|Year : 2015 | Volume
| Issue : 3 | Page : 354-358
The effect of an upper respiratory care program on incidence of ventilator-associated pneumonia in mechanically ventilated patients hospitalized in intensive care units
Soheila Bakhtiari1, Ahmadreza Yazdannik2, Saeid Abbasi3, Nasim Bahrami4
1 Department of Operating Room Nursing, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Critical Care Nursing, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Anesthesiology, Anesthesiology and Critical Care Research Center, Isfahan University of Medical sciences, Isfahan, Iran
4 Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Submission||04-Aug-2014|
|Date of Acceptance||09-Dec-2014|
|Date of Web Publication||29-May-2015|
Department of Critical Care Nursing, Nursing and Midwifery School, Isfahan University of Medical Sciences, Hezar Jerib Avenue
Source of Support: Isfahan University of Medical Sciences, Conflict of Interest: None
Clinical trial registration IRCT2013122215898N1
Background: Ventilator-associated pneumonia (VAP) is a common side effect in patients with an endotracheal tube. This study aimed to evaluate the effect of an upper respiratory care program on the incidence of VAP in mechanically ventilated patients.
Materials and Methods: In this clinical trial, 62 patients with endotracheal tube were selected and randomly allocated to intervention or control group. In the intervention group, an upper respiratory care program was performed and in the control group, routine care was done. Modified Clinical Pulmonary Infection Questionnaire was completed before, and on the third, fourth, and fifth day after intervention. Data were analyzed by repeated measure analysis of variance (ANOVA), chi-square, and independent t-test through SPSS 13.
Results: The results of this study showed that until the fourth day, the incidence of VAP was similar in both intervention and control groups (P > 0.05), but on the fifth day, the incidence of VAP in the intervention group was significantly lower than in the control group (P < 0.05).
Conclusions: The results of this study showed that in patients with an endotracheal tube, an upper respiratory care program may reduce the incidence of VAP. Therefore, in order to prevent VAP, nurses are recommended to perform this upper respiratory care program.
Keywords: Nursing, suction, ventilator-associated pneumonia
|How to cite this article:|
Bakhtiari S, Yazdannik A, Abbasi S, Bahrami N. The effect of an upper respiratory care program on incidence of ventilator-associated pneumonia in mechanically ventilated patients hospitalized in intensive care units. Iranian J Nursing Midwifery Res 2015;20:354-8
|How to cite this URL:|
Bakhtiari S, Yazdannik A, Abbasi S, Bahrami N. The effect of an upper respiratory care program on incidence of ventilator-associated pneumonia in mechanically ventilated patients hospitalized in intensive care units. Iranian J Nursing Midwifery Res [serial online] 2015 [cited 2021 Jul 24];20:354-8. Available from: https://www.ijnmrjournal.net/text.asp?2015/20/3/354/157837
| Introduction|| |
Proper function of respiratory system is essential to live. Preservation of an open airway is a crucial factor facilitating O2 and CO2 exchange.  Airway care and keeping it open for appropriate ventilation is a priority in the intensive care unit (ICU). Although preservation of a natural airway and avoidance of an artificial airway is a priority, when the patients are unable of preserving their airway naturally, application of an artificial airway is inevitable. , One of the most common and risky complications among mechanically ventilated patients is ventilator-associated pneumonia (VAP). ,, Hospital-acquired pneumonia is the second common hospital infection after urinary tract infection and is often observed among the patients under ventilation. , Incidence of pneumonia in mechanically ventilated patients has been estimated to be 9-27%.  Afhami et al. showed that the prevalence of VAP was 22.5% and 18.2% in general and intensive surgical wards of the hospitals affiliated to Tehran University of Medical Sciences, respectively.  VAP increases the treatment costs and mortality, and the length of being mechanically ventilated and hospitalized in the ICU. ,, With regard to the high prevalence and numerous physiologic and economic effects of VAP, the best strategy against VAP is its prevention and controlling the risk factors.  Nowadays, various strategies have been suggested to prevent VAP, including bed head elevation up to 30° -45° , suctioning the mouth and subgluteal space, and regulating the pressure of cuff in the tracheal tube in the range of 20-30 cm H 2 O.
