dr win Hospital acquired Pneumonia.PPT
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About This Presentation
dr win Hospital acquired Pneumonia.ppt
Slide Content
Hospital acquired
Pneumonia
(HAP)
TIM PPI RSUD DR SOETOMO SURABAYA
OKTOBER 2018
1
Pneumonia
(HAP)
TIM PPI RSUD DR SOETOMO SURABAYA
OKTOBER 2018
1
Definition
Hospital-acquired pneumonia (HAP)
acute lower respiratory tract infection that is by
definition acquired after at least 48 hours of
admission to the hospital and is not incubating
at the time of admission.
Most cases are caused by bacteria, especially
aerobic gram-negative bacilli, such as
Pseudomonas aeruginosa , Escherichia coli ,
Klebsiella pneumoniae , and Acinetobacter
species.
2
Hospital-acquired pneumonia (HAP)
acute lower respiratory tract infection that is by
definition acquired after at least 48 hours of
admission to the hospital and is not incubating
at the time of admission.
Most cases are caused by bacteria, especially
aerobic gram-negative bacilli, such as
Pseudomonas aeruginosa , Escherichia coli ,
Klebsiella pneumoniae , and Acinetobacter
species.
2
What is HAP ?
Hospital Acquired Pneumonia (HAP) is an
infection in the lung that occurs more than 48
hours after admission to a hospital.
It is an infection that was not present before the
patient came to the hospital.
HAP is the second most common hospital
acquired infection.
It is the most common cause of death among
hospital acquired infections.
3
Hospital Acquired Pneumonia (HAP) is an
infection in the lung that occurs more than 48
hours after admission to a hospital.
It is an infection that was not present before the
patient came to the hospital.
HAP is the second most common hospital
acquired infection.
It is the most common cause of death among
hospital acquired infections.
3
Risk factors
poor infection control/hand hygiene
head of bed at <30° angle
intubation and mechanical
ventilation; endotracheal cuff
pressure <20 cm H2O
H2 antagonist and antacid use.
4
poor infection control/hand hygiene
head of bed at <30° angle
intubation and mechanical
ventilation; endotracheal cuff
pressure <20 cm H2O
H2 antagonist and antacid use.
4
Risk factors
Weakened cough
Tracheostomy tubes
Suctioning
Weakened immune system from
disease or medications
5
Weakened cough
Tracheostomy tubes
Suctioning
Weakened immune system from
disease or medications
5
Clinical manifestation
Patients with hospital-acquired
pneumonia usually present with a
combination of fever (or hypothermia),
leukocytosis (or leukopenia), increased
tracheal secretions, and poor
oxygenation.
Alveolar shadowing on CXR or CT scan
supports the diagnosis.
6
Patients with hospital-acquired
pneumonia usually present with a
combination of fever (or hypothermia),
leukocytosis (or leukopenia), increased
tracheal secretions, and poor
oxygenation.
Alveolar shadowing on CXR or CT scan
supports the diagnosis.
6
Symptom
Fever
Green, yellow or pus filled secretions
productive cough
dyspnea
Increased fatigue
Shortness of breath
Loss of appetite
Coarse (crackling) breath sounds
7
Fever
Green, yellow or pus filled secretions
productive cough
dyspnea
Increased fatigue
Shortness of breath
Loss of appetite
Coarse (crackling) breath sounds
7
Physical Diagnostic
chest pain
asymmetric expansion of the chest
diminished resonance
8
chest pain
asymmetric expansion of the chest
diminished resonance
8
Diagnostic Investigation
CXR
WBC count with differential
pulse oximetry
culture of lower respiratory tract
sample
9
CXR
WBC count with differential
pulse oximetry
culture of lower respiratory tract
sample
9
Laboratorium Diagnosis
Blood Gas Analysis
diagnostic thoracentesis
CT scan chest
CRP
10
Blood Gas Analysis
diagnostic thoracentesis
CT scan chest
CRP
10
What treatments are available for
patients with HAP?
