General  Measures:

1. Conduct active surveillance for ventilator associated conditions,10 including but not limited to:

  • Ventilator associated pneumonia
  • Pulmonary edema
  • Acute respiratory distress syndrome
  • Atelectasis

2. Perform daily assessments of readiness for extubation including:

  • Daily sedation interruptions for patients in whom it is not contra-indicated (e.g., severe cerebral edema).
  • Protocoled conduction of spontaneous breathing trials for all patients meeting the following criteria:

Required criteria

a. The cause of the respiratory failure has improved.

b. PaO2/FiO2 ≥150 or SpO2 ≥90 percent on FiO2 ≤ 50 percent and positive end-expiratory pressure (PEEP) ≤ 8 cmH2O

c. pH >7.25

d. Hemodynamic stability (no or low dose vasopressor medications)

e. Able to initiate a spontaneous inspiratory effort.

Additional criteria (optional criteria)

a. Hemoglobin ≥7 mg/dL

b. Core temperature ≤38 to 38.5°Centigrade

c. Mental status awake and alert or easily arousable with ability to protect airway.

Staff  Education  priorities

1. Epidemiology of Ventilator Associated Events

2. Infection-control procedures for prevention of VAP

  • Avoid intubation and utilize non-invasive ventilation when possible.
  • ABCDEF bundle11 (see Appendix C)
  • VAP bundle components and use12 (See below.)

3. Periodic audits of the use of guidelines with aggressive education and enforcement of procedures.

    

VAP BUNDLE COMPONENTS

Respiratory  Equipment  Management

Breathing  Circuits  with  Humidifiers

Change the circuit when it is visibly soiled or mechanically malfunctioning. Do not routinely change on the basis of duration of use of the breathing circuit (i.e. ventilator tubing and exhalation valve and the attached humidifier) that is in use on an individual patient.

Breathing  Circuit/Tubing  Condensation

Periodically drain and discard any condensation that collects in the tubing of mechanical ventilators, taking precautions not to allow condensation to drain toward the patient. Wear gloves to perform the procedure and/or when handling the fluid. Decontaminate hands with soap and water (if hands are visibly soiled) or with an alcohol-based hand solution before and after performing the procedure or handling the fluid.

Humidifiers

Use sterile (not distilled, nonsterile) water to fill bubbling humidifiers. Between the uses of reusable hand-powered resuscitation bags on different patients, sterilize or subject to high-level disinfection. Do not routinely sterilize or disinfect the internal machinery of anesthesia equipment. Between uses on different patients, clean reusable components of the breathing system or patient circuit (e.g., tracheal tube or face mask) inspiratory and expiratory breathing tubing, y-piece, reservoir bag, humidifier, and tubing, and then sterilize or subject them to high-level liquid chemical disinfection or pasteurization in accordance with the device manufacturers’ instructions for their reprocessing.

Keep all ventilators covered when not in use to reduce dust accumulation on devices.

Prevention  of  Person-to-Person  Transmission  of Bacteria 

Cohorting

Implement patient and staff cohorting whenever possible by using geographically distinct areas of care. In the deployed setting, this includes separating Host National from non-Host National patient due to differences in the microbiomes. Disinfect all patient care equipment after each patient transfer. Terminally clean rooms between patients and consider periodic (monthly) ICU/ICU subunit closure for thorough cleaning and disinfection. In deployed settings, this should be conducted as regularly as field conditions permit. 

Standard Precautions

Decontaminate hands by washing either with antimicrobial soap and water (if hands are visibly dirty or contaminated with blood or body fluids), or by using an alcohol-based waterless antiseptic agent if hands are not visibly soiled. Use personal protective equipment based on clinical circumstance.  

Contact precautions with gloves and gown for all patient contact for patients infected or suspected with epidemiologically significant pathogens, specifically MDR Acinetobacter spp., ESBL-producing Klebsiella spp. and Escherichia coli, carbapenem-resistant Enterobacteriaceae, vancomycin-resistant Enterococcus spp., and methicillin-resistant Staphylococcus aureus. Decontaminate hands before and after patient contact and use gloves as below.

Gloves

Wear gloves for handling secretions or objects contaminated with secretions of any patient. Change gloves and decontaminate hands as described previously between contacts with different patients. When anticipating becoming soiled from secretions, wear a gown and change it after soiling occurs and before providing care to another patient.

Care of patients with Tracheostomy

Perform tracheostomy care under aseptic conditions. When changing a tracheostomy tube, wear a gown and mask, use aseptic technique. Providers should familiarize themselves with manufacturers recommendations regarding the quality and frequency recommended for tracheostomy care. Additionally, the life expectancy of inner cannula is variable depending on the product used (e.g., 24h to 29 days). Tracheostomy care orders should be written specific to the product used.

Suctioning of respiratory tract secretions

Appropriate to use either the multiuse closed system suction (Ballard) catheter or the single-use open system suction catheter. Patients persistently on the ventilator should have a Ballard system in line, while those intermittently on or off the ventilator with a tracheostomy in place can have the open suction employed as appropriate. If the open-system suction is employed, use a sterile, single-use catheter and sterile technique when suctioning. Use only sterile fluid to remove secretions from the suction catheter if the catheter is to be used for re-entry into the patient’s lower respiratory tract.

Prevention  of  Mucus  Plugging  (Endotracheal Tube)

  • If feasible, use an endotracheal tube (Hi Lo Tube) with a dorsal lumen above the endotracheal cuff to allow drainage of tracheal secretions that accumulate in the patient’s subglottic area.
  • Before deflating the cuff of an endotracheal tube in preparation for extubation, ensure that secretions are cleared from above the tube cuff.

Prevention  of  Aspiration Related  Infection (Gastrointestinal)

  • Head of bed elevation: In the absence of contraindication(s), elevate the head of bed at an angle of 30° to 45° of a patient at high risk for aspiration (e.g., traumatic brain injury, mechanically assisted ventilation).
  • As soon as the clinical indications for their use are resolved, remove devices such as endotracheal, tracheostomy, and/or enteral tubes from patients.
  • Feeding tube verification: Verify appropriate placement of the feeding tube prior to use.
  • Due to recent studies questioning the value and safety12 of chlorhexidine-based oral care, this guideline does not advocate for the routine use of chlorhexidine-based oral decontamination. Routine oral hygiene with a tooth brush or oral sponge should continue to be provided with the goals of removal of dental plaque and other debris from teeth, tongue and oral mucosa.

Prevention  of  Postoperative  Pneumonia

  • Encourage all postoperative patients to take deep breaths, move about the bed, and ambulate unless medically contraindicated.
  • Use incentive spirometry on postoperative patients.
  • Incorporate rehabilitation therapy as early as possible in the post-operative period.
  • Antibiotic therapy:
    •  Surgical prophylaxis: Minimize the duration and spectrum of surgical antibiotic prophylaxis in accordance with the JTS Infection Prevention Clinical Practice Guideline, 08 Aug 2016.13
    •  Suspected infection: Initial therapy should be broad spectrum and informed by each facility’s antibiotic susceptibility patterns, if available. When possible, cultures should be obtained prior to initiation of antibiotic therapy. Infectious Disease Society of America guidelines state that non-invasive sampling with semi-quantitative cultures is the preferred methodology. Therapy should be tailored based on culture results and should be given for a 7 day course.14