One of the methods effective on reduction of VAP is bed head elevation. In the clinical guideline of Disease Control and Prevention and the clinical guideline of American ICU Nursing Association, it is recommended to elevate the bed head up to 30° -45° in the patients with a tracheal tube.  Kollef et al. and Lyerla et al. showed that laying the patient in the supine position during the first 24 h of mechanical ventilation is indirectly associated with the incidence of VAP and its mortality. , Drakulovic et al. showed that elevation of the patients' bed head up to 45° , compared to supine position, significantly reduced VAP.  On the other hand, Van Nieuwenhoven et al. showed that laying patients' bed head in 45° elevation did not result in a reduction of VAP, compared to 10° of elevation.  Another intervention to diminish VAP is lowering the risk of oral secretions' aspiration.  Chow et al. showed that continuous oral suctioning of oral secretions plays a key role in reduction of VAP and shortening the length of mechanical ventilation and hospitalization in the ICU.  Chao et al. showed that removal of oral secretions prior to a position change could reduce the incidence of VAP.  Another nursing care administered to reduce aspiration of the secretions remaining in the subgluteal space is controlling and regulating the cuff pressure in the tracheal tube.  If the cuff leaks or has inadequate pressure, the secretions over the cuff can leak to the airway and predispose the patient to VAP. , If the cuff pressure reaches less than 20 cm H 2 O, the incidence of VAP is significantly increased. Rello et al. showed that the risk of VAP increases by fourfold in pressure less than 20 cm H 2 O.  As indicated earlier, the methods that can affect the incidence of VAP include oral and subgluteal space suctioning before each position change, elevation of bed head up to 45° , and regulation of the cuff pressure to about 25 cm H 2 O during the entire hospitalization time. In the ICU ward of Alzahra hospital in Isfahan, oral and subgluteal space suctioning in mechanically ventilated patients is performed every 2 h, regardless of the time of patients' position change. There is no specific protocol to control and regulate the cuff pressure, and the nurses regulate the cuff pressure in different ranges. Although elevation of bed head is followed, there is no specific protocol for its level in degrees and the nurses regulate this differently. Therefore, in the ICUs of Alzahra hospital in Isfahan, none of these methods are followed with a unique protocol now. No study has investigated the effect of simultaneous application of these three methods on the incidence of VAP. Therefore, the researcher investigated the effect of simultaneous application of oral and subgluteal space suctioning, elevation of bed head up to 45° , and preservation of cuff pressure of the tracheal tube in the range of 25 cm H2O on the incidence of VAP among the patients mechanically ventilated in ICUs.
| Materials and Methods|| |
This is a blind clinical trial. None of the subjects knew about the group that they were in. The study was approved by the ethics committee of Isfahan University of Medical Sciences and conducted on mechanically ventilated patients hospitalized in the ICUs of Alzahra hospital. Based on the report of Vincent et al., with first type error of 0.05 and test power of 0.80, the number of the subjects was calculated as 32 in each group.  Sampling followed was convenient sampling, and then, the subjects were assigned to study or control group through random allocation. An informed consent was obtained from all the patients (from their parents if the patients were unconscious). Inclusion criteria were age over 18 years, being under ventilation for more than 24 h, not having been affected by pneumonia or respiratory infection (at the time of entrance to hospital, before intubation, and during the first 48 h of intubation), and the prohibition of bed head elevation, ordered by the physician. Exclusion criteria were parents' refusal to continue with the study, patient's expiration before the end of study, being extubated before the end of study, transfer to other wards or hospitals during the study, and undergoing a surgery during the study.
