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Nursing Home-Acquired Pneumonia (NHAP)


Nursing Home-Acquired Pneumonia (NHAP) NHAP is defined as pneumonia occurring in a resident of a long-term care facility Second leading cause of infection and a ... – PowerPoint PPT presentation

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Title: Nursing Home-Acquired Pneumonia (NHAP)

Nursing Home-Acquired Pneumonia (NHAP)
  • NHAP is defined as pneumonia occurring in a
    resident of a long-term care facility
  • Second leading cause of infection and a
    significant cause of morbidity and mortality
    among residents of long-term care facilities
  • More closely resembles community-acquired
    pneumonia (CAP) than hospital-acquired pneumonia
  • NHAP is a common diagnosis applied at admission
    but is the definitive diagnosis in only 33 of
  • RAR - 2015

DIAGNOSISClinical diagnosis
  • Chest x-ray... New, persistent infiltrate- best
  • indicator. NHAP often mimics congestive
    heart failure,
  • pulmonary embolism, bronchogenic
  • COPD, and others. Non-infectious infiltrates
  • misdiagnosed as NHP
  • Symptoms and physical findings of infection
  • Fever, frequently 102 and above -may be low
    or absent Cough
  • Rales over involved lung segments, signs of
    consolidation, or pleural effusion
  • Shortness of breath, pulse above 100,
    respirations above 25. oxygen saturation 94
  • Acute change in cognitive or functional

Laboratory findings
  • Leukocytosis Not helpful because results are
    nonspecific. Left shift due to stress to the
    individual may also occur with MI, pulmonary
    embolism, dehydrations, any stress
  • Blood cultures usually positive if causative
    agent is Streptococcus Pneumoniae or Haemophilus
  • Sputum culture may be useful if specimen reflects
    lower respiratory flora
  • Definitive microbiologic method specimen
    collected by bronchoscopy, or transtracheal

Most common pathogens
  • Streptococcus pneumoniae
  • Haemophilus influenza
  • Gram-negative rods
  • Moxcella
  • Note Antibiogram will provide information
  • specific to the organization
  • Role of viruses as cause of NHAP is unclear

Treatment goal
  • Reduce morbidity and mortality, and
  • eradicate infection
  • Clinicians generally approach treatment of NHAP
    and Community-acquired pneumonia (CAP) with
    similar antibiotic coverage
  • Initiation of empiric therapy critical in the
    medical management of NHAP
  • Select agents that have appropriate spectrum,
    minimal resistance profiles and are

Management of Pneumonia with a Clinical Pathway,
Loeb M JAMA 2006
Aspiration Pneumonia
  • Aspiration pneumonia results microbioligically
    from aspirated/inhalation of anaerobic
    oropharyngeal flora or gastric contents into one
    or more lung segments or lobes. May also occur if
    distant focus of infection disseminates to the
    lungs. Small volume aspirate that produce no
    overt changes common often not discovered until
    condition progresses to pneumonia
  • Preventing aspiration reduces the risk of the
  • resident acquiring aspiration pneumonia
  • Major sources of aspiration
  • Dysphagia
  • Mouth/oral cavity
  • Medications especially to treat Gastric
    regurgitation/Gasto-esophygeal reflux disease

  • Symptoms, by observation
  • Sudden appearance of respiratory symptoms -
    coughing associated with eating or drinking
  • Increased respirations
  • Delerium
  • Regurgitation of gastric contents
  • Voice changes after swallowing
  • Confirmatory tests, such as
  • Modified barium swallow
  • Video fluoroscopy (a swallowing study)
  • Fiberoptic endoscopy
  • Evaluation by qualified O.T. or speech and
    language pathologist

Dysphagia, Prevention Strategies
  • Scant literature available that provides
  • interventions. Basic care appears to be the most
  • effective preventive measure
  • Optimize nutritional status - Suggest developing
    facility meal/feeding program or guidelines -
    include caregiver education, encourage food and
    fluid, positioning, e.g. upright feeding
    position, adaptive eating equipment, utilize
    assisted-eating techniques, careful, appropriate
    decisions regarding non-oral feeding
  • and
  • Encourage sedentary residents to ambulate -
  • walk, or propel their wheelchairs

  • Norma A. Metheny. Preventing Aspiration in Older
    Adults with Dysphagia. From the Hartland Group
    for Geriatric Nursing, 2012
  • John Liantonio et al. Preventing Aspiration
    Pneumonia by Addressing Three Key Risk Factors
    Dysphagia, Poor Oral Hygiene, and Medication Use. Volume 22 Issue 10
    Oct 2014

Prevent aspiration via ORAL CARE
  • Resident hygiene is recognized as an important
    aspect of nursing care but mouth care is often a
    stressful and neglected procedure.
  • Evidence increasingly recognizes that aspiration
    of oral secretions and their bacteria are
    important factors in pneumonia.
  • In multiple studies study (first in 2002), oral
    care has been shown to reduce NHAP, reinforcing
    that adequate oral care is a modifiable risk

Preventing NHAP, cont. ORAL CARE
  • GOAL Develop and implement a
  • comprehensive oral hygiene program
  • for all residents.
  • 1. Oral health assessment and
  • individualized program
  • 2. Daily oral care - real teeth, dentures,
  • edentuous. Manual brushing and rinse
  • 3. Preventive care by dental professionals

Oral Care, continued
  • Healthcare worker
  • Basic information
  • Organizations protocol
  • Resident/family

  • Mary E. McNally et al. Action Planning for Daily
    Mouth Care in Long-Term Care The Brushing Up on
    Mouth Care Project. Research Article. 2012
  • Implementing a Geriatric Oral health Aid Model in
    a Long Term Care Facility. University of KY,
    2012. (slide set)
  • Vincent Quagliarello et al. Pilot Testing of
    intervention Protocols to Prevent Pneumonia among
    Nursing Home Residents. 2009 NIH Public Access

Preventing NHAP, cont. Medications
  • Minimize use of medications that block acid
    secretion and promote bacterial overgrowth.
  • Offer between meal snacks for residents with
    GERD, or GI-conditions that limit bulk food
  • Treat GI symptoms that may hinder absorption of
  • Avoid NPO restriction whenever possible
  • Elevate head of bed at all times (30-45 degrees)

Prevention strategy VACCINATION
  • Residents
  • Two separate vaccine directed at preventing
  • Pneumoccocal conjugate vaccine (PCV13,
    Prevnar-13) and
  • Pneumococcal polysaccharide vaccine
  • Pneumovax 23)
  • Influenza - annual
  • Healthcare personnel (HP)
  • Influenza - annual
  • Note Specifics to be presented Day 3

Performance Measures Process and Outcome
  • PROCESS examples
  • 1. Vaccination Assess population
  • a. Influenza residents and HPs
  • b. Pneumococcal residents
  • c. Or Prevnar-13 prn
  • 2. Oral care
  • a. Assess availability of supplies
  • b. Assess adherence to protocol
  • OUTCOME examples
  • Incidence pneumonia, influenza/influenza-like
  • Targeted - before and after prevention strategies

Additional References
  • Raghavendran K et al. Periodontics 2000,
    200744164-177, Nursing home-associated
    pneumonia, hospital-acquired pneumonia and
    ventilator-associated pneumonia the contribution
    of dental biofilms and periodontal inflammation
  • Cunha B, Bronze M. Nursing Home Acquired
    Pneumonia. Nursing Home Acquired Pneumonia.
  • Multiple references and resources are cited with
    links and ordering information in the MARR 2008
    Long-Term Care Toolkit 2998. Steps 1,2
    currently in revision