Antibiotic therapy may be used
Frequent turns may be done in order to prevent
secretions from building up in the lungs making
breathing easier
Lung treatments/medications may be given to help
loosen and remove thick secretions from the lungs
and improve the body’s ability to carry oxygen in
the blood
Oxygen may be provided in order to maintain good
oxygen levels
11
patients with HAP?
Antibiotic therapy may be used
Frequent turns may be done in order to prevent
secretions from building up in the lungs making
breathing easier
Lung treatments/medications may be given to help
loosen and remove thick secretions from the lungs
and improve the body’s ability to carry oxygen in
the blood
Oxygen may be provided in order to maintain good
oxygen levels
11
HAP Prevention Bundle
Craig Hospital has adopted a group of
prevention strategies to reduce the
chance of getting HAP. This group of
strategies is called the “HAP Prevention
Bundle”. Some of the components of the
bundle include:
12
Craig Hospital has adopted a group of
prevention strategies to reduce the
chance of getting HAP. This group of
strategies is called the “HAP Prevention
Bundle”. Some of the components of the
bundle include:
12
Clean Hands – all staff will wash hands or use
antibacterial hand gel before and after each
patient interaction. Additionally, gloves are worn
by staff during all direct patient contact
Frequent Oral Care – research studies have
shown that providing frequent oral care for
patients with artificial airways (e.g. tracheostomy
tubes) reduces the amount of bacteria in the
mouth, decreasing chances of HAP occurring
13
antibacterial hand gel before and after each
patient interaction. Additionally, gloves are worn
by staff during all direct patient contact
Frequent Oral Care – research studies have
shown that providing frequent oral care for
patients with artificial airways (e.g. tracheostomy
tubes) reduces the amount of bacteria in the
mouth, decreasing chances of HAP occurring
13
HOB elevation - Keeping the patient’s head of the bed at
30 degrees, when safe and appropriate, reduces the
chance of germs from the patient’s mouth coming in
contact with the lungs.
Please keep in mind that increasing the head of bed to 30
degrees may require more frequent skin checks and
turning
Clean Suction Technique and Closed Suction Catheters –
when used correctly during suctioning they decrease the
chances of introducing any outside germs to the patient’s
lungs
14
30 degrees, when safe and appropriate, reduces the
chance of germs from the patient’s mouth coming in
contact with the lungs.
Please keep in mind that increasing the head of bed to 30
degrees may require more frequent skin checks and
turning
Clean Suction Technique and Closed Suction Catheters –
when used correctly during suctioning they decrease the
chances of introducing any outside germs to the patient’s
lungs
14
What can YOU do to help prevent
HAP?
Clean Hands – we encourage (menganjurkan)
all family, friends, and visitors to use the same
hand hygiene methods as staff while spending
time at Craig.
Antibacterial soap and antibacterial hand gel
are available in each patient room and
available for your use
15
HAP?
Clean Hands – we encourage (menganjurkan)
all family, friends, and visitors to use the same
hand hygiene methods as staff while spending
time at Craig.
Antibacterial soap and antibacterial hand gel
are available in each patient room and
available for your use
15
Prevention of hospital-acquired pneumonia
in non-ventilated adult patients: a narrative
review.
Findings:
recommendations for HAP prevention in non-ventilated patients are
available. There is reasonable evidence available that oral care is
associated with a reduction in HAP.
Early mobilization interventions, swift diagnosis and treatment of
dysphagia, and multimodal programmes for the prevention of
nosocomial influenza cross-infection, have a positive impact on HAP
reduction.
The impact of bed position and stress bleeding prophylaxis remains
uncertain.
Systematic antibiotic prophylaxis for HAP prevention should be
avoided
16
Pássaro et al. Antimicrobial Resistance and Infection Control (2016)
in non-ventilated adult patients: a narrative
review.
Findings:
recommendations for HAP prevention in non-ventilated patients are
available. There is reasonable evidence available that oral care is
associated with a reduction in HAP.
