VAP reduction in one randomized study. so
A more recent study by van Nieuwenhoven et al, in which patients receiving mechanical ventilation were randomly assigned to backrest elevation of 45° vs the standard of 10°, demonstrated barriers to implementing this strategy. Backrest elevation was measured continuously during the first week of ventilation with a monitoring device. The targeted backrest elevation of 45° was not reached; the actual achieved difference was 28° vs 10°, which did not reduce VAP. Similarly, Grap and Munro monitored patient position in ICU patients using a bed frame elevation gauge or electronic bed readout and found very low compliance with maintaining semirecum-bent patient position, with a mean backrest elevation of only 19.2° with 70% of subjects maintained in a supine position. Maintaining patients receiving mechanical ventilation or who are enterally fed in a semirecumbent position may need to evaluate more realistic targets.
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Preventing Ventilator-Associated Pneumonia in Adults: Infection Control

Infection control programs have repeatedly demonstrated efficacy in reducing infection rates and in controlling the spread of MDR organisms. Unfortunately, staff compliance with proven infection control measures, such as hand disinfection, is often poor and inconsistent. Staff education aimed at infection control must be inclusive, frequent, and reiterative. Special attention must be directed to house staff, students, volunteers, and visitors who may not be included in regularly scheduled infection control educational programs.
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Preventing Ventilator-Associated Pneumonia in Adults: Addressing Barriers to Translating Guidelines Into Practice

Preventing Ventilator-Associated Pneumonia in Adults: Addressing Barriers to Translating Guidelines Into PracticeAs with other prevention efforts, interventions aimed at reducing VAP should focus on evidence-based interventions, for which efficacy and cost-effectiveness have been clearly supported by clinical studies and experts in the field (Table 1). Initially, it may be more prudent to focus on a limited number of feasible, cost-effective prevention strategies for VAP prevention. In the Institute for Healthcare Improvement (IHI) 100,000 Lives Campaign, hospitals are challenged to adopt as many of the six recommended initiatives to reduce health-care-associated infections. The VAP or “ventilator bundle” initiative includes five simple components: elevation of the head of the bed to between 30° and 45°, a daily “sedation vacation,” daily assessment for readiness to extubate, and prophylaxis for peptic ulcer disease and deep vein thrombosis. Some participating hospitals using this approach are reporting zero episodes of VAP over sustained periods of time (Donald Berwick, MD; IHI National Forum; personal correspondence; December 13, 2005). Confirmation of these dramatic results in peer-reviewed journals is eagerly anticipated.
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Preventing Ventilator-Associated Pneumonia in Adults: Methods

Furthermore, the recent outbreak of vancomycin-resistant or glycopeptide-resis-tant S aureus infections in a French ICU was difficult to control, and costly, and may be a harbinger of future problems, especially with the recent reduction in vancomycin sensitivity from a minimum inhibition concentration of 4 to 2 ^g/mL. Control of MRSA will require more aggressive antibiotic control, focused on reduced use of antibiotics, such as fluoroquinolones and improved infection control. Infection control for high-risk populations and certain health-care facilities may require improved screening, isolation, and eradication of MRSA, such as the “search and destroy” strategy recently outlined by Vos and coworkers.
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