A 63-year-old man with chronic obstructive pulmonary disease comes to the emergency department due to 3 days of increasing dyspnea after running out of his maintenance and rescue inhalers. At first, he had dyspnea with exertion only, but it is now present at rest and associated with wheezing and a nonproductive cough. Chest x-ray reveals lung hyperinflation but no infiltrates. The patient is admitted to the medical floor and started on appropriate therapy. He does not respond to treatment; therefore, he is intubated and mechanically ventilated for worsening hypercapnia and increased work of breathing. Following intubation, portable chest radiograph confirms appropriately positioned endotracheal tube with no infiltrates, effusions, or pneumothorax. Which of the following interventions would be most likely to prevent this patient from developing ventilator-associated pneumonia?

Question

A 63-year-old man with chronic obstructive pulmonary disease comes to the emergency department due to 3 days of increasing dyspnea after running out of his maintenance and rescue inhalers.  At first, he had dyspnea with exertion only, but it is now present at rest and associated with wheezing and a nonproductive cough.  Chest x-ray reveals lung hyperinflation but no infiltrates.  The patient is admitted to the medical floor and started on appropriate therapy.  He does not respond to treatment; therefore, he is intubated and mechanically ventilated for worsening hypercapnia and increased work of breathing.  Following intubation, portable chest radiograph confirms appropriately positioned endotracheal tube with no infiltrates, effusions, or pneumothorax.  Which of the following interventions would be most likely to prevent this patient from developing ventilator-associated pneumonia?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d944_6dd7_bc81_3f9075bdcae5_MD0003_00 Ventilator-associated pneumonia (VAP) is defined as pneumonia that develops ≥48 hours after endotracheal intubation. It is generally caused by aspiration of microorganisms from the oropharynx or stomach into the pulmonary parenchyma. Although endotracheal tubes have inflatable cuffs that seal the upper airway to prevent passage of secretions into the lungs, aspiration can still occur due to leakage around the cuff because of supine positioning, pooling of secretions in the subglottal area, or excessive endotracheal tube movement (eg, during patient transport). leakage around the cuff The following is recommended for intubated patients to reduce the risk of VAP: Head of bed elevation at 30-45 degrees to reduce retrograde movement of gastric secretions Continuous or intermittent suction of subglottic secretions to prevent pooling above the endotracheal cuff Minimization of patient transport to prevent movement of the endotracheal tube Limited use of gastric acid inhibitors (eg, proton pump inhibitor, histamine-2 receptor blockers, antacids) to reduce the burden of microorganisms in gastric secretions (Choice A) Although enteral nutrition through a nasogastric tube can increase the risk of aspiration (particularly when patients are supine), it should be used when possible because total parenteral nutrition, which is administered through a central line, is associated with a high rate of complications (eg, bloodstream infection due to the central line). (Choice C) Excessive sedation increases the risk of VAP because it prolongs the number of days on mechanical ventilation and suppresses gag reflex. Daily sedation breaks help lower the risk of VAP due to the reduction of time on mechanical ventilation. (Choice D) Elevated gastric pH allows microorganisms to grow in gastric secretions, which increases the risk of VAP. Therefore, gastric acid suppression (eg, via proton pump inhibitor) should not be routinely used for stress ulcer prophylaxis. Acid suppression is generally reserved for patients at high risk for gastrointestinal bleeding (eg, thrombocytopenia, a recent gastrointestinal bleed). (Choice E) Tight glycemic control is not recommended in the intensive care unit setting due to an elevated risk of hypoglycemia. In general, blood glucose levels between 140 and 180 mg/dL are recommended. Although poor glycemic control increases the risk of infection, rates of VAP are not strongly linked to moderate elevations in blood glucose. Educational objective: Ventilator-associated pneumonia is a hospital-acquired pneumonia that develops ≥48 hours after endotracheal intubation. Most cases arise due to aspiration of oropharyngeal or gastric secretions. Therefore, the risk is reduced by elevating the head of the bed to 30-45 degrees, suctioning subglottic secretions, limiting endotracheal tube movement, and avoiding gastric acid suppression, unless patients are at high risk of stress ulcers. References: Drakulovic MB1, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999 Nov 27;354(9193):1851-8. (http://www.ncbi.nlm.nih.gov/pubmed/10584721) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med.171:388-416 2005 (http://www.ncbi.nlm.nih.gov/pubmed/15699079) Hellyer TP1, Ewan V1, Wilson P2, Simpson AJ1 The Intensive Care Society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. J Intensive Care Soc. 2016 Aug;17(3):238-243. doi: 10.1177/1751143716644461. Epub 2016 Apr 20. (http://www.ncbi.nlm.nih.gov/pubmed/28979497) Torres A, Niederman MS, Chastre J, Ewig S, Fernandez-Vandellos P, Hanberger H, Kollef M, Li Bassi G, Luna CM, Martin-Loeches I, Paiva JA, Read RC, Rigau D, Timsit JF, Welte T, Wunderink R. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J. 2017 Sep 10;50(3). (http://www.ncbi.nlm.nih.gov/pubmed/28890434) Kalil AC1, Metersky ML2, Klompas M3, Muscedere J4, Sweeney DA5, Palmer LB6, Napolitano LM7, O'Grady NP8, Bartlett JG9, Carratalà J10, El Solh AA11, Ewig S12, Fey PD13, File TM Jr14, Restrepo MI15, Roberts JA16, Waterer GW17, Cruse P18, Knight SL18, Brozek J Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63(5):e61-e111 (http://www.ncbi.nlm.nih.gov/pubmed/27418577)

A 63-Year-Old Man with Chronic Obstructive Pulmonary Disease Comes to the Emergency