Patients are at risk of experiencing lung injuries, especially in the perioperative period, including such conditions as pneumonia, atelectasis, pneumothorax, and other respiratory syndromes. Anesthetic management can trigger, intensify, or ameliorate most of them. The intervention of mechanical ventilators is often a life-saving options to the patients with severe illnesses, and it is usually applied in the intensive care unit. Moreover, mechanical ventilators are often associated with respiratory tract infections that appear as septic or sepsis shock with the respiratory dysfunction in the intubated patients (Kalanuria, Zai, & Mirski, 2014). Therefore, despite the life-saving benefit of mechanical ventilators for the patients with chronic illnesses, their extended use causes respiratory infections, such as pneumonia and tracheobronchitis, that can be reduced by clinicians with the underlying knowledge on the management of these machines. This paper aims at analyzing the PICOT question of how respiratory infections in patients using mechanical ventilators can be reduced. Then, this work will summarize a case study from an evidence-based quantitative article from the PubMed and Cochrane collaboration database.
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Developing a PICOT Question
Respiratory infections are common among the patients of intensive care units. Most patients who require mechanical ventilators suffer from respiratory infections, thus resulting in a high mortality rate among the patients in the older adult age group not from their illnesses but from the subsequent processes, caused by the use of this equipment. Furthermore, pneumonia falls in the list of the top nosocomial infections common in patients under mechanical ventilation (Kalanuria et al., 2014). The ventilator-associated pneumonia might develop after a patient has been on mechanical ventilation. Thus, diagnosing it requires significant clinical efforts including bedside examination and a microbiologic analysis of the respiratory secretions as well as a radiographic examination.
Preventing ventilator-associated pneumonia might require some prevention strategies that ICU nurses can apply to reduce the respiratory infections in their patients. However, it is crucial to know that mechanical ventilation is the main component that gives supportive therapy for the patients in critical care who need help to breathe. While mechanical ventilator is usually a life-saving measure, it also frequently causes complications such as nosocomial infection that develops a while after intubation (Kalanuria et al., 2014).
The risk factors of contracting respiratory infections in patients under mechanical ventilation exist in separate cases. Firstly, the associated infections occur after a patient’s pulmonary system has been invaded by bacteria. The endotracheal tube itself is the primary risk factor since it can store pathogens by allowing the secretions to pool as well as allow access of airborne pathogens directly into the lungs (Kalanuria et al., 2014). In addition to the mentioned risk factors, endotracheal tube also negates some protective mechanisms of the body such as prevention from coughing (P?ssaro, Harbarth, & Landelle, 2016). Thus, elderly patients and those with compromised immunity to diseases are also at an increased risk of ventilator-associated infections as well as those with existing pulmonary illnesses (P?ssaro et al., 2016). Being under mechanical ventilation for a long time is also a risk factor for the development of infections. Additionally, other factors include staff noncompliance with infection control protocols, such as hand washing, maintaining patients in a stretched-out position, and feeding them via nasogastric tube (Rittayamai & Brochard, 2015).
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Improving the nursing practices can minimize the respiratory infections caused by mechanical ventilators, which helps promote a better life quality, especially for the patients in the ICU. This research’s aim has been unusually hectic because respiratory infections caused by mechanical ventilators allow for patients to be treated with this the use of this machine without fear of contracting associated infections (Kalanuria et al., 2014). Furthermore, aside from reducing respiratory infections, this research would increase patient satisfaction by decreasing the healthcare costs related to the treatment of these infections. Hence, some initial questions considered before developing the PICOT question were “are respiratory infections common in patients with mechanical ventilators?” and “how do mechanical ventilators cause respiratory infections in patients in the ICU?” However, after conducting a literature search, the PICOT question was refined to the question “How can respiratory infections be reduced in patients with mechanical ventilators?”
Conducting a Literature Search
To research the PICOT question, the researchers used the Cochrane and PubMed databases by resorting to advanced search as well as key words and phrases that did not yield expected results. At first, using the phrases “respiratory infections” or “mechanical ventilators” separately did not yield many essential articles. However, upon enhancing the search to use both phrases at once, the findings were more productive, bringing over 100 articles. After attempting to sort the articles by relevance to the PICOT question and the selection of evidence-based quantitative items, the researchers have managed to decrease the resulting numbers to five relevant articles. The research did not consider articles older than ten years due to technological developments.
