RESPIRATORY THERAPY

KING KHALID HOSPITAL INFECTION PREVENTION

ANDCONTROL MANUAL

Dr. Nahla Abdel Kader, MD, PhD.Infection Control Consultant, MOHInfection Control CBAHI Surveyor

Infection Prevention Control DirectorKKH.

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DEFINITION

To describe Infection Control standards for the respiratory therapy services and to avoid any improper handling of respiratory care equipment that might lead to increased incidence of nosocomial infections

COMMENTS

1. Certain interventions used by the Respiratory therapy service may influence infection risks to patients and HCWs.

2. Mechanical ventilation, ventilator circuit channels, handling of condensate, use ofnebulizers, suction catheters and humidification methods are potential infection risks.

3. Respiratory care devices that touch mucous membranes are classified as semicritical and must be sterilized. When these items can not be sterilized they may have high-level disinfection

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A. Standard Precautions:

1. Use standard precautions for all patient care2. Use personal protective equipment (PPE) singly or in

combination for any /all of the following procedures as indicated.

3. Wear gloves for handling respiratory secretions and objects contaminated with respiratory secretions of any patient.

4. Wear facial protection when contamination of the face with aerosolized particles is likely.

5. Wear gown/ plastic apron when soiling with respiratory secretions from a patient is likely.

6. Change the gown / plastic apron after such contact, and before providing care to another patient.

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B. Hand hygiene:

1. Wash or cleanse hands thoroughly before and after all contact with the patient and the patient’s environment refer to ICM-II-04 Hand Hygiene.

2. Wash and dry or cleanse hands before and after glove use refer to ICM-II-04 Hand Hygiene.

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C. Mechanical Ventilation and Circuit Changes:

1. Ensure that patient is positioned with head elevated at 30○-45○except during postural drainage procedures, to minimize aspiration of secretions.

2. Use high-efficiency bacterial filters in the breathing circuit of the ventilation unit.a. Use filters on the inspiratory limb to eliminate contaminated

fluids from entering the inspired gas thereby contaminating of the ventilator.

b. Place bacterial filters appropriately to avoid any potential interference to the operating characteristics of the ventilator by impeding high gas flows.

c. Carefully test reusable filters periodically to ensure efficient functioning.

3. Use closed continuous-feed humidification on all ventilator circuits to minimize/ prevent aerosols thus preventing transmission of bacteria from the humidifier reservoir to patients

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4. Heated humidification systems often operate at temperatures that reduce/ eliminate bacterial pathogens. Use sterile water only to fill humidifiers and change every 24 hours. Tap or distilled water may harbor Legionella spp. That is more heat resistant than other bacteria.

5. Sterilize or high-level disinfect circuits, humidifiers and nebulizers between patients.

6. Do not routinely change the ventilator circuit used with a particular patient more frequently than 48 hours.

7. Frequent circuit-change intervals have been identified as a risk factor for increased Ventilator associated pneumonia.

4. Heated humidification systems often operate at temperatures that reduce/ eliminate bacterial pathogens. Use sterile water only to fill humidifiers and change every 24 hours. Tap or distilled water may harbor Legionella spp. That is more heat resistant than other bacteria.

5. Sterilize or high-level disinfect circuits, humidifiers and nebulizers between patients.

6. Do not routinely change the ventilator circuit used with a particular patient more frequently than 48 hours.

7. Frequent circuit-change intervals have been identified as a risk factor for increased Ventilator associated pneumonia.

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D. Condensate:1. Drain and discard condensate that collects in the tubing of the

ventilator to prevent it draining towards the patient.2. Use water traps to minimize spillage.a. Place traps appropriately in the ventilator circuits so as to allow

gravity to drain condensate continuously away from the patient.3. Micro-organisms contaminate condensate and must be treated as

waste and properly dispose of it through the standard hospital waste system.

4. Use heated wire circuits to reduce/ eliminate condensate formation in the ventilator circuit.

a. Set heated wire circuits so that a small amount of condensate forms on the inspiratory limb of the circuit, indicating 100% relative humidity.

b. Adjust heated wire circuit properly to deliver appropriate humidity to the patient.

c. If humidity is decreased, it will result in damage to the epithelium of the respiratory tract with potential occlusion of artificial airways especially in infants and small children.

D. Condensate:1. Drain and discard condensate that collects in the tubing of the

ventilator to prevent it draining towards the patient.2. Use water traps to minimize spillage.a. Place traps appropriately in the ventilator circuits so as to allow

gravity to drain condensate continuously away from the patient.3. Micro-organisms contaminate condensate and must be treated as

waste and properly dispose of it through the standard hospital waste system.

