Reducing Morbidity of Acute Respiratory Distress Syndrome in Hospitalized Patients: Preventing Nosocomial Infection or Aspiration

Sandra Huggins RN, BSN, CCRN

Disclosures

Topics in Advanced Practice Nursing eJournal. 2006;6(2) 

In This Article

Strategies in ARDS Prevention

Nutrition plays an important role in maintaining the pulmonary and immune systems. Intubated patients and patients exhibiting poor dietary intake should receive some form of nutrition via feeding tube unless contraindicated. The appropriate enteral feeding should be initiated early in the hospitalization. Selecting a tube feeding lower in carbohydrates with adequate protein and fat composition can reduce carbon dioxide levels, maintain a positive nitrogen balance, and reduce muscle breakdown. Other nutrients involved in the prevention of disease and healing include amino acids, fatty acids, trace minerals, and antioxidants.[2,3] The APN can request a nutritional consult or facilitate the initiation or maintenance of nutritional therapy based on the patient's metabolic needs.

Another concern is supplemental hydration to ensure adequate circulating volume and tissue perfusion. Invasive monitoring of pulmonary artery pressures can help guide fluid replacement to achieve adequate preload without worsening pulmonary edema and further compromising the patient's fragile pulmonary status.[2,8] Closely monitor pulmonary artery pressures, report changes, and execute changes in fluid and drug therapy as indicated.

Time-cycled prone positioning can be considered for the patient suffering from ARDS and may optimize postural drainage and secretion mobilization.[1,4,6] However, many factors exclude patients from being good candidates for prone therapy. Some exclusion criteria include inadequate staffing, obesity, pregnancy, recent trauma, abdominal or cardiothoracic surgery, recent tracheostomy, history of poor tolerance to prone positioning, or recent cardiac arrest.[6]

In order for the patient to be placed in prone position safely, ensure that at least 7 staff members are dedicated and available for positioning (3 on each side for log rolling and 1 at the head for lines and tubes). Pronating devices are available but are rarely used in medical facilities.[2] The positive effects of prone positioning should be evident by an increase in oxygen saturation with positioning, improvement in P/F ratios, and increased alveolar recruitment and lung expansion on auscultation and chest films.[1,2,6]

Kinetic therapy is a good alternative to prone positioning for reducing atelectasis, mobilizing secretions, and reducing ventilator-acquired pneumonia and ARDS progression. The APN requesting a specialty bed with kinetic therapy for the patient with ARDS should ensure that the patient receives at least 18 hours of continued lateral rotation therapy at the highest angle tolerated, up to 40 degrees.[19] Patient tolerance to turning therapy and prone positioning should be monitored closely for deteriorations in vital signs and labored respiratory effort. These positioning measures should be discontinued immediately if the patient exhibits signs of intolerance.[1,2,4,6,19]

Another consideration is the administration of oral chlorhexidine. Oral chlorhexidine application is beneficial in reducing oropharyngeal colonization and nosocomial pneumonia. Cardenosa Cendrero and colleagues[20] found that over 70% of mechanically ventilated patients had oropharyngeal and tracheal colonization within 24 hours of intubation. Fourrier and partners[21] conducted a study on the impact of oral care in reducing pneumonia and found that oropharyngeal colonization was reduced from 66% to 29% when chlorhexidine gel was used 3 times daily in patients receiving mechanical ventilation.

Several oral care protocols have been initiated by hospitals in response to these studies. The administration of chlorhexidine rinse or gel significantly reduces bacterial colonization when used 2 to 3 times daily.[22] Consider initiating stringent oral care protocols as a means to prevent nosocomial pneumonia in hospitalized patients.

The prevention of ARDS is based upon aggressive treatment of causal etiology and effective diagnostic approaches in identifying early phases of disease progression. It is imperative that adequate empiric antibiotic coverage is initiated once a diagnosis of nosocomial or aspiration pneumonia is presumed. Microbial colonization varies depending on early-onset or late-onset nosocomial pneumonia.[12,16,17] As a result, microbial treatment will vary accordingly. It is suggested that a concomitant therapy using a second- or third-generation cephalosporin, a beta-lactamase inhibitor, clindamycin, or a fluoroquinolone and aztreonam be considered in early-onset nosocomial pneumonia.

In late-onset nosocomial pneumonia, a combination of an aminoglycoside or ciprofloxacin plus imipenem is considered the most beneficial antimicrobial therapy. Meropenem or cefipime is effective if Pseudomonas aeruginosa is present, while vancomycin is the standard antimicrobial therapy for MRSA.[12] The most effective means of managing antimicrobial therapy is administering broad-spectrum antibiotic coverage initially until a more formal microbial diagnosis is established and then switching to the appropriate narrow spectrum therapy.[12] Concomitant antibiotic coverage should be continued for at least 2 weeks; however, more prolonged therapy with antibiotic cycling may be required in progressive ARDS.[23]

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