Early mobilization interventions, swift diagnosis and treatment of
dysphagia, and multimodal programmes for the prevention of
nosocomial influenza cross-infection, have a positive impact on HAP
reduction.
The impact of bed position and stress bleeding prophylaxis remains
uncertain.
Systematic antibiotic prophylaxis for HAP prevention should be
avoided
16
Pássaro et al. Antimicrobial Resistance and Infection Control (2016)
Ventilator
associated
Pneumonia (VAP)
17
associated
Pneumonia (VAP)
17
Ventilator-associated pneumonia
(VAP)
Defined as pneumonia that occurs 48–72 hours
or thereafter following endotracheal intubation,
characterized by
the presence of a new or progressive infi ltrate,
signs of systemic infection (fever, altered white
blood cell count), changes in sputum
characteristics, and detection of a causative
agent .
18
(VAP)
Defined as pneumonia that occurs 48–72 hours
or thereafter following endotracheal intubation,
characterized by
the presence of a new or progressive infi ltrate,
signs of systemic infection (fever, altered white
blood cell count), changes in sputum
characteristics, and detection of a causative
agent .
18
Ventilator-associated pneumonia (VAP) is a lung
infection that develops in a person who is on a
ventilator.
An infection may occur if germs enter through
the tube and get into the patient’s lungs.
Ventilator-associated pneumonia (VAP) results
from the invasion of the lower respiratory tract
and lung parenchyma by microorganisms.
Intubation compromises the integrity of the
oropharynx and trachea and allows oral and
gastric secretions to enter the lower airways.
19
infection that develops in a person who is on a
ventilator.
An infection may occur if germs enter through
the tube and get into the patient’s lungs.
Ventilator-associated pneumonia (VAP) results
from the invasion of the lower respiratory tract
and lung parenchyma by microorganisms.
Intubation compromises the integrity of the
oropharynx and trachea and allows oral and
gastric secretions to enter the lower airways.
19
VAP contributes to approximately half of all
cases of hospital-acquired pneumonia
VAP is estimated to occur in 9–27 % of all
mechanically ventilated patients, with the
highest risk being early in the course of
hospitalization.
It is the second most common nosocomial
infection in the intensive care unit (ICU) and the
most common in mechanically ventilated
patients.
20
cases of hospital-acquired pneumonia
VAP is estimated to occur in 9–27 % of all
mechanically ventilated patients, with the
highest risk being early in the course of
hospitalization.
It is the second most common nosocomial
infection in the intensive care unit (ICU) and the
most common in mechanically ventilated
patients.
20
Why do patients need a ventilator?
A patient may need a ventilator when he
or she is very ill or during and after surgery.
Ventilators can be life-saving, but they
can also increase a patient’s chance of
getting pneumonia by making it easier for
germs to get into the patient’s lungs.
21
A patient may need a ventilator when he
or she is very ill or during and after surgery.
Ventilators can be life-saving, but they
can also increase a patient’s chance of
getting pneumonia by making it easier for
germs to get into the patient’s lungs.
21
Ventilator-associated pneumonia (VAP) is a type of hospital-
acquired pneumonia that develops after more than 48 hours of
mechanical ventilation.
Patients with severe hospital-acquired pneumonia who require
mechanical ventilation after the onset of infection do not meet the
definition of VAP.
VAP is a common and serious problem in the intensive care unit that
is associated with an increased risk of death.
Accurate diagnosis is important so that appropriate treatment can
be instituted early while simultaneously avoiding antibiotic overuse
and consequently, antibiotic resistance.
22
Marin H Kollef, 2018
acquired pneumonia that develops after more than 48 hours of
mechanical ventilation.
Patients with severe hospital-acquired pneumonia who require
mechanical ventilation after the onset of infection do not meet the
definition of VAP.
VAP is a common and serious problem in the intensive care unit that
is associated with an increased risk of death.
Accurate diagnosis is important so that appropriate treatment can
be instituted early while simultaneously avoiding antibiotic overuse
and consequently, antibiotic resistance.