4. Use heated wire circuits to reduce/ eliminate condensate formation in the ventilator circuit.

a. Set heated wire circuits so that a small amount of condensate forms on the inspiratory limb of the circuit, indicating 100% relative humidity.

b. Adjust heated wire circuit properly to deliver appropriate humidity to the patient.

c. If humidity is decreased, it will result in damage to the epithelium of the respiratory tract with potential occlusion of artificial airways especially in infants and small children.

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5. Heat-Moisture Exchangers (HMEs) is another approach to heat/humidify inspirited gas and reduces condensate formation.

NB: HMEs can increase dead space and resistance to breathing and at the same time providing less humidity than active systems previously discussed, resulting in thick plugging secretions in some patients. To be effective, >70% of the gas entering the airway must be exhaled through the HMEs; so when leaks occur (e.g., with broncho pulmonary fistulae or cuffless endotracheal tubes), active humidification systems can be more effective.

a. There is no CDC recommendation for preferential use of HMEs rather than heated humidifier to prevent nosocomial pneumonia.

b. The HMEs, should be changed when gross contamination or mechanical dysfunction of the device is present, commonly 24 hours.

c. Vent circuits should not routinely be changed when HME is in use on a patient.

d. HMEs designed to act as bacterial filters have not been proven to significantly reduce Ventilator- Associated Pneumonia (VAP) over other less expensive HMEs.

e. Place HMEs between the ventilator circuit and the patient’s airway.

5. Heat-Moisture Exchangers (HMEs) is another approach to heat/humidify inspirited gas and reduces condensate formation.

NB: HMEs can increase dead space and resistance to breathing and at the same time providing less humidity than active systems previously discussed, resulting in thick plugging secretions in some patients. To be effective, >70% of the gas entering the airway must be exhaled through the HMEs; so when leaks occur (e.g., with broncho pulmonary fistulae or cuffless endotracheal tubes), active humidification systems can be more effective.

a. There is no CDC recommendation for preferential use of HMEs rather than heated humidifier to prevent nosocomial pneumonia.

b. The HMEs, should be changed when gross contamination or mechanical dysfunction of the device is present, commonly 24 hours.

c. Vent circuits should not routinely be changed when HME is in use on a patient.

d. HMEs designed to act as bacterial filters have not been proven to significantly reduce Ventilator- Associated Pneumonia (VAP) over other less expensive HMEs.

e. Place HMEs between the ventilator circuit and the patient’s airway.

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E. Nebulizers:1. Large-volume nebulizers and mist tents:a. Sterilize or high-level disinfect large volume nebulizers, mist

tents, and hoods between patients, and after every 24 hours of use on the same patient.

2. Room humidifiers that create aerosols have been associated with healthcare associated pneumonia, secondary to contamination of their reservoir. The CDC recommends that aerosol-generating room humidifiers not be used unless they can be sterilized or high-level disinfected every 24 hours and filled only with sterile fluids.

3. Change disposable large volume nebulizers every 72 hrs.4. Small volume medication nebulizers: Handheld and inline:a. Sterilize or disinfect nebulizers between patients.

Sterilize/disinfect or rinse with sterile water and air dry after each treatment on the same patient.

b. Use only sterile fluids and dispense aseptically.c. Remove inline nebulizers from the ventilator circuit between

treatments, then disinfect or rinse nebulizers with sterile water and air dry on the same patient.

E. Nebulizers:1. Large-volume nebulizers and mist tents:a. Sterilize or high-level disinfect large volume nebulizers, mist

tents, and hoods between patients, and after every 24 hours of use on the same patient.

2. Room humidifiers that create aerosols have been associated with healthcare associated pneumonia, secondary to contamination of their reservoir. The CDC recommends that aerosol-generating room humidifiers not be used unless they can be sterilized or high-level disinfected every 24 hours and filled only with sterile fluids.

3. Change disposable large volume nebulizers every 72 hrs.4. Small volume medication nebulizers: Handheld and inline:a. Sterilize or disinfect nebulizers between patients.

Sterilize/disinfect or rinse with sterile water and air dry after each treatment on the same patient.

b. Use only sterile fluids and dispense aseptically.c. Remove inline nebulizers from the ventilator circuit between

treatments, then disinfect or rinse nebulizers with sterile water and air dry on the same patient.