The first article found through PubMed suggested that the respiratory infections caused by mechanical ventilators were a serious issue since their severity went with stages (Rittayamaiv & Brochard, 2015). The authors searched widely through PubMed and other clinical trial databases, selecting randomized and quasi-randomized controlled trials that examined ways of reducing ventilator-associated infections. Thus, Rittayamai and Brochard (2015) reviewed a total of 66 studies, with the years of publication ranging from 1967 to 2014 and examining the therapies that might be beneficial in reducing ventilator-associated infections. Based on the systematic review, the authors have concluded that the severity of ventilator-associated respiratory infections is the primary indicator of individualizing treatment (Rittayamai & Brochard, 2015). They recommend the use of high PEEP based more on the individual response as well as new monitoring tools such as the Poes measurements (Rittayamai & Brochard, 2015).
Another meta-analysis that also examined mechanical ventilators and the respiratory infections among the elderly patients was also found through PubMed (P?ssaro et al., 2016). Accordingly, ventilator-associated pneumonia (VAP) among patients under mechanical ventilation is a worldwide known infection that causes lengthy hospital stays, high healthcare costs, and high mortality rates among the victims. Thus, ICU nurses should be ahead as caregivers who try help ventilated patients to evade the risk of VAP. To achieve this, nurses should understand how VAP develops, know the prevention strategies of VAP, and the importance of following guidelines. Mechanical ventilation is an essential object of supportive therapy for individuals with breathing problems. With a ventilator acting as a life-saving instrument, it can easily cause complications, such as VAP, that come after intubation. Thus, ventilated patients who contract VAP have a higher mortality rate of 45% as compared to 28% of ventilated patients with no VAP. The patients at a greater risk of VAP are older adults and patients suffering from pulmonary illnesses such as asthma and emphysema. One preventative method is the use of non-invasive ventilations and those of positive pressure in the place of intubation (P?ssaro et al., 2016). Another way to reduce the cases of VAP is the reduction of ventilation duration. Proactive surveillance and check-ups on patients under ventilation are essential. Additional measures, which nurses should consider while taking care of ventilated patients, include practicing good hygiene and maintaining the oral health of patients to prevent the colonization of endotracheal tube by bacteria (P?ssaro et al., 2016). To help avoid aspiration, the authors suggest that nurses should maintain the patients in a semi-recumbent position, with the head elevated for 30 to 40 degrees.
In another article retrieved from CINAHL, the authors have explored the current opinion regarding the support techniques of mechanical ventilators (Parissopoulos, Mpouzika, & Timmins, 2015). The authors’ search criteria included clinical trials, discussion papers, reviews, observation studies, clinical guidelines, and meta-analyses from CINAHL, PubMed, and Cochrane databases. The analysis concluded that patients with severe respiratory infections could benefit from nursing practices such as pressure limitation and prone positioning as well as low tidal volume (Parissopoulos et al., 2015). Moreover, the authors also concluded that there was the need for more research as well as further development to give clear guidelines to the nurses handling patients in critical care (Parissopoulos et al., 2015).
Finally, a meta-analysis, found through PubMed, examined the occurrence rate of ventilator-associated pneumonia and its relation to the morbidity of critically ill patients (Kalanuria et al., 2014). The authors searched CINAHL, Cochrane, and PubMed databases to find 49 articles ranging from 1972 to 2013 on clinical trials that fit their criteria concerning mechanical ventilators and related respiratory infections (Kalanuria et al., 2014). The authors concluded that enough evidence had indicated that the ventilator-associated infections were preventable and they could be reduced (Kalanuria et al., 2014). They suggested that managing respiratory infections involved early and appropriate antibiotics offered in adequate doses (Kalanuria et al., 2014).