22
Marin H Kollef, 2018
Clinical features VAP
Most patients with VAP present with a gradual or
sudden onset of the following :
Symptoms – dyspnea (few patients have
symptoms since most are nonverbal on
mechanical ventilation)
Signs – fever, tachypnea, increased or purulent
secretions, hemoptysis, rhonchi, crackles,
reduced breath sounds, bronchospasm
23
Most patients with VAP present with a gradual or
sudden onset of the following :
Symptoms – dyspnea (few patients have
symptoms since most are nonverbal on
mechanical ventilation)
Signs – fever, tachypnea, increased or purulent
secretions, hemoptysis, rhonchi, crackles,
reduced breath sounds, bronchospasm
23
Diagnosis of ventilator-associated pneumonia:
a systematic review of the literature
Clinical criteria, used in combination, may be helpful in diagnosing VAP,
however, the considerable inter-observer variability and the moderate
performance should be taken in account.
Bacteriologic data do not increase the accuracy of diagnosis as
compared to clinical diagnosis.
Quantitative cultures obtained by different methods seem to be rather
equivalent in diagnosing VAP.
Blood cultures are relatively insensitive to diagnose pneumonia.
The rapid availability of cytological data, including inflammatory cells
and Gram stains, may be useful in initial therapeutic decisions in
patients with suspected VAP.
C-reactive protein, procalcitonin, and soluble triggering receptor
expressed on myeloid cells are promising biomarkers in diagnosing
VAP.
24
Neto AR. Crit Care. 2008;
a systematic review of the literature
Clinical criteria, used in combination, may be helpful in diagnosing VAP,
however, the considerable inter-observer variability and the moderate
performance should be taken in account.
Bacteriologic data do not increase the accuracy of diagnosis as
compared to clinical diagnosis.
Quantitative cultures obtained by different methods seem to be rather
equivalent in diagnosing VAP.
Blood cultures are relatively insensitive to diagnose pneumonia.
The rapid availability of cytological data, including inflammatory cells
and Gram stains, may be useful in initial therapeutic decisions in
patients with suspected VAP.
C-reactive protein, procalcitonin, and soluble triggering receptor
expressed on myeloid cells are promising biomarkers in diagnosing
VAP.
24
Neto AR. Crit Care. 2008;
What are some of the things that
hospitals are doing to prevent VAP?
To prevent ventilator-associated pneumonia, doctors, nurses, and
other healthcare providers can do the following things:
Keep the head of the patient’s bed raised between 30 and 45
degrees unless other medical conditions do not allow this to occur.
Check the patient’s ability to breathe on his or her own every day
so that the patient can be taken off of the ventilator as soon as
possible.
Clean their hands with soap and water or an alcohol-based hand
rub before and after touching the patient or the ventilator.
Clean the inside of the patient’s mouth on a regular basis.
Clean or replace equipment between use on different patients.
25
hospitals are doing to prevent VAP?
To prevent ventilator-associated pneumonia, doctors, nurses, and
other healthcare providers can do the following things:
Keep the head of the patient’s bed raised between 30 and 45
degrees unless other medical conditions do not allow this to occur.
Check the patient’s ability to breathe on his or her own every day
so that the patient can be taken off of the ventilator as soon as
possible.
Clean their hands with soap and water or an alcohol-based hand
rub before and after touching the patient or the ventilator.
Clean the inside of the patient’s mouth on a regular basis.
Clean or replace equipment between use on different patients.
25
What can patients do to help prevent VAP?
Patients and family members can do the following things to help
prevent VAP:
Patients
Quit smoking. Patients who smoke get more infections. Seek information
about how to quit before surgery.
If healthcare providers do not clean their hands, ask them to do so.
Patients and Family Members
Ask about raising the head of the bed.
Ask when the patient will be allowed to try breathing on his or her own.
If healthcare providers do not clean their hands, ask them to do so.
Ask about how often healthcare providers clean the patient’s mouth.
