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A 25-year-old man is admitted to the intensive care unit after sustaining a closed head injury and a pneumothorax in a motor vehicle accident. He scores 5/15 on the Glasgow Coma Scale. A ventriculostomy tube and chest tube are placed, and intubation and mechanical ventilation are required to reduce elevated intracranial pressure. Enteral feedings are resumed on the second hospital day, but mechanical ventilation is needed for 1 week.
Which of the following may reduce the risk of ventilator-associated pneumonia in this patient?
A Begin H2-receptor antagonists
B Begin prophylactic intravenous antibiotics
C Keep the patient in a semi-recumbent (45-degree angle) position
D Change the ventilator tubing every 3 days
] E Avoid subglottic suctioning through the endotracheal tube
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Correct Answer = C)
Key Point
Keeping mechanically ventilated patients semi-recumbent (at a 45-degree angle) helps prevent development of ventilator-associated pneumonia.
This patient is at high risk for ventilator-associated (nosocomial) pneumonia because of chest trauma, a Glasgow Coma Scale score of less than 9, the need for mechanical ventilation, and the early resumption of enteral feedings. To prevent nosocomial pneumonia, the U.S. Centers for Disease Control and Prevention recommend interventions to decrease aspiration, such as raising the head of the bed to a 45-degree angle, maintaining gastric acidity, maximizing nutrition, preventing colonization or cross-contamination by the hands of heath care workers, and manipulating respiratory-tract equipment in a sterile fashion and disinfecting the equipment appropriately.
Maintaining patients in a semi-recumbent position has been shown to decrease ventilator-associated pneumonia. Drakulovic and colleagues demonstrated that nosocomial pneumonia developed in 8% of mechanically ventilated patients kept semi-recumbent and 43% of those kept supine.
H2-receptor blockers are a risk factor for development of ventilator-associated pneumonia because these agents reduce gastric acidity. There are no data to confirm that use of prophylactic intravenous antibiotics prevents pneumonia, and antibiotics may increase the risk of colonization with resistant organisms. Changing tubing every 3 days is not necessary. Several clinical trials have shown that changing circuit tubing only every 2 weeks in adult patients does not increase the risk of infection. Use of endotracheal tubes that do not allow suctioning of subglottic secretions increases, rather than decreases, the risk of pneumonia in patients who are intubated for long periods of time.
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OK vent tubing is changed q 7 days I think.