Data collection tool had two sections. The first section included demographic and clinical characteristics and the second contained Modified Pulmonary Infection Clinical Scale. This is a standard scale including five criteria of body temperature, pulmonary secretion, WBC, PO 2 -FiO 2 ratio based on mmHg, and a chest X-ray. Each subscale is scored 0-2 in this tool and the maximum score that could be obtained is 10. Obtaining scores over 5 in this scale reveals involvement in VAP [Table 1]. , The Persian version of the Modified Pulmonary Infection Clinical Scale was used in the present study. Sabery et al. calculated the reliability of this scale through Cronbach's alpha and internal consistency was found to be 91%.  This scale was recorded on the third, fourth, and fifth days of the study at 8:00 AM. After random selection of the subjects and their allocation to study or control group, the researcher firstly extracted patients' clinical demographic data from their medical records in the hospital and recorded them in the first section of the data collection tool. Before intervention, the Modified Pulmonary Clinical Infection Scale was completed for all the subjects. The subjects with VAP were excluded. Then, the researcher performed a scheduled upper respiratory care in the study group, which included oral subgluteal space suctioning before each position change, measuring and regulating the cuff pressure of tracheal tube in the range of 25 cm H 2 O (twice a day at 8:00 AM and 8:00 PM), and checking the bed head elevation at 45° by use of a bevel (twice a day at 8:00 PM). The subjects in the control group underwent upper respiratory routine care.
Data were analyzed by SPSS 13. Independent t-test was used to check subjects' age homogeneity and Chi-square test was used for subjects' homogeneity concerning sex, hospitalization cause, medical history, smoking history, and immune system defects. Independent t-test and repeated measure analysis of variance (ANOVA) were adopted to compare mean scores of Modified Pulmonary Clinical Infection Scale before and after intervention in the study and control groups.
| Results|| |
The present study was conducted on 72 subjects in two groups of intervention (n = 35) and control (n = 37) with participants who met the inclusion criteria. During the study, 8 subjects (3 in the study group and 5 in the control group) not meeting the inclusion criteria were excluded and the study was conducted on 32 subjects in the study and control groups. Mean ages of the subjects in suctioning intervention and control groups were 50.96 (18.7) and 49.50 (17.9) years, respectively. Subjects' intubation lengths in the study and control groups were 3.12 (0.8) and 3.12 (0.9) days, respectively. About 53% of the subjects were male and 47% were female. The cause of hospitalization was internal (29%), surgical (31%), and internal-surgical (40%). Most of the subjects had history of non-pulmonary diseases (45%) and were non-smokers (70%). No subjects had a history of immune system defect. Independent t-test and Chi-square test showed no significant difference in subjects' age, intubation length, sex, hospitalization cause, disease history, history of smoking, and immune system defect before intervention (P > 0.05) [Table 2]. Repeated measure ANOVA showed a significant difference in the trend of Modified Pulmonary Infection Clinical Scale score changes in the study and control groups (P < 0.05), but the difference was not significant between groups (P > 0.05). Independent t-test showed no significant difference in the mean scores of Modified Pulmonary Infection Clinical Scale before intervention and on the third and the fourth days after intervention, as both the groups showed similar changes (P < 0.05). Meanwhile, mean score of Modified Pulmonary Infection Clinical Scale was significantly lower on the fifth day after intervention in the study group, compared to the control group (P < 0.05) [Table 3].
|Table 2: Comparison of subjects' clinical and demographic characteristics in study and control groups |
Click here to view
|Table 3: Comparison of mean modified pulmonary clinical infection scale scores before and after intervention between the study and control groups |
Click here to view
| Discussion|| |
Our obtained results showed that simultaneous administration of three modes of airway care including regulating the cuff pressure in range of 25 cm H 2 O, elevation of bed head up to 45° and its maintenance at this position, and oral and subgluteal suctioning before each patient's position change resulted in a reduction in VAP. Previous studies have not investigated the simultaneous and cumulative effect of these variables on VAP, but some studies have been conducted on the effect of each of these methods on VAP. Drakulovic et al. also showed that elevation of patients' bed head up to 45° significantly decreased the incidence of VAP, compared to supine position, which is consistent with the present study.  Chow et al. showed that continuous oral suctioning led to lowered incidence of VAP. 