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F. Suction catheters:1. Open Suction System: Sterile Single-use cathetersa. Use sterile single catheters and sterile technique when

suctioning with open systems.b. Use sterile water to flush catheter while suctioning.c. Carefully dispose of used catheter in regular hospital waste

system.d. Use sterile gloves and a surgical mask for suctioning.

(N95/Particulate mask for PMTB)2. Closed-suction systems:a. Use only sterile fluid to flush secretions from the suction

catheter.b. Change suction collection tubing and canisters between

patients.c. Change in line suction catheters when grossly soiled or

malfunctioning.

F. Suction catheters:1. Open Suction System: Sterile Single-use cathetersa. Use sterile single catheters and sterile technique when

suctioning with open systems.b. Use sterile water to flush catheter while suctioning.c. Carefully dispose of used catheter in regular hospital waste

system.d. Use sterile gloves and a surgical mask for suctioning.

(N95/Particulate mask for PMTB)2. Closed-suction systems:a. Use only sterile fluid to flush secretions from the suction

catheter.b. Change suction collection tubing and canisters between

patients.c. Change in line suction catheters when grossly soiled or

malfunctioning.

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G. Resuscitation bags:1. Rinse immediately with sterile water when the bag valve is

visibly soiled with secretions for use on the same patient.2. Sterilize or high-level disinfect bags between patients.3. Wash hands before and after all contact with patient and

patient equipment.H. Artificial airways:1. Place patient with head up at 30 to 40 degree angle during use

of artificial airways (unless contraindicated) especially during feedings and for one hour after.

2. Do not routinely deflate the cuff of the endotracheal tube to determine the filling volume of the cuff. Alternative techniques to assure proper cuff pressure (such as minimal leak or minimal occluding pressure) should be substituted.

3. Perform tracheostomy when indicated under sterile conditions. Elective tracheostomy should be performed in the operating room.

4. Use aseptic technique to replace tracheal tube.a. Replace tube with one that has undergone sterilization or high-

level disinfection

G. Resuscitation bags:1. Rinse immediately with sterile water when the bag valve is

visibly soiled with secretions for use on the same patient.2. Sterilize or high-level disinfect bags between patients.3. Wash hands before and after all contact with patient and

patient equipment.H. Artificial airways:1. Place patient with head up at 30 to 40 degree angle during use

of artificial airways (unless contraindicated) especially during feedings and for one hour after.

2. Do not routinely deflate the cuff of the endotracheal tube to determine the filling volume of the cuff. Alternative techniques to assure proper cuff pressure (such as minimal leak or minimal occluding pressure) should be substituted.

3. Perform tracheostomy when indicated under sterile conditions. Elective tracheostomy should be performed in the operating room.

4. Use aseptic technique to replace tracheal tube.a. Replace tube with one that has undergone sterilization or high-

level disinfection

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I. Immobility:1. Turn patients from the supine to lateral position every 2

hours. Encourage sit-up regimens as tolerated.2. Patients receiving mechanical ventilation with a

nasogastric or other enteral tube in place should be positioned with head elevated at an angle of 30 to 45 degrees.

J. Provision of oxygen by mask or cannula:1. Change the tubing, as well as any device such as a cannula

and mask, used to administer oxygen from a wall outlet, between patients.

2. Restrict the use of Bubble Type Humidifiers (BTHs) to appropriate situations. Humidifiers are not indicated for oxygen flows less than 4L/minute in adult patients under normal conditions. When operated at flows above 10 L/minute, a standard unheated BTH designed for oxygen delivery is less efficient as a humidifier and may create aerosols that can transmit bacteria

I. Immobility:1. Turn patients from the supine to lateral position every 2

hours. Encourage sit-up regimens as tolerated.2. Patients receiving mechanical ventilation with a

nasogastric or other enteral tube in place should be positioned with head elevated at an angle of 30 to 45 degrees.

J. Provision of oxygen by mask or cannula:1. Change the tubing, as well as any device such as a cannula

and mask, used to administer oxygen from a wall outlet, between patients.