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Description of the Systematic Review
This is a comprehensive systematic review that includes the databases for research and the number of articles used in the study as well as their years of publishing. This comprehensiveness shows that the survey has been conducted in a thorough manner, focusing on important details such as their relation to the PICOT question. Furthermore, it has helped to pinpoint the vital points, mentioned by researchers, while it also notes their conclusions and recommendations as they are most crucial in finding the answer to the PICOT question. Conversely, some of the articles are not quite dependable due to their content. Some items lack enough information necessitated by the study, and as such, there is a need in more research from other articles. However, the systematic review has covered many necessary things to be able to find a proper answer to the PICOT question.
Study of Interest
A randomized control trial, sourced from the PubMed database, aims to determine the effectiveness of oral decontamination that contains a 2% chlorhexidine solution to help prevent ventilator-associated pneumonia (Tantipong, Morkchareonpong, Jaiyindee, & Thamlikitkul, 2008). The design comprises of both a randomized control trial and a meta-analysis. This trial is implemented in Siriraj tertiary care hospital in Bangkok, Thailand. The populations studied in were adult patients aged 18 years and above who had been accorded mechanical ventilation in intensive care units on 36 beds and general medical wards on 240 beds (Tantipong et al., 2008). However, patients who already had pneumonia at the time of enrollment or who suffered from chlorhexidine allergy were excluded.
The sample size used was 108 patients. These patients were placed in two groups. A randomized strategy was used to achieve the overall objective – to show if oral decontamination using a 2% chlorhexidine solution would be effective in reducing the VAP rate from 14 to seven episodes per every 1,000 ventilator days (Tantipong et al., 2008). There was a 5% type I error and a significant 80% power. Data analysis was done by descriptive analysis, unpaired Student t test, the Mann-Whitney U test, and X2 square statistics; a P value of 0.5 was a significant statistical consideration (Tantipong et al., 2008).
The characteristics of the individual patients placed in the chlorhexidine group (n=102) and the saline team (n=105) were not expressively different (Tantipong et al., 2008). In the former group, the VAP incidence was 4.9%, or five out of ten. In the latter group, the incidence was 11.4%, or 12 of 105; here, P=.08 and the VAP rate among the patients in the chlorhexidine group was a significant seven episodes per 1,000 ventilator days (Tantipong et al., 2008). The VAP rate in the second group stood at 21 events per 1,000 ventilator days, with P=0.4. It was observed that the irritation of oral mucosa affected 10 (9.8%) of patients placed in the chlorhexidine group (Tantipong et al., 2008). On the other hand, the irritation of oral mucosa seemed to affect only one patient in the saline group, which was 0.9% of the total number of patients in this group, so P=.001 (Tantipong et al., 2008). Thus, oropharyngeal colonization with gram-negative bacilli had seen a significant delay or even reduction among the patients in the chlorhexidine group (Tantipong et al., 2008).
The study approach was the use of a random strategy that was used to determine the patients who would receive oral decontamination, containing a 2% chlorhexidine solution or a saline solution (Tantipong et al., 2008). The casual approach used two factors of concern, mainly sex and the location of eligible patients in the hospital, while oral decontamination was to be taken four times a day by the random number of patients selected (Tantipong et al., 2008). Thus, oral decontamination was to be performed on these patients until their endotracheal tubes were removed. The outcome measures included the development of oropharyngeal colonization with gram-negative bacilli and VAP (Tantipong et al., 2008). A meta-analysis was undertaken via bringing together the results of the current study from a different randomized control trial that also utilized a 2% chlorhexidine formulation for oral decontamination. The significance of the random strategy was the reduction of the selection bias since with this strategy, a patient would be allocated in any group (Tantipong et al., 2008).
