By: Caitlyn Miller, University of Toledo

2016-03-05_04.59.14

About the author: 

Caitlyn grew up in Celina, Ohio and graduated from Celina High school. She is now attending the University of Toledo as a nursing senior. She hopes to work in an intensive care unit in Columbus, Ohio post-graduation.

Introduction

Hospital-Associated Infections are big concern for the nursing profession. Ventilator-Associated Pneumonia (VAP) is the second most common Healthcare-Associated Infection in the United States. VAP contributes to increased death rates, longer hospital stays, and higher healthcare costs are associated with VAP. As patients’ frontline caregivers and advocates, nurses need to understand effective interventions that they can perform to avoid VAP. Research supports the use of nursing interventions such as: VAP bundle, continuous oral suctioning and the less-common method of abdominal massage to prevent the development of VAP.

 VAP bundle

Curtin (2011) stated, “Over the past 10 years, literature on nursing interventions for reducing VAP has focused on elevating the head of the patient’s bed and providing mouth care. Elevating the head of the bed for mechanically ventilated patients is a critical and well-documented way to help reduce the possibility of VAP.” (p. 10).

Providing mouth care is imperative due to the colonization of dental plaque from organisms in the mouth that can lead to VAP for patients on ventilators. Curtin (2011) states that the American Association of Critical Care Nurses (AACN) recommends providing mouth care every 2 to 4 hours (p.10). The patient’s teeth, gums, and tongue must be thoroughly cleaned in order to correctly perform oral care, along with moisturizing the entire oral mucosa. Curtin (2011) found that during the past 2 years, researchers have explored the importance of maintaining optimal Endotracheal-tube cuff pressure. (pp. 9-10) The lower end of the ET cuff is used to seal the airway during mechanical ventilation and reduce aspiration into the respiratory tract. Cuff pressure needs to be monitored closely because if pressure is too low the aspiration risk increases, and if pressure is too high the patient risks tracheal erosion.

Curtin’s research has many benefits for nurses such as providing an effective method that can save a nurse time and resources by reducing the frequency of VAP. Bundling multiple interventions can help you better take care of your mechanically ventilated patients. However, this writer has concerns about the frequency of mouth care due to the collective growth of bacteria in patients’ mouths. Also, this writer would recommend routinely checking the height of the patients’ head of bed due to movement by family or other medical personnel to avoid aspiration and improve patient’s ventilation. This writer would use this research in her future nursing practice by making sure the patient’s head of the bed is always inclined to at least 30-45°, providing frequent mouth care or delegating that mouth care be done routinely to avoid bacteria accumulation. Lastly, this writer would check the ET-cuff pressure to make sure the pressure is not too high or low as to avoid hurting her patients further or creating openings, therefore allowing possible infections to occur.

Continuous Oral Suctioning

Continuous suctioning of the oral cavity is another method chosen to help prevent VAP for mechanically ventilated patients. Chow (2012) conducted a study design of a parallel-group randomized controlled trial that included 25 patients after exclusions were made to the original 197. While both the experimental and control groups used the conventional endotracheal tube, the saliva ejector was only applied to patients assigned to the experimental group (p. 1333). The saliva ejector was put between the patient’s cheek and teeth and then connected to 100mmHg suction. Thirteen of the twenty-five patients (52%) developed a ventilator-associated infection in the experimental group and 10 in the control group. A Kaplan-Mejer analysis confirmed a significantly lower incidence of VAP in the experimental group than in the control group. Chow (2012) concluded in this study “Although the nurses adhered to the measures for preventing VAP, the relatively high incidence of pneumonia in this study may have been due to an overall increase in the need to make multiple attempts at intubation in the experimental and control groups” (p.1338).

Although there was not significant decline in VAP from continuous oral suction, this writer believes there are future possible benefits. Continuous oral suctioning removes bacteria that would remain in the patients’ mouth between oral cavity cleaning, consequently removing the possibility of VAP. This technique would not be this writer’s first option in her future-nursing career because there has not been a significant result proving the benefits of continuous oral suctioning. Also, there are many factors to continuous oral suctioning that would take more time than necessary, such as constantly repositioning the suction if the patient moves. If this writer were to make changes to this study she would get a greater number of patients for the research study for a better display of the results. Also, this writer would have medical professionals who were better trained at intubating patients, to avoid the unnecessary trauma and contamination.

Abdominal Massage

With the percent of HAIs increasing rapidly, researchers are looking for less conservative ways to avoid VAP. Kahraman (2014) stated that aspiration and gastric reflux from enteral nutrition are major risk factors for ventilator-associated pneumonia. Abdominal massage is assumed to prevent the development of ventilator-associated pneumonia by reducing residual gastric volume (p. 519). This study was done to understand the effectiveness of abdominal massage in preventing VAP with mechanical ventilation and enteral feeding. The research was done on 32 patients, 16 received abdominal massage and 16 remained in the control group. Fifteen-minute abdominal massages were given to the patients in the intervention group twice with no intervention at all done to the control group. Supine positioning, knee flexion, and raising the head of the bed were performed successfully before the intervention. Kahraman (2014) found that regarding patients’ head of bed elevation, a study identified a difference in gastric residual volume between less than 30 degrees and higher (p.522). A statistical difference was found, an increase in volume in the control group was identified, and a decrease or equality was found in the intervention group. Kahraman (2014) proved that gastric residual volume, abdominal distention and VAP decrease with the administration of abdominal massage (p.523).

There are many benefits to abdominal massage including that it’s an easily implemented and cost-effective intervention that will prevent the development of serious complications. However, this writer has some concerns with the massages, such as applying too much pressure to the abdomen subsequently creating physical issues and possible aspiration. The sample size is the only thing this writer would change about this research, to give readers and learners better results from a wider range of adults. This writer would definitely use the abdominal massage technique in her future nursing practice. This research showed me a less-conventional intervention to keep her patients free of VAP. Also, this method is very cost effective and less time consuming than other methods used today.

Conclusion

There are many different techniques used to elude ventilator-associated pneumonia that can be used in nursing practice. Incorporating the VAP bundle incorporates three major factors in counteracting VAP, along with proven results that show a decrease in morbidity and frequency of VAP. On the other hand, there was continuous oral suctioning, which did not prove to reduce VAP and was not time effective. If more research is done on the topic, this writer can see a possibility of this decreasing infection rates. This writer believes that the VAP bundle would be her first choice in ventilator-associated pneumonia prevention, but unless contraindicated, she would also provide the nursing intervention of abdominal massage due to the decrease in gastric content that reduce the frequency of VAP.

References: 

Chow, M., Kwok, S., Luk, H., Law, J., & Leung, B. (2012). Effect of continuous oral suctioning

on the development of ventilator-associated pneumonia: A pilot randomized controlled trial. International Journal of Nursing Studies, 49, 1333-1341.

Curtin, L. (2011). Preventing ventilator-associated pneumonia: A nursing-intervention

bundle. American Nurse Today, 6(3), 9-11.

Kahraman, B., & Ozdemir, L. (2014). The impact of abdominal massage administered to

intubated and enterally fed patients on the development of ventilator-associated pneumonia: A randomized controlled study. International Journal of Nursing Studies, 52, 519-524.