26
Patients and family members can do the following things to help
prevent VAP:
Patients
Quit smoking. Patients who smoke get more infections. Seek information
about how to quit before surgery.
If healthcare providers do not clean their hands, ask them to do so.
Patients and Family Members
Ask about raising the head of the bed.
Ask when the patient will be allowed to try breathing on his or her own.
If healthcare providers do not clean their hands, ask them to do so.
Ask about how often healthcare providers clean the patient’s mouth.
26
Can VAP be treated?
Most of the time, these infections can be treated
with antibiotics.
The choice of antibiotics depends on which
specific germs are causing the infection.
The healthcare provider will decide which
antibiotic is best.
27
Most of the time, these infections can be treated
with antibiotics.
The choice of antibiotics depends on which
specific germs are causing the infection.
The healthcare provider will decide which
antibiotic is best.
27
Prevention
Although VAP has multiple risk factors, many nursing interventions can
reduce the incidence of this disease.
Prevention of pneumonia, both in and outside of the hospital, begins
with vaccination .
Nurses are the first line of defense in preventing bacterial colonization
of the oropharynx and the gastrointestinal tract.
Meticulous (dengan teliti) hand washing for 10 seconds should be
performed before and after all contact with patients.
In addition, gloves should be worn when contact with oral or
endotracheal secretions is possible.
Strategically placing a sign on a patient’s door to remind health-care
workers to wash their hands and wear gloves is an easy and cost-
effective measure that can help minimize transmission of bacteria
between patients.
The use of protective gowns is not recommended as routine practice,
but gowns should be used when antibiotic-resistant pathogens have
been isolated and identified.
28
Although VAP has multiple risk factors, many nursing interventions can
reduce the incidence of this disease.
Prevention of pneumonia, both in and outside of the hospital, begins
with vaccination .
Nurses are the first line of defense in preventing bacterial colonization
of the oropharynx and the gastrointestinal tract.
Meticulous (dengan teliti) hand washing for 10 seconds should be
performed before and after all contact with patients.
In addition, gloves should be worn when contact with oral or
endotracheal secretions is possible.
Strategically placing a sign on a patient’s door to remind health-care
workers to wash their hands and wear gloves is an easy and cost-
effective measure that can help minimize transmission of bacteria
between patients.
The use of protective gowns is not recommended as routine practice,
but gowns should be used when antibiotic-resistant pathogens have
been isolated and identified.
28
29
Oral decontamination, by reducing the amount of
bacteria within a patient’s oral cavity, can be
accomplished by both mechanical and
pharmacological interventions.
Mechanical interventions include tooth brushing
and rinsing of the oral cavity to remove dental
plaque;
pharmacological interventions involve the use of
antimicrobial agents.
Bacteria in dental plaque can be removed by
brushing the teeth and thoroughly suctioning
secretions from the mouth. Both of these
interventions decrease the likelihood of colonization
of the oropharynx.
30
bacteria within a patient’s oral cavity, can be
accomplished by both mechanical and
pharmacological interventions.
Mechanical interventions include tooth brushing
and rinsing of the oral cavity to remove dental
plaque;
pharmacological interventions involve the use of
antimicrobial agents.
Bacteria in dental plaque can be removed by
brushing the teeth and thoroughly suctioning
secretions from the mouth. Both of these
interventions decrease the likelihood of colonization
of the oropharynx.
30
5 Nursing strategies to prevent
ventilator-associated pneumonia
1 Minimize ventilator exposure
2 Provide excellent oral hygiene care
3 Coordinate care for subglottic suctioning
4 Maintain positioning and encourage mobility
5 Ensure adequate staffing
31
American Nurse Today , 2017
ventilator-associated pneumonia
1 Minimize ventilator exposure
2 Provide excellent oral hygiene care
3 Coordinate care for subglottic suctioning
4 Maintain positioning and encourage mobility
5 Ensure adequate staffing
31
American Nurse Today , 2017
32
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