Rello et al. also showed that regulation of cuff pressure over 20 cm H 2 O led to reduced incidence of VAP,  which is consistent with the present study. Our results also showed that the incidence of VAP was similar until the fourth day after intervention in both study and control groups. But on the fifth day, the incidence of VAP was significantly lower in the study group, compared to control, which reveals the effect of conducting three simultaneous airway care protocols including regulating the tracheal tube cuff pressure to about 25 cm H 2 O, maintenance of bed head elevation up to 45° , and oral and subgluteal space suctioning before each position change on the incidence of VAP.
Salimi et al. studied the effect of standard care including sterile suctioning of tracheal tube, mouth wash, and oral suctioning every 4 h, body position change and chest postural drainage every 2 h, encouraging the patient to cough every 2 h, fixing the head elevation at 30° , and washing hands before administration of care programs on the incidence of VAP and reported that conducting long-term standard airway care (4 months) led to the reduction of VAP from 17.18 to 3.48. 
Grap et al. also showed that the risk of VAP is higher among the patients with bed head elevation of less than 30° . The present study showed that an increase in bed head elevation up to 45° for seven straight days could reduce the risk of VAP in clinically critical patients. Chao et al. showed that oral suctioning before position change, in long term, could reduce the incidence of VAP by 32%.  A reduction in the incidence of VAP resulted from airway care protocols such as regulating the cuff pressure to about 25 cm H 2 O, maintaining the bed head elevation up to 45° , and oral and subgluteal suctioning before each position change, which seems to be associated with aspiration of patients' secretions. ,, Therefore, nursing staff can reduce the incidence of VAP through administration of such an intervention in addition to other interventions, thereby decreasing the risk of patients' aspiration. There were two limitations in the present study: the absence of an identical tracheal tube suctioning method and not administering an identical respiratory physiotherapy in the patients that could have affected the incidence of VAP. These two limitations might have affected the results obtained in our study.
| Conclusion|| |
Regulating the tracheal tube cuff pressure to about 25 cm H 2 O, maintaining the bed head elevation up to 45° , and oral and subgluteal space suctioning before each position change led to lowered incidence of VAP. The nurses are recommended to consider this issue in giving care to mechanically ventilated patients.
| Acknowledgments|| |
This article was derived from a master thesis of Bahrami Nasim with project number 393161 Isfahan University of Medical Sciences, Isfahan, Iran. with clinical trial code of IRCT2013122215898N1. The authors greatly appreciate the kind cooperation of vice chancellery for research in Isfahan University of Medical Sciences as well as the staff in the ICU wards of Alzahra hospital in Isfahan who helped them with this research.
| References|| |
Marino PL, Sutin KM. The ICU book: Williams & Wilkins; 2007.
Irwin RS, Rippe JM. Irwin and Rippe′s intensive care medicine: Lippincott Williams & Wilkins; 2008.
Irajpour A, Abbasinia M, Hoseini A, Kashefi P. Effects of shallow and deep endotracheal tube suctioning on cardiovascular indices in patients in intensive care units. Iran J Nurs Midwifery Res 2014;19:366-70.
Porzecanski I, Bowton DL. Diagnosis and treatment of ventilator-associated pneumonia. Chest 2006;130:597-604.
Pileggi C, Bianco A, Flotta D, Nobile CG, Pavia M. Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: A meta-analysis of randomized controlled trials in intensive care units. Critical care (London, England) 2011;15:155-66.
Rocha L, Vilela C, Cezário R, Almeida A, Gontijo F. Ventilator-associated pneumonia in an adult clinical-surgical intensive care unit of a Brazilian university hospital: Incidence, risk factors, etiology, and antibiotic resistance. Braz J Infect Dis 2008;12:80-5.
Fauci AS. Harrison′s principles of internal medicine: McGraw-Hill Medical New York; 2008.
Muscedere JG, Martin CM, Heyland DK. The impact of ventilator-associated pneumonia on the Canadian health care system. J Crit Care 2008;23:5-10.
Kalanuria AA, Zai W, Mirski M. Ventilator-associated pneumonia in the ICU. Critical care (London, England) 2014;18:208.
Afhami S, Hadadi A, Khorami E, Seifi A, Bazaz N. Ventilator-associated pneumonia in a teaching hospital in Tehran and use of the Iranian Nosocomial Infections Surveillance Software. East Mediterr Health J 2013;19:883-7.
Buczko W. Ventilator-Associated Pneumonia among Elderly Medicare Beneficiaries in Long-Term Care Hospitals. Health Care Financ Rev 2009;31:1.
Hutchins K, Karras G, Erwin J, Sullivan KL. Ventilator-associated pneumonia and oral care: A successful quality improvement project. Am J Infect Control 2009;37:590.
Klompas M. Ventilator-associated pneumonia: is zero possible? Clin Infect Dis 2010;51:1123-6.
Tablan O, Anderson L, Besser R, Bridges C, Hajjeh R. Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care-associated pneumonia, 2003. MMWR Recomm Rep 2004;53:1-36.
Kollef MH. Ventilator-associated pneumonia. A multivariate analysis. JAMA 1993;270:1965-70.
Lyerla F, LeRouge C, Cooke DA, Turpin D, Wilson L. A nursing clinical decision support system and potential predictors of head-of-bed position for patients receiving mechanical ventilation. Am J Crit Care 2010;19:39-47.
Drakulovic MB, 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;354:1851-8.
Van Nieuwenhoven C, Vandenbroucke-Grauls C, Van Tiel F, Joore H, Van Schijndel R, Van der Tweel I, et al
. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: A randomized study. Crit Care Med 2006;34:396-402.
Young PJ, Pakeerathan S, Blunt MC, Subramanya S. A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med 2006;34:632-9.
Chow M, Kwok S-M, Luk H-W, Law JW, Leung BP. Effect of continuous oral suctioning on the development of ventilator-associated pneumonia: A pilot randomized controlled trial. Int J Nurs Stud 2012.
Chao YFC, Chen YY, Wang KWK, Lee RP, Tsai H. Removal of oral secretion prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: a clinical controlled trial study. J Clin Nurs 2009;18:22-8.
Diaz E, Rodríguez AH, Rello J. Ventilator-associated pneumonia: Issues related to the artificial airway. Respir care 2005;50:900-9.
Rello J, Sonora R, Jubert P, Artigas A, Rué M, Vallé s J. Pneumonia in intubated patients: Role of respiratory airway care. Am J Respir Crit Care Med 1996;154:111-5.
Vyas D, Inweregbu K, Pittard A. Measurement of tracheal tube cuff pressure in critical care. Anaesthesia 2002;57:275-7.
Vincent JL. Ventilator-associated pneumonia. J Hosp Infect 2004;57:272.
Lauzier F, Ruest A, Cook D, Dodek P, Albert M, Shorr AF, et al
. The value of pretest probability and modified clinical pulmonary infection score to diagnose ventilator-associated pneumonia. J Crit Care 2008;23:50-7.
Koenig SM, Truwit JD. Ventilator-associated pneumonia: diagnosis, treatment, and prevention. Clinical microbiology reviews 2006;19:637-57.
Sabery M, Shiri H, Moradiance V, Taghadosi M, Gilasi HR, Khamechian M. The frequency and risk factors for early-onset ventilator-associated pneumonia in intensive care units of Kashan Shahid-Beheshti hospital during 2009-2010. KAUMS Journal (FEYZ ) 2013;16:560-9.
Salimi S, Akdemir N, Anami I, Nowrooznia S, Rastat M. Effect of standardization of nursing cares on incidence of nosocomial infection in MICU. URMIA MEDICAL JOURNAL. 2009;19:310-5. [In Persian].
[Table 1], [Table 2], [Table 3]