Vol. 19 •Issue 26 • Page 15
Know the Symptoms, Know the Precautions
Pneumonia is not one of the first things a therapist thinks about when intubating patients and placing them on ventilators. Post-intubation X-rays generally show the lungs are clear, and there may be no signs of pneumonia for days post-intubation.
However, when you find the patient’s sputum has changed color and consistency, that may be the first sign there is a problem. This may be your first inclination the patient has pneumonia.
That is the reason her family found it hard to believe Elizabeth Willis had developed pneumonia after she had a stroke that rendered her unconscious and required surgery.
“She was completely healthy. She didn’t have any breathing problems,” explained one of her daughters. “Her lungs were fine, the doctor said. I really can’t understand how she had a stroke a week ago and now she can’t get off the ventilator because she has pneumonia.”
Elizabeth Willis, like so many patients, developed ventilator-associated pneumonia (VAP), a complication caused by measures taken earlier to save her life. VAP will slow her progression and may increase her days on the ventilator.
Pneumonia Hot Zones
According to the Centers for Disease Control (CDC), pneumonia accounts for about 15 percent of all hospital-associated infections. Most of these occur in ICUs or coronary care units (CCUs). Infections acquired in these units are the second most common hospital-associated infections after urinary tract infections. The primary risk factor for the development of hospital-associated bacterial pneumonia is mechanical ventilation with its requisite endotracheal intubation.
The CDC defines VAP as “pneumonia in patients who have been on mechanical ventilation for more than 48 hours, a pneumonia most accurately diagnosed by quantitative culture and microscopic examination of lower respiratory tract secretions, which are best obtained by bronchoscopy-directed techniques such as the protected specimen brush and bronchoalveolar lavage.”
Because people on mechanical ventilation are often sedated, typical signs and symptoms of pneumonia may not be readily detected. For this reason, health care workers need to be watchful for the presence of fever, hypoxia and purulent sputum.
“VAP should be suspected in any person with an increasing white blood cell count, infiltrates on chest radiography and blood cultures which reveal the presence of microorganisms,” suggest both the American Thoracic Society and the Infectious Diseases Society of America.
VAP primarily occurs because the endotracheal or tracheostomy tube allows free passage of bacteria into the lower segments of the lung in a person who often has underlying lung or immune problems.
In a 2005 article, titled “ATS/IDSA Guidelines: Guidelines for the management of adults with HAP, VAP, and HCA,” published in the American Journal of Resiratory Critical Care Medicine, the American Thoracic Society and the Infectious Disease Society of American noted: “Bacteria travel in small droplets both through the endotracheal tube and around the cuff. Often, bacteria colonize the endotracheal or tracheostomy tube and are embolized into the lungs with each breath. Bacteria may also be brought down into the lungs with procedures such as deep suctioning or bronchoscopy.”
Treatments and Precautions
Treatment of VAP typically involves broad-spectrum antibiotics. However, researchers suggest that limiting exposure to resistant bacteria, discontinuing mechanical ventilation as soon as possible and a variety of other strategies may help limit infections among the intubated. Most importantly for health care workers are proper hand washing, use of sterile technique for invasive procedures and isolation of individuals with known resistant organisms for effective infection control.
“Several other methods for limiting VAP exist,” researchers explained in their guidelines. “Raising the head of the bed to at least 45 degrees results in fewer episodes of VAP. Placement of feeding tubes beyond the pylorus of the stomach my also result in fewer episodes of ventilator associated pneumonia.”
It took a while, but doctors were able to treat Elizabeth Willis’ VAP. Her lungs are now clear, but she isn’t the same person anymore. I went to visit my grandmother a couple of weeks ago while I was in Philadelphia. She’s awake, her eyes are open and she talks and seems to recognize her nurses and some family members. Nonetheless, the stroke took away her vibrant life and spirit.
Marc Willis is a Pennsylvania television reporter.