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The patients from the chlorhexidine group were prescribed to receive oral care four times a day, and this care included brushing their teeth, suctioning orals secretions, and rubbing oropharyngeal mucosa using 15 ml of 2% chlorhexidine (Tantipong et al., 2008). All wards participating in the plan used their conventional care protocols. Nevertheless, whenever possible, nurses tried to maintain a semi-recumbent body position of their patients. Every patient underwent a daily examination that tested the presence of pneumonia with no particular order in which this was done, which also reduced bias (Tantipong et al., 2008). A diagnosis was necessary in the case the patient had a new or progressive infiltrate that was observed on a chest radiograph, including at least three of these factors such as body temperature above 38 C or below 35.5 C, leucocytosis or leucopenia, purulent tracheal aspirate, and tracheal aspirate samples that revealed the presence of pathogenic bacteria (Tantipong et al., 2008). An oropharyngeal swab sample was obtained from every patient after endotracheal tube intubation had been done on day three during intubation, seven days after intubation, and every seven days until the removal of endotracheal tube or if the patient had been tested for pneumonia. The swab sample was tested and graded for growth (Tantipong et al., 2008).
According to the trial results, demographics, disease severity, location, and time span of mechanical ventilation had no significant difference between the two groups. The occurrence of ventilator-associated infections among patients in the chlorhexidine group was 4.9%, or five out of 102, while it was 11.4% in the saline group, or 12 out of 105 (Tantipong et al., 2008). The mean number of VAP cases in the former group was seven episodes per 1,000 ventilator-days, and in the latter group, the results showed 21 episodes in every 1,000 ventilator-days (Tantipong et al., 2008). VAP developed as the result of gram-negative bacilli among patients in both groups. The results showed that patients of the chlorhexidine group had little risk of obtaining VAP as compared to those of the saline group (Tantipong et al., 2008). According to the results, the mortality rate of the patients in the former group was 32.3%, while 35.2% of patients in the latter group died.
The total death rate of two groups had no significant difference. A meta-analysis, which was performed via two randomized controlled trials. showed that there was an overall risk of VAP among the patients placed in the chlorhexidine group of 0.53 (95% confidence interval, 0.31-0.90; P=.02) (Tantipong et al., 2008). According to Tantipong et al. (2008), oral decontamination with the use of a 2% chlorhexidine solution is an efficient and secure method that can be used to prevent VAP among patients under mechanical ventilation. Randomized controlled trials, which utilized a 2% chlorhexidine formulation as the only intervention of patients under mechanical ventilation and which showed pneumonia as a study outcome, were chosen in the studies involved in the three recent meta-analyses (Tantipong et al., 2008). The reviewing of the details of selected studies was done, and the data was combined with that of the current randomized controlled trial by using a RevMan program version 4.2.
A meta-analysis of an approved quality randomized controlled trial of oral decontamination using antibiotics among patients who underwent mechanical ventilation to help prevent pneumonia showed that topical antibiotic therapy was not a quality and efficient technique for preventing VAP (Tantipong et al., 2008). On the other hand, randomized control trials verified that the topical utilization of 0.12%, or 0.2%, chlorhexidine solution was an effective method of preventing VAP among patients after cardiothoracic surgery (Tantipong et al., 2008). Conversely, this meta-analysis had revealed that using 2% chlorhexidine oral decontamination was appropriate for preventing pneumonia among patients under mechanical ventilation, with only a relative risk of 0.58 (Tantipong et al., 2008).
One flaw was that there was only one randomized controlled trial that assessed the oral decontamination with 2% chlorhexidine as the only intervention for patients under mechanical ventilation and that verified that pneumonia was a study outcome, which left the study with no room for a fair comparison with other studies (Tantipong et al., 2008). Chlorhexidine is an antiseptic agent that can be utilized for both gram-negative and gram-positive bacteria. Even though oral decontamination using a low concentration of chlorhexidine is efficient in preventing pneumonia among patients after cardiothoracic surgery, its part in the preventing cases of pneumonia among critically sick patients under mechanical ventilation has not been established, which implies the option to use a 2% chlorhexidine solution in this practice (Tantipong et al., 2008).
A challenge encountered was the inability to undertake a blind study since the tastes and odors of chlorhexidine and normal saline solutions were different. The assessors who ascertained if a patient had developed pneumonia were not aware of the study group assignment of the patient. Thus, the results showed that the oral decomposition using 2% chlorhexidine solution was efficient among patients under mechanical ventilation (Tantipong et al., 2008). This study mainly focused on pharyngeal colonization with gram-negative bacilli since they were the causative of more than 90% of VAP incidences in the hospital (Tantipong et al., 2008). However, a combination of chlorhexidine and colistin produced a more efficient oropharyngeal decontamination for gram-negative bacteria as compared to chlorhexidine alone (Tantipong et al., 2008). However, both regimes proved equally useful for the prevention of VAP.
Another problem encountered in this study was that 9.8% of the patients, to whom chlorhexidine was administered had suffered from irritation of oral mucosa (Tantipong et al., 2008). These patients were taken to the health care personnel, responsible for oral care who rubbed their oropharyngeal mucosa by using gauze, soaked in 2 % chlorhexidine solution (Tantipong et al., 2008). According to Tantipong et al. (2008), gentle cleaning of oropharyngeal mucosa proved effective in reducing irritation. Therefore, healthcare personnel ought to be aware of the side effects of chlorhexidine solution and they should not continue administering it to the patient if they develop some irritation of oral mucosa. Additionally, there was no selective decontamination of the gut as well as no continuous aspiration of subglottic secretions performed on the patients (Tantipong et al., 2008).
The VAP rate in a hospital in Bangkok, Siriraj Hospital was 14 episodes for every 1,000 ventilator-days (Tantipong et al., 2008). At the same time, 90% of the causative agents of VAP among patients were gram-negative bacilli (Tantipong et al., 2008). Thus, the episodes of VAP among patients in Siriraj Hospital increased hospital stay days by an average of 13.2, and the events raised the antimicrobial therapy cost by an average of $400, thus being a contributing factor to a 20% rise in mortality (Tantipong et al., 2008). Therefore, dental and oral colonization with pathogens among patients under mechanical ventilation was connected to the development of VAP (Tantipong et al., 2008).
This study analysis had utilized the concentration of chlorhexidine in a randomized controlled trial. Although it was observed that the formulation of 2% chlorhexidine solution and the criteria of determining patients’ eligibility, the heterogeneity showed a P value of more than 0.1, revealing that there was no substantial heterogeneity in the study (Tantipong et al., 2008). Therefore, the results gathered showed that although oral decomposition with chlorhexidine had decreased the risk of VAP among patients under mechanical ventilation, there was no notable difference in the duration of stay in the intensive care unit, mechanical ventilation, or mortality (Tantipong et al., 2008). Furthermore, oral decomposition with the 2% chlorhexidine solution for preventing VAP is still seen as a cost-effective strategy since the cost of this solution was 40 cents daily (Tantipong et al., 2008). The mean value of 2% chlorhexidine solution for 14 patients stood at $34, which was considerably lower as compared to the average cost of using antibiotic therapy, which was $400. Therefore, it is clear that using chlorhexidine solution for the prevention of ventilator-associated pneumonia is more efficient as compared to antibiotic treatment.
The current study shows that reducing respiratory infections among patients under mechanical ventilation is demanding enough. The important aspect of trying to cut these respiratory diseases is the understanding of the severity of illness, the location of various strategies to deal with sickness, and choosing the best. Two standard methods used to try to prevent cases of ventilator-associated pneumonia are the use of antibiotic therapy and the use of chlorhexidine. However, the latter proves more effective than the former. The randomized controlled trial on the use of chlorhexidine in preventing ventilator-associated pneumonia has demonstrated its effectiveness. However, various flaws and challenges were associated with this method. For example, the authors were unable to undertake a blind study because the tastes and odors of chlorhexidine and normal saline solutions were different. The assessors who determined if a patient had developed pneumonia were not aware of the study group assignment of the patient. Additionally, 8% of the patients, to whom chlorhexidine had been administered, suffered from the irritation of oral mucosa. The cost-effectiveness of the use of chlorhexidine as opposed to antibiotic therapy was also evident. Healthcare personnel in charge of ventilated patients should make the use of non-invasive ventilations and ventilations of positive pressure in place of intubation as well as make sure they reduce the duration of ventilation. Proactive surveillance and check-ups on patients are essential practices, and nurses should also ensure they oversee both the physical and oral hygiene of their patients.