2. Restrict the use of Bubble Type Humidifiers (BTHs) to appropriate situations. Humidifiers are not indicated for oxygen flows less than 4L/minute in adult patients under normal conditions. When operated at flows above 10 L/minute, a standard unheated BTH designed for oxygen delivery is less efficient as a humidifier and may create aerosols that can transmit bacteria

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K. Provision of diagnostic testing:1. Percutaneous blood gases:a. Perform hand hygiene and use clean gloves.b. Perform adequate skin preparation on the patient using hospital

approved antiseptic.c. Use sterile supplies.d. Do not precool syringes by submerging in ice water.e. Avoid repeating unsuccessful arterial punctures with the same

needle or cannula.f. Handle all body fluids as if contaminated.g. Dispose/transport specimens as appropriate.2. Pulse oximetry:a. Disinfect probes as thoroughly as possible, and do not use over

broken skin.b. Avoid use of clip-on probes over edematous areas. Check site

frequently, reposition as necessary.c. Reposition all probes at appropriate time intervals in accordance

with manufacturer’s recommendation

K. Provision of diagnostic testing:1. Percutaneous blood gases:a. Perform hand hygiene and use clean gloves.b. Perform adequate skin preparation on the patient using hospital

approved antiseptic.c. Use sterile supplies.d. Do not precool syringes by submerging in ice water.e. Avoid repeating unsuccessful arterial punctures with the same

needle or cannula.f. Handle all body fluids as if contaminated.g. Dispose/transport specimens as appropriate.2. Pulse oximetry:a. Disinfect probes as thoroughly as possible, and do not use over

broken skin.b. Avoid use of clip-on probes over edematous areas. Check site

frequently, reposition as necessary.c. Reposition all probes at appropriate time intervals in accordance

with manufacturer’s recommendation

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3. Pulmonary function testing (PFT):

h. Disinfect surfaces of device that come into patient contact, between uses. Do not routinely disinfect the internal machinery of PFT machines between uses.

i. Sterilize or disinfect mouthpieces and nose clips between patients.

NB: The use of low-resistance, high-efficiency filters has been advocated for use between the mouthpiece and the spirometer to minimize contamination between device and patient. This filter may also reduce HCW exposure to droplet nuclei generated by the patient during forced expiratory maneuvers.

3. Pulmonary function testing (PFT):

h. Disinfect surfaces of device that come into patient contact, between uses. Do not routinely disinfect the internal machinery of PFT machines between uses.

i. Sterilize or disinfect mouthpieces and nose clips between patients.

NB: The use of low-resistance, high-efficiency filters has been advocated for use between the mouthpiece and the spirometer to minimize contamination between device and patient. This filter may also reduce HCW exposure to droplet nuclei generated by the patient during forced expiratory maneuvers.

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4. Sputum induction for specimen collection:

a. Sterilize or high-level disinfect the nebulizers between patients. Clean and disinfect all surfaces on equipment that patient’s respiratory secretion would contaminate during procedures.

b. Perform sputum inductions in a private room with six air exchanges per hour if possible. Keep door closed during procedure.

c. Wear a surgical mask or particulate respirator during the sputum induction.

d. Ask patient’s visitors to leave the room during the sputum induction.

4. Sputum induction for specimen collection:

a. Sterilize or high-level disinfect the nebulizers between patients. Clean and disinfect all surfaces on equipment that patient’s respiratory secretion would contaminate during procedures.

b. Perform sputum inductions in a private room with six air exchanges per hour if possible. Keep door closed during procedure.

c. Wear a surgical mask or particulate respirator during the sputum induction.

d. Ask patient’s visitors to leave the room during the sputum induction.

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L. Cleaning and disinfection of respiratory-care devices

a. Thoroughly clean all equipment before disinfection and/or sterilization. Use methods of sterilization such as pasteurization at 75○C for 30 minutes for items that cannot be sterilized by ethylene oxide or heat.

b. Use only sterile water when a device needs to be rinsed after it has been disinfected. Tap water or locally prepared distilled water may harbor microorganisms that can cause pneumonia.

c. Do not reprocess equipment and devices that are manufactured “for single use only”; refer to ICM – IX-03 Reprocessing/ Reuse of Disposable Items.

NB: Proper cleaning and sterilization or high-level disinfection of reusable equipment is important to reduce infection. Respiratory-care devices have been classified as semicritical because they come into contact with mucous membranes but do not ordinarily penetrate body surfaces

L. Cleaning and disinfection of respiratory-care devices

a. Thoroughly clean all equipment before disinfection and/or sterilization. Use methods of sterilization such as pasteurization at 75○C for 30 minutes for items that cannot be sterilized by ethylene oxide or heat.

b. Use only sterile water when a device needs to be rinsed after it has been disinfected. Tap water or locally prepared distilled water may harbor microorganisms that can cause pneumonia.

c. Do not reprocess equipment and devices that are manufactured “for single use only”; refer to ICM – IX-03 Reprocessing/ Reuse of Disposable Items.

NB: Proper cleaning and sterilization or high-level disinfection of reusable equipment is important to reduce infection. Respiratory-care devices have been classified as semicritical because they come into contact with mucous membranes but do not ordinarily penetrate body surfaces

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