Hospital-acquired pneumonia prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Prevention

Sterilization or Disinfection and Maintenance of Equipment and Devices

Preventive Measures	Description
General measures	Thoroughly clean all equipment and devices to be sterilized or disinfected. Whenever possible, use steam sterilization (by autoclaving) or high-level disinfection by wet heat pasteurization at >158 F (>70°C) for 30 minutes for reprocessing semicritical equipment or devices Use sterile water for rinsing reusable semicritical respiratory equipment and devices when rinsing is needed after they have been chemically disinfected. Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators Wear gloves to perform the previous procedure and/or when handling the fluid Use sterile (not distilled, nonsterile) water to fill bubbling humidifiers
Mechanical ventilators	Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators
Breathing circuits with humidifiers	Do not change routinely, on the basis of duration of use, the breathing circuit (i.e., ventilator tubing and exhalation valve and the attached humidifier) that is in use on an individual patient. Change the circuit when it is visibly soiled or mechanically malfunctioning Periodically drain and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward the patient
Ventilator breathing circuits with heat-and-moisture exchangers (HME)	No recommendation can be made for the preferential use of either HMEs or heated humidifiers to prevent pneumonia in patients receiving mechanically assisted ventilation Change an HME that is in use on a patient when it malfunctions mechanically or becomes visibly soiled
Small-volume medication nebulizers: in-line and hand-held nebulizers	Between treatments on the same patient clean, disinfect, rinse with sterile water (if rinsing is needed), and dry small-volume in-line or hand-held medication nebulizers Use only sterile fluid for nebulization, and dispense the fluid into the nebulizer aseptically
Other devices used in association with respiratory therapy	Respirometer and ventilator thermometer: between their uses on different patients, sterilize or subject to high-level disinfection portable respirometers and ventilator thermometers Resuscitation bags: between their uses on different patients, sterilize or subject to high-level disinfection reusable hand-powered resuscitation bags
Anesthesia machines and breathing systems or patient circuits	Do not routinely sterilize or disinfect the internal machinery of anesthesia equipment Between uses on different patients, clean reusable components of the breathing system or patient circuit (e.g., tracheal tube or face mask) inspiratory and expiratory breathing tubing, y-piece, reservoir bag, humidifier, and tubing, and then sterilize or subject them to high-level liquid chemical disinfection or pasteurization
Pulmonary-function testing equipment	Do not routinely sterilize or disinfect the internal machinery of pulmonary-function testing machines between uses on different patients. Change the mouthpiece of a peak flow meter or the mouthpiece and filter of a spirometer between uses on different patients
Table adapted from CDC

Prevention of Person-to-Person Transmission of Bacteria

Preventive Measures	Description
Standard Precautions	Decontaminate hands by washing them with either antimicrobial soap and water or with nonantimicrobial soap and water. Wear gloves for handling respiratory secretions or objects contaminated with respiratory secretions of any patient Change gloves and decontaminate hands as described previously between contacts with different patients. When soiling with respiratory secretions from a patient is anticipated, wear a gown and change it after soiling occurs and before providing care to another patient
Care of patients with tracheostomy	Perform tracheostomy under aseptic conditions When changing a tracheostomy tube, wear a gown, use aseptic technique, and replace the tube with one that has undergone sterilization or high-level disinfection
Table adapted from CDC

Prevention of Postoperative Pneumonia

Patients at high risk of post-operative pneumonia
Abdominal aortic aneurysm repair, thoracic surgery, or emergency surgery.
Patients who will receive general anesthesia
Aged >60 years
Totally dependent functional status
Weight loss >10%
Using steroids for chronic conditions
Recent history of alcohol use, history of COPD, or smoking during the preceding year
Impaired sensorium, a history of cerebrovascular accident with residual neurologic deficit,
Received >4 units of blood before surgery
Low (<8mg/dL) or high (>22 mg/dL) blood urea nitrogen level.

• Instruct preoperative patients, especially those at high risk for contracting pneumonia, about taking deep breaths and ambulating as soon as medically indicated in the postoperative period.
• Encourage all postoperative patients to take deep breaths, move about the bed, and ambulate unless medically contraindicated.
• Use incentive spirometry on postoperative patients at high risk for pneumonia.
• No recommendation can be made about the routine use of chest physiotherapy on all postoperative patients at high risk